Every finding on record at Chandler Post Acute and Rehabilitation

Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure that a medication was administered following the physician ordered parameters for one resident (#135). The deficient practice resulted in hospitalization due to lowered blood pressure. Findings included:Resident #135 was admitted to the facility on [DATE].Review of the hospital records revealed the resident #135 had a past medical history of urinary tract infection (UTI), Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea (OSA), Hypertension, and Cerebrovascular Disease (CVA).The admission progress note dated November 10, 2025 included the resident arrived at the facility; and that the resident was alert, oriented x 4, awake and able to make needs known. The care plan dated November 10, 2025 included interventions to administer medications/treatments as ordered, to monitor/document for side effects and effectiveness and to report occurrences to the physician.A review of the order summary report revealed that a physician order dated November 10, 2025 for Losartan Potassium (antihypertensive) 50 mg (milligrams), give two tablets by mouth one time a day for hypertension; and to hold for SBP (systolic blood pressure) of less than 130. This order has a start date of November 11, 2025.This order was transcribed onto the MAR (medication Administration record) for November 2025 and was scheduled to be administered at 8:00 a.m.The blood pressure summary report on November 10, 2025, at 8:00 p.m. revealed a BP (blood pressure) of 120/76 mmHg (millimeters Mercury); and, at 11:59 p.m., her BP was 131/78 mmHg.The eMAR (electronic medication administration record) note dated November 11, 2025 at 1:17 a.m., the resident was on a change of condition for new admit, oral antibiotic therapy for UTI (urinary tract infection). per the documentation, the resident was alert, oriented x 4, was able to make needs known and was on antibiotic for UTI and had a PRN (as needed) narcotic medication.The eMAR note dated November 11, 2025 at 6:36 a.m. revealed the resident was sitting in the bed with no complaint of pain or discomfort.A review of Blood Pressure Summary record revealed that on November 11, 2025, at 7:04 a.m., Resident #135's blood pressure was 90/55 mmHg. Review of the MAR entry for November 11, 2025 revealed the resident's BP reading recorded at 8:00 a.m. was 103/65. Despite having a SBP of less than 130, the documentation in the MAR revealed Losartan was administered on November 11, 2025 at 8:00 a.m. scheduled time.The clinical record revealed no documentation why Losartan was administered outside of the physician ordered parameters; and that the physician was notified.The Blood Pressure summary report revealed that on November 11, 2025 at 8:40 a.m., the resident's blood pressure was 103/65 mmHg.The therapy progress note dated November 11, 2025 at 9:27 a.m. revealed the resident had a blood pressure of 63/39 mmHg and had visual and auditory hallucinations. Per the documentation, the resident reported feeling yucky; and that, the therapist immediately notified the registered nurse (RN) who confirmed resident had an extremely low blood pressure.The nursing progress note dated November 11, 2025 at 9:46 a.m. revealed that the resident's blood pressure was 69/45 mmHg; and, was hallucinating, anxious, was alert/ oriented x2. was unable to answer questions, had sweaty skin, and had trouble keeping her eyes open or moving positions from supine. The documentation also included that the resident reported she was tensed from stress and crasps she was feeling on her left side. Further, the documentation included the provider and resident's family were notified; and that, 911 was called to transport the resident to the hospital.The nursing progress note dated November 11, 2025 at 9:55 a.m., revealed that a report was called to the ER (emergency room).Another nursing progress note dated November 11, 2025 at 2:15 p.m. included Resident #135 was admitted to the hospital for hypotension.An interview was conducted on December 11, 2025, at 11:00 a.m. with a Licensed Practical Nurse (LPN/Staff #493) who stated that before giving a blood pressure medication like Lisinopril, he will confirm the blood pressure parameter, and if the resident's blood pressure was below the parameter, he will not administer the blood pressure medication. The LPN stated that another antihypertensive medication, such as metoprolol, would include a do not give order if the systolic blood pressure was less than 110 or the heart rate less than 60. Further, he said that he will follow the physician order including the ordered parameters because the physician knows their resident's best interest and safety.A phone interview with the primary physician (Staff #700) was conducted on December 12, 2025, at 11:02 a.m. The physician stated that he saw Resident #135 from her previous admissions at the facility, but did not see her in November 2025. He said he did not have a written note from November regarding the resident's admission orders; but, the facility follows the orders received from the hospital where the resident was admitted and then enters those orders into the resident's electronic record. Regarding Losartan, the physician stated this medication was typically prescribed for high blood pressure; and, if an order includes instructions to hold the medication at certain blood pressure levels, it is because the resident may have unstable (labile) blood pressure. He stated that that giving blood pressure medication when the resident's blood pressure is already low could cause it to drop further. He stated that if the resident's blood pressure was below the ordered parameters, Losartan should not have been given to Resident #135.A phone interview was conducted on December 12, 2025, at 11:42 a.m. with an RN (Staff #556), the nurse who administered Losartan to Resident #135 on November 11, 2025. The RN stated that medication administration includes following the five rights, verifying the right patient, right medication, right dose, right time, right route, and right documentation. He stated that giving blood pressure medications depends on the specific medication and the resident's condition. He said he checks the resident's blood pressure and heart rate, reviews the ordered parameters, and confirms it is safe to give the medication. He stated that if a resident's blood pressure is low, he would contact the provider and hold the medication with the provider's approval. Regarding Losartan, the RN stated he would check the resident's blood pressure first. If there was a hold order and the blood pressure was below or outside the ordered parameters, he would notify the provider, hold the medication, and document this in the medical record. He stated that not holding the medication could cause the resident's blood pressure to drop further. Regarding Resident #135, the RN stated he does not recall any incident in which a resident was sent out due to low blood pressure. He further stated that a systolic blood pressure in the 60s would typically present with signs and symptoms such as pale appearance, fatigue, sweating, lightheadedness, and increased heart rate and breathing as the body attempts to compensate.In an interview with the Director of Nursing (DON/Staff #301)conducted on December 12, 2025, at 12:16 p.m., the DON stated that staff were expected to follow physician orders when administering medications; and that, the impact of not following an order depends on the type of order and could place the resident at risk for side effects. Regarding blood pressure medications, the DON stated that medications should be given as ordered; and, if the order includes blood pressure parameters, staff must follow those parameters. She said that if a medication needs to be held, the nurse should notify the provider of the reason and document it in the clinical record. She stated that if a blood pressure medication with hold parameters is not followed, the resident's blood pressure could either increase or decrease. For medications such as Losartan, the DON stated that if there was a blood pressure parameter order, staff were expected to take the resident's blood pressure. She said that blood pressures were usually taken by certified nursing assistants (CNAs) around 7:00 a.m. or earlier, and the nurse then has one hour before or one hour after the scheduled 8:00 a.m. medication time to administer the medication. She stated that blood pressure readings were expected to be documented in the electronic record; and, if the nurse takes the blood pressure, it should be documented at the time of medication administration or before giving the medication when parameters apply. The DON also stated that medications such as Losartan can lower blood pressure. During the interview, a review of the clinical record was conducted with the DON who stated that Resident #135 had an order for Losartan with instructions to hold the medication if the systolic blood pressure was less than 130 mmHg. She further stated that on November 11, 2025, the resident's blood pressure was 103/65, and Losartan was administered. The DON stated that progress notes indicated Resident #135 went to physical therapy and began hallucinating. She further stated that the resident was sent to the hospital for hypotension.A review of the facility policy titled Physician Orders, revised in September 2025, revealed that it is their policy to accurately implement medication orders only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care; and, drugs shall be administered only upon the order of a person duly licensed and authorized.The facility policy on Medication Administration-Oral, revised in September 2025, revealed that it is their policy to accurately prepare, administer, and document oral medications, and when administering unit doses, identify resident eMAR orders, take vital signs if required, and hold drugs if indicated. The policy also included to no medication is to be administered without a physician's written order.

Based on the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure hand hygiene was performed and PPE was appropriately applied for one resident (Resident #9) , and infection control measures were implemented for a resident with a urinary catheter (Resident #71) and during a dressing change (Resident #166). This deficient practice can result in contamination and spread of infection. Findings include: Regarding Resident # 71 Resident #71 was admitted to the facility on [DATE], with conditions that included encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg above knee, long-term (current) use of anticoagulants, need for assistance with personal care, generalized muscle weakness, and cognitive communication deficit, hypertension, wound infection, and diabetes mellitus. A review of the admission Minimum Data Set (MDS) accepted November 30, 2025, revealed the resident had a Brief Interview Mental Status Score (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS also revealed the resident had an indwelling catheter, and was on antibiotic therapy. A review of the facility list of all current residents with catheter orders, revealed resident # 71 with an active order for catheter drainage bag was allowed to be changed every 12 hours as needed for standard of care if soiled or leaking. An observation was conducted on December 11, 2025, at 12:13 p.m., with Licensed Practical Nurse (LPN/Staff #417) of a urinary catheter contained in a privacy bag that was in direct contact with the floor while the resident was sleeping in bed. An interview was conducted on December 11, 2025, at 12:16 p.m. with LPN/Staff #417. The LPN stated that the urinary catheter drainage bag should never be placed on the floor and should be hung on the bed frame below bladder level or placed in a basin. The LPN stated that direct contact with the floor increases the risk of infection transmission and did not meet facility expectations. The LPN stated that at the time of observation, there was no basin or other barrier in place to prevent the catheter drainage bag from touching the floor. An interview was conducted on December 12, 2025, at 3:13 p.m. with Certified Nurse Assistant (CNA/Staff #442). The CNA stated that training on catheter care and infection prevention was provided upon hire, and that training included completion of a skills checkoff to ensure proper technique. The CNA stated that catheter drainage bags should never be allowed to touch the floor, as the floor is considered contaminated at all times; if the drainage bag contacts the floor, it is considered contaminated. The CNA stated that if a drainage bag touches the floor, it is thoroughly cleaned with alcohol, before it is rehung on the bed frame below the level of the bladder. The CNA stated that once the bag is properly secured, the nurse is immediately notified. The CNA revealed sometimes wash basins are used to help keep catheter drainage bags off the floor. The CNA stated that facility policy requires catheter drainage bags to be kept off the floor and below bladder level to promote urine flow and reduce the risk of infection. The CNA stated that there are typically no significant barriers to maintaining proper bag placement within the facility. However, the CNA stated that catheter clips do not always grip the bed frame securely, which can occasionally interfere with correct positioning. The CNA stated that improved or additional catheter clips would help prevent future catheter bag securement issues. A follow-up interview was conducted on December 12, 2025, at 3:20 p.m. with Licensed Practical Nurse (LPN/Staff #417). The LPN stated that they were not aware of any issues with catheter drainage bag clips. The LPN stated that the facility provides resident education on the importance of not lowering the bed in order to help keep the catheter drainage bag from contacting the floor. An interview was conducted on December 12, 2025, at 3:26 p.m. with the Infection Preventionist (IP/Staff #456). The IP stated that catheter drainage bags should be hung below the level of the bladder and must not touch the floor in order to reduce the risk of infection. The IP stated that if a drainage bag is touching the floor, a basin would be placed underneath the bag. The IP stated that the resident is independent with bed controls, which may have contributed to the drainage bag coming in contact with the floor. The IP stated that the facility had begun staff in-services earlier in the day to address catheter care and proper drainage bag placement. The IP stated that there have been no increasing trends in catheter-related infections at the facility. An interview was conducted on December 12, 2025, at 3:38 p.m. with the Director of Nursing (DON/Staff #301). The DON stated that the resident raises and lowers the bed independently. The DON stated that both the resident and staff were educated to ensure a basin is placed under the catheter drainage bag to prevent it from touching the floor. The DON stated that if a catheter drainage bag does touch the floor, it must be replaced to reduce the risk of infection. In regards to cleaning the drainage bag with alcohol, the DON was not able to answer the question, due to the need to review catheter drainage bag instructions. The DON stated that facility expectations for catheter care include strict adherence to infection control guidelines to prevent complications. Regarding Resident # 166 Resident # 166 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, unspecified, need for assistance with personal care, muscle weakness (generalized), and abdominal aortic aneurysm, without rupture, unspecified. A review of the Minimum Data Set (MDS), dated [DATE] revealed the resident entered the facility from a Short-Term General Hospital, with an admission date of December 5, 2025. The facility was within the window for Completion of the admission MDS. A review of the order summary revealed an active order start date of December 6, 2025 for the resident's right lower arm skin tear to be cleansed with Normal Saline, patted dry, apply xeroform and covered with a hydrogel dressing every day shift and as needed for if soiled or dislodged. Further review of the order summary did not reveal orders for enhanced barrier precautions. A review of the care plan revealed no focus or interventions for enhanced barrier precautions. A wound care observation was conducted on December 11, 2025 at 1:23 p.m. for a right lower arm skin tear with Wound Care Nurse (WCN/Staff # 478). The Staff #478 prepared the necessary items, including a folded pink absorbent pad, 4 x 4 gauze placed in a medicine cup and saturated with normal saline spray, one 5x9 petrolatum gauze cut in half, and a hydrogel dressing. Staff #478 gathered supplies from the wound care cart and placed the items on the tray table without first cleaning or sanitizing the tray table. The pink absorbent pad remained folded, with the dressing change supplies sitting on top of the absorbent pad. The old dressing was removed and placed in the trash, Staff #478 was observed with gloves and no protective gown. Staff # 478 washed hands again, and donned a yellow protective gown and fresh gloves before returning to the resident to complete the procedure. The wound was cleansed with Normal Saline, patted dry, petrolatum gauze was applied, and covered with a hydrogel dressing An interview was conducted on December 11, 2025, at approximately 1:30 p.m. with the Wound Care Nurse (WCN). Staff #478 reported experiencing significant nervousness during the wound care observation and stated that several steps were inadvertently missed. Staff #478 acknowledged that a protective gown should have been worn during removal of the prior dressing and throughout the new dressing change. Staff # 478 also admitted to forgetting to disinfect the table prior to placing the dressing change supplies and stated that this lapse constituted a break in infection control policy, which could contribute to the spread of infection. An interview was conducted on December 12, 2025 at 3:13 p.m. with CNA/Staff # 442. The CNA revealed that if a dressing falls off, it is the CNA's responsibility to notify the nurse. The CNA stated that when assisting with dressing changes they are expected to wear PPE, in order to decrease the chance of infection. An interview was conducted on December 12, 2025 at 3:20 p.m. with LPN/Staff # 417. The LPN stated the type wound to determine if a full gown is needed during the dressing change, such as contact precautions. The LPN continued that once dressing change supplies are gathered, the bedside table should be cleaned and sanitized, prior to laying down the barrier pad, and supplies. An interview was conducted on December 12, 2025 at 3:26 with the IP/Staff # 456. The IP stated infection control standards are to be maintained throughout the entire dressing change, which includes proper use of PPE. The IP explained that PPE is to protect everyone, and if a resident has an open wound, staff are expected to wear PPE based on the type of enhanced barrier precautions. The IP also stated that while preparing for a dressing change, the bedside table has to be cleared, cleaned, and sanitized with approved wipes in order to decrease the risk of contamination and spread of illness. An interview was conducted on December 12, 2025 at 3:38 p.m. with the DON/Staff # 301. The DON stated the facility expectation for dressing changes include following the provider orders, donning appropriate PPE, and maintaining infection control practices while handling dressing supplies. -Regarding Resident #9 Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrotomy, anoxic brain damage, anxiety, and dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #9's cognitive skills for daily decision-making were severely impaired. The MDS further revealed that Resident #9 has a nutritional approach via feeding tube. A care plan initiated on June 01, 2024, revealed a focus area for risk for infections related to an indwelling device. The goal indicated to mitigate the risk of pathogen transmission. Intervention included Enhanced Barrier Precautions (EBP) during the provision of close contact care. A physician's order dated August 08, 2025 prescribed EBP related to the PEG (Percutaneous Endoscopic Gastrostomy) tube. An incontinence care observation was conducted on December 09, 2025, at 9:33 AM. During the observation, Licensed Practical Nurse (LPN/Staff # 452) used the same gloves from the brief change to put on Resident #9's shirt. Further observation revealed that when Certified Nursing Assistant (CNA/Staff #445) assisted /Staff #452), gown was not completely covering his pants , which made contacted with Resident #9's mattress. An observation was conducted on December 12, 2025, at 9:55 AM. During the observation, a CNA (Staff # 471) repositioned the resident back to bed without wearing a gown. Additionally, staff #471 was not observed performing hand hygiene prior to and after Resident #9 was repositioned Staff #471 was observed touching another resident's wheelchair when she finally sanitized her hands. An interview was conducted on December 12, 2025, at 9:48 AM with a Certified Nursing Assistant (CNA/Staff #471) who stated that Resident #9 has bilateral soft mittens and abdominal covering to prevent him from pulling out his G-tube (Gastrostomy tube). Per Staff #471 staff need to sanitize their hands and wear PPE prior to entering residents' room to provide direct care. She noted that since Resident #9 has a G-tube, staff need to wear a gown and gloves during incontinence care. She admitted that when she repositioned Resident #9 back to bed, she did not wear a gown because the resident's stomach was not exposed and there was no direct care provided. An interview was conducted on December 12, 2025, at 2:10 PM with the Infection Control Preventionist (IP/Staff #306), who stated that during infection control meetings with staff, they discuss topics such as: Hand Hygiene, Enhanced Barrier Precautions (EBP), and Transmission-Based Precautions (TBP). She indicated that the type of precaution a resident is placed on is displayed on the side of the resident's door. She said that EBP is used for indwelling devices. Per Staff #306 staff should sanitize their hands before and after leaving a resident's room. Furthermore, when a task required physical contact, the staff need to gown up and wear gloves. She stated that it would not meet the facility's expectation for a staff member not to wear a gown when repositioning a resident with a G-tube because it can lead to a risk of infection. She said that she will conduct an in-service for her staff members to wear longer gowns or create a barrier when they are providing resident care. She noted that gowns protect the residents from infections. An interview was conducted on December 12, 2025, at 2:49 PM with the Director of Nursing (DON/Staff #301), stated that she along with the Infectious Disease Doctor, and IP discuss new infections, new policies, and trends. She noted that they brief their staff regarding the different types of infections, and hand hygiene. She said that staff should perform hand hygiene, wear a gown, and gloves during pericare. She noted that after pericare, staff need to remove their gown and gloves and perform hand hygiene because there can be feces or urine on the gloves. She said that if the gloves are not changed after each task, it can cause the G-tube area to get infected. Per the DON, the purpose of using gloves is to prevent infections. She stated that if a gown does not cover staff properly, then this can cause an adverse reaction, like an infection or rash, because staff clothing can carry feces or urine. She also stated that staff need to wash their hands if visibly soiled. A policy Titled Hand Hygiene Reviewed in July 2025 stated that hand hygiene prevents the transmission of possible infection. A policy titled IPCP (Infection Prevention and Control Program) Standard and Transmission - Based Precautions, directed to wear a gown and gloves for all interactions that may involve contact with the patient or the patient environment. This policy instructed to Don PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient's room to contain pathogens. This policy further stated that Enhanced Barrier Precautions applies to wounds and/or indwelling devices and the use of PPE for activities: Transferring, providing hygiene, changing briefs, feeding tube, and urinary catheter.

Based on observation, staff interviews, facility documents, and policy, the facility failed to ensure several residents' rooms were equipped with a working communication system to call for staff assistance. The deficient practice could place residents' safety at risk.Findings include:An observation in the behavioral unit was conducted on December 9, 2025 at 10:50 AM and revealed the call light in one room (#1) was on the floor behind the resident's bed and was out of reach.An observation of another room (#2) in the behavioral unit was conducted on December 9, 2025 at 1:33 PM, and there was no call light available for resident use. In a later observation of room (#1) conducted on December 9, 2025 at 3:20 PM, the same room (#1) continued to have the call light out of the resident's reach. The call light was on the floor behind the resident's bed.During a medication administration observation conducted on December 11, 2025, at 6:22 AM, an interview was conducted with a Licensed Practical Nurse (LPN/Staff #468) who stated that the behavioral unit was staffed with 1 nurse and 3-4 certified nursing assistants (CNAs) for 16 residents in the unit. He stated that when providing care to nonverbal residents, the staff do regular checks by rounding every 15 minutes and more often for residents with higher acuity. He stated that for residents who can verbalize their needs, the residents can use their call lights for assistance.An observation of resident rooms in the behavioral unit to check on the call lights was conducted with a CNA (Staff #459) on December 11, 2025 at 6:46 AM. In the bathroom of one resident room, the call light string was approximately 12 inches from the wall. The CNA stated that the bathroom call light was a short string; and, if the resident had a fall in the bathroom and was on the floor, the resident could not reach the call light string to alert staff for assistance. The CNA then proceeded to another bathroom of another resident room, and pulled the call light string; however, the light on the hallway outside of the resident's room was not lit up to indicate that the call light in the bathroom was pulled. The call button on the wall by the resident's bed in the same resident room was pushed. The light on the hallway outside of the same resident's room did not turn on. The CNA stated that the call lights were not working, and that, the light outside the room did not turn on. She further stated that if the call lights were not working, the residents would be in trouble. The CNA said that she will inform the maintenance staff that the call lights were not working on these 2 resident rooms.In an interview with the administrator (staff #300) conducted on December 12, 2025, at approximately 6:00 PM, the Administrator provided a Work Order document dated December 11, 2025, and another document with room numbers and a hand written note on top of the page that read, all call light strings and lights audited and corrected.Review of facility's policy titled Fall Management System, reviewed on September 2025, revealed that the facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible, through providing the resident with adequate supervision, assistive devices and functional programs as appropriate to prevent accidents.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#9) and/or the resident representative were informed of the risks and benefits of restraints prior to usage of abdominal binder, waist/seat belt restraint and bilateral mitt restraints. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and risks of restraints. The census was 109.Findings include:Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrostomy, anoxic brain damage, anxiety, and dementia. A behavior progress note dated October 22, 2022 revealed that a binder was placed over the resident's peg tube to prevent him pulling the peg tube out.Review of progress notes dated October 22, 2022 through February 24, 2025 revealed no evidence of a consent for the use of a binder from the resident's representative, or acknowledgement of risks/benefits.A care plan initiated on February 25, 2024, revealed a focus for physical restraints that included behaviors of putting self on floor, pulling at PEG tube, and history of pulling out PEG tube and PICC line. Interventions included abdominal support to secure feeding tube and prevent dislodgement, abdominal support belt to secure feeding tube and prevent dislodgement.Further review of progress notes dated February 25, 2024 through September 2, 2024, revealed no evidence of a consent for the use of an abdominal binder from the resident's representative, or acknowledgement of risks/benefits.A Restraint/Enabling Device/Safety Device Evaluation dated September 3, 2024, revealed that abdominal support garment was recommended to protect feeding tube and prevent dislodgement related to resident unintentionally removing feeding tube due to lack of awareness. The evaluation indicated that the abdominal support garment was a restraint. The evaluation further relayed that the benefits for the restraint related to potentially protecting the resident from injury, removing his feeding tube. The evaluation also indicated that consent was obtained from the resident's family member.A change of condition note, dated January 31, 2025, revealed that the G-tube was replaced per orders received from Nurse Practitioner. The note included that family was present on unit and aware of occurrence with good understanding, and the new abdominal binder was placed over site. A physician progress note dated February 10, 2025 revealed that an abdominal binder was in place. A behavioral progress note dated February 13, 2025, indicated that a G-tube was replaced, a new hand mitts and binder placed.Review of progress notes dated February 26, 2024 - August 24, 2025 revealed no evidence of Resident and/or Resident Representative consent for bilateral soft mitts, abdominal binder or seatbelt restraints. A March 4, 2025 behavior note revealed that the resident had been restless and agitated, posey mitts were in place and abdominal binder to protect G-tube site.A care plan initiated on May 21, 2025, revealed a focus for physical restraints that included the use of the bilateral soft wrist mittens related to Traumatic Brain Injury. Interventions included the use of a fastened seatbelt in a wheelchair, abdominal support to secure feeding tube and prevent dislodgement, ongoing evaluation for restraint risk/benefits, alternatives, and ongoing use.A May 21, 2025 Medication Administration Note was written to remove bilateral soft wrist mittens every 2 hours for 10 minutes for skin checks, check circulation, and ROM.An Assistive Device consent dated July 15, 2025, revealed consent for the use of restraints including an abdominal binder, bilateral soft mitts, and a seatbelt, related to behaviors of unintentionally removing the feeding tube, and impaired safety awareness. The potential benefits on the consent were listed as enhanced self-independence with transfers/bed mobility and increased feeling of safety and security. The potential risk on the consent was documented as accidental injury from the device. However, the risks/benefits listed on the consent form did not accurately reflect the risks/benefits of these restraints. Continued review of the clinical record revealed no evidence that the risk and benefits were explained to the resident and/or responsible party from July 16, 2025 through August 25, 2025. A behavior progress note dated April 16, 2025, revealed that resident was observed to be severely agitated, with increased incidents of pulling on feeding tube, and abdominal binder reinforced.A physician's order dated August 26, 2025, revealed the following orders: OK to have a seatbelt while in a wheelchair. Bilateral soft wrist mittens to prevent removal of medical device: Peg tube every shift A Restraint/Enabling Device / Safety Device Evaluation form dated August 26, 2025, revealed no evidence of all measures tried before implementing the recommended device. The device recommended portion of the evaluation, revealed that furniture was removed from the room and his mattresses were on the floor, specialized pro wheelchair with seatbelt, bilateral soft wrist mittens. The evaluation included that the device was considered a restraint, and placed due to the resident unintentionally removing the feeding tube, impaired safety awareness, inability to seat still related to traumatic brain injury, as the resident was unaware of what he was doing. The risk and benefits portion of the evaluation regarding what the device will enable the resident to do included, potentially protect resident from injury and enabled the resident to maintain proper body positioning/alignment. The benefits listed on the evaluation included improved mobility, improved comfort/safety and security, decreased anxiety, prevention of falls, improved posture/alignment, enhanced dependence, greater self-sufficiency, medical treatment allowed to proceed without resident interference, and decreased falls. However, the risks/benefits on this evaluation were not the same risks and benefits that were listed on the Assistive Device consent dated July 15, 2025. The evaluation did include that consent was obtained from the resident's family. Further review of the evaluation revealed no evidence of the risks related specifically to the use of the wrist and seatbelt restraints related to increased agitation, pressure ulcers, accidental injuries, loss of independent mobility, withdrawal/depression, death by strangulation, and suffocation.An annual IDT (interdisciplinary team) Care Plan Review dated September 2, 2025, revealed that the POA (power of attorney) was not present during the meeting for consent. The review included person-centered comprehensive care planning related to restraint, enabling device, safety device. Additional nursing plan of care notes in the review, included to continue with current plan of care, care plan updated. However, the review did not include specific changes to the resident's current restraints, or implementing less restrictive restraints. However, further review of the evaluation revealed documentation that the resident and/or Resident Representative agreed with the established plan of care, despite documentation that the Resident Representative was not present for the meeting.A September 17, 2025 Physician Progress note, revealed that bowel sounds were present in all four quadrants of the abdomen. the note did not include evidence regarding the use of the hand mitts or seat belt restraintsA Physician Progress Note dated October 20, 2025, revealed that abdominal bowel sounds were present in all four quadrants, and abdominal binder was in place, g-tube noted. However, the note did not include evidence regarding the use of the hand mitts or seat belt restraints.A Physician Progress Note dated November 5, 2025, revealed that abdominal bowel sounds were present in all four quadrants, and abdominal binder was in place. However, the note did not include evidence regarding the use of the hand mitts or seat belt restraints. A Quarterly Data Set Minimal Data Set (MDS) assessment dated [DATE], revealed no BIMS (brief interview of mental status) score; however, it did reveal that Resident #9's cognitive skills for daily decision-making were severely impaired. The MDS further revealed the resident's upper extremity was impaired on one side and that a wheelchair was used for mobility. The assessment revealed no evidence of restraint use In-chair or out-of-bed for trunk restraints and limb restraints, and no evidence of a trunk restraint used In-bed. A Restraint/Enabling Device / Safety Device Evaluation form dated November 25, 2025. The device recommended portion of the assessment revealed that furniture was removed from the room and his mattresses were on the floor, specialized pro wheelchair with seatbelt, bilateral soft wrist mittens. The evaluation included that the device was considered a restraint, and placed due to the resident unintentionally removing the feeding tube, impaired safety awareness, inability to seat still related to traumatic brain injury, as the resident is unaware of what he is doing. The risk and benefits portion of the evaluation regarding what the device will enable the resident to do included, potentially protects resident from injury and enables the resident to maintain proper body positioning/alignment. The benefits listed on the evaluation included improved mobility, improved comfort/safety and security, decreased anxiety, prevention of falls, improved posture/alignment, enhanced dependence, greater self-sufficiency, medical treatment allowed to proceed without resident interference, and decreased falls. However, the risks/benefits on this evaluation were not the same risks and benefits that were listed on the Assistive Device consent dated July 15, 2025. The evaluation did include that consent was obtained from the resident's family. Further review of the evaluation revealed no evidence of the risks related specifically to the use of the wrist and seatbelt restraints related to increased agitation, pressure ulcers, accidental injuries, loss of independent mobility, withdrawal/depression, death by strangulation, and suffocation. The evaluation revealed no evidence to indicate all measures that had been tried Before Implementing Recommended Device.A Physician Progress Note dated November 28, 2025, revealed that abdominal bowel sounds were present in all four quadrants, and abdominal binder was in place. However, the note did not include evidence regarding the use of the hand mitts or seat belt restraints.A Treatment Administration Record (TAR) dated December 2025, revealed evidence that bilateral soft wrist mittens and seatbelt were placed as ordered. However, there was no evidence on the TAR that the abdominal binder was placed, despite observations of an abdominal binder placed on the resident.A December 2, 2025 quarterly IDT Care Plan Review, revealed that the POA was present for the review for consent. not part of the review. However, the review indicated that the resident and/or Resident Representative agreed with the established plan of care, despite documentation revealing that the POA was not present during the IDT meeting. The review included person-centered comprehensive care planning related to restraint, enabling device, safety device. Additional nursing plan of care notes in the review, included to continue with current plan of care, care plan updated. However, the review did not include specific changes to the resident's current restraints, or implementing less restrictive restraints.An observation was conducted on December 09, 2025, at 9:13 AM. The resident was observed reclining in a wheelchair with bilateral soft mitts (limb restraint) applied to hands, an abdominal binder (trunk restraint) around the waist, and a seat belt (rising prevention restraint) fastened across his waist/lap. Another observation was conducted on December 11, 2025, at 7:02 AM. The resident was observed to be sitting in a reclining wheelchair with a seatbelt fastened around the resident's waist/lap, and bilateral mitts in place on his hands. Further observation of the resident was conducted on December 11, 2025, at 11:14 AM in the dayroom. The resident was observed to be wearing bilateral mitts on his hands, a seatbelt was fastened across his waist/lap while he was reclining in a wheelchair.An observation was conducted on December 12, 2025, at 3:21 PM with the Director of Nursing (DON). The resident was observed lying on his bed with bilateral mitts applied to his hands. At this time the DON asked the resident if he was able to take off the mitts, and the resident attempted to remove the mitts, but was unable to remove them from his hands.An interview was conducted on December 12, 2025, at 10:04 AM with a Licensed Practical Nurse (LPN/Staff # 417), who stated that Resident #9 started using bilateral soft mittens on August 26, 2025, because he tends to pull the G-tube. He further stated that the seat belt on the wheelchair was used to prevent the resident from falling. He also stated that the Assistive Device Consent form had not been updated to show the benefits and risks of the current restraints. He then stated the benefit of the abdominal binder and soft mitt use was to prevent the resident from removing the G-tube, and to allow the resident to receive nutrition through the tube feeding. He further stated that the benefit of using a fastened seatbelt in a wheelchair would include the prevention of falls. The LPN further stated that the risk of using the restraints could result in the resident pulling on the G-tube causing trauma and possible return to the hospital. He stated that there was no documentation that the family were informed/educated before the consent was obtained. An interview was conducted on December 12, 2025, at 2:49 PM with the Director of Nursing (DON/Staff #30), who stated that the Assistive Device form was discussed with Resident #9's family who was aware. A policy titled, Informed Consent, revised May 2025, revealed that it is the facility policy that resident rights are not violated and a copy of these rights are made available to the resident and to any representative of the resident. The policy indicated that the rights included the right to receive in advance all information that is material to a decision to accept or refuse treatment. A policy titled, Restraints, Physical/Safety Devices, revised May 2025, included that it is the policy of the facility that the resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to that the resident's medical symptoms. The policy relayed that a physician's order is necessary for the use of a physical restraint. The policy also relayed that the faiclty must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use.

Based on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation were conducted for the least restrictive alternatives for the least amount of time and conduct ongoing evaluations of the need for physical restraints for one resident (Resident #9). The deficient practice could result in the resident not able to use a less restrictive alternative. The census was 109. Findings include:Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrostomy, anoxic brain damage, anxiety, and Dementia.A behavior progress note dated October 22, 2022 revealed that a binder was placed over the resident's peg tube to prevent him pulling the peg tube out.A nursing progress note dated October 23, 2022, revealed the patient tried to pull out a PICC line and tube feeding while he was in a geri-chair and he required 1-2 staff members to be with him just to keep him safe.A physician progress note dated February 10, 2025 revealed that an abdominal binder was in place.Review of progress notes dated February 25, 2024 - August 24, 2025 revealed no evidence of Resident and/or Resident Representative consent for bilateral soft mitts, abdominal binder or seatbelt restraintsA behavioral progress note dated February 13, 2025, indicated that a G-tube was replaced, and new hand mitts and binder placed.A March 4, 2025 behavior note revealed that the resident had been restless and agitated, posey mitts were in place and abdominal binder to protect G-tube site.A December 2, 2025 quarterly IDT Care Plan Review, revealed that the POA was present for the review for consent. not part of the review. However, the review indicated that the resident and/or Resident Representative agreed with the established plan of care, despite documentation revealing that the POA was not present during the IDT meeting. The review included person-centered comprehensive care planning related to restraint, enabling device, safety device. Additional nursing plan of care notes in the review, included to continue with current plan of care, care plan updated. However, the review did not include specific changes to the resident's current restraints, or implementing less restrictive restraints.A Care Plan initiated on May 21, 2025, revealed a focus for physical restraints that included the use of the bilateral soft wrist mittens related to Traumatic Brain Injury. Interventions included the use of a fastened seatbelt in a wheelchair, abdominal support to secure feeding tube and prevent dislodgement, ongoing evaluation for restraint risk/benefits, alternatives, and ongoing use.A physician's order dated August 26, 2025, revealed the following orders:OK to have a seatbelt while in a wheelchair.Bilateral soft wrist mittens to prevent removal of medical device: Peg tube every shiftA Restraint/Enabling Device/Safety Device Evaluation form dated August 26, 2025, included a device recommended portion of the evaluation, which revealed that furniture was removed from the room and his mattresses were on the floor, specialized pro wheelchair with seatbelt, bilateral soft wrist mittens. The evaluation included that the device was considered a restraint, and placed due to the resident unintentionally removing the feeding tube, impaired safety awareness, inability to seat still related to traumatic brain injury, as the resident was unaware of what he was doing. However, the evaluation revealed no evidence that alternatives were attempted, prior to the use of the wheelchair seat belt and bilateral soft mitt restraints. An annual IDT (interdisciplinary team) Care Plan Review dated September 2, 2025, included person-centered comprehensive care planning related to restraint, enabling device, safety device. Additional nursing plan of care notes in the review, included to continue with current plan of care, care plan updated. However, the review did not include specific changes to the resident's current restraints, or implementing less restrictive restraints.A Quarterly Data Set Minimal Data Set (MDS) assessment dated [DATE], revealed no BIMS (Brief Interview of Mental Status) score; however, it did reveal that Resident #9's cognitive skills for daily decision-making were severely impaired. The MDS further revealed the resident's upper extremity was impaired on one side and that a wheelchair was used for mobility. The assessment revealed no evidence of restraint use In-chair or out-of-bed for trunk restraints and limb restraints, and no evidence of a trunk restraint used In-bed.A Restraint/Enabling Device/Safety Device Evaluation form dated November 25, 2025, included that the device was considered a restraint, and placed due to the resident unintentionally removing the feeding tube, impaired safety awareness, inability to seat still related to traumatic brain injury, as the resident is unaware of what he is doing. However, the evaluation revealed no evidence that alternatives were attempted, prior to the use of the wheelchair seat belt and bilateral soft mitt restraints. A December 2, 2025 quarterly IDT Care Plan Review, included person-centered comprehensive care planning related to restraint, enabling device, safety device. Additional nursing plan of care notes in the review, included to continue with current plan of care, care plan updated. However, the review did not include specific changes to the resident's current restraints, or implementing less restrictive restraints.An observation was conducted on December 09, 2025, at 9:13 AM. The resident was observed reclining in a wheelchair with bilateral soft mitts (limb restraint) applied to hands, an abdominal binder (trunk restraint) around the waist, and a seat belt (rising prevention restraint) fastened across his waist/lap. Another observation was conducted on December 11, 2025, at 7:02 AM. The resident was observed to be sitting in a reclining wheelchair with a seatbelt fastened around the resident's waist/lap, and bilateral mitts in place on his hands. Further observation of the resident was conducted on December 11, 2025, at 11:14 AM in the dayroom. The resident was observed to be wearing bilateral mitts on his hands, a seatbelt was fastened across his waist/lap while he was reclining in a wheelchair.An interview was conducted on December 12, 2025, at 10:04 AM with a Licensed Practical Nurse (LPN/Staff # 417), who stated that Resident #9 started using bilateral soft mittens on August 26, 2025, because he tends to pull the G-tube. He stated that there have not been any other alternatives to minimize the use of the abdominal binder and the bilateral mitts. An interview was conducted on December 12, 2025, at 2:49 PM with the Director of Nursing (DON/staff # 30), who stated that the Interdisciplinary Team (IDT) consists of: Medical Director, Unit Manager, Minimum Data Set (MDS) Coordinator, Wound Nurse, and Administrator. She further stated that the (IDT) will review the need for the restraints. She further stated that there were no alternative measures used for the restraint documented in the Restraint/Enabling Device/Safety evaluations dated May 21, 2025, July 15, 2025, August 26, 2025, and November 25, 2025.A policy titled, Restraints, Physical/safety Devices, revised May 2025, revealed that the facility must explain alternatives to restraint use. The policy included that medical symptoms that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments, and care plans.

Based on clinical record review, staff interviews, and policy and procedure review, the facility failed to ensure a thorough investigation of an allegation of neglect was completed for one resident (#9). The census was 109. The deficient practice could result in incomplete investigations of allegations of abuse.Findings included: Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrotomy, anoxic brain damage, anxiety, and dementia. A Comprehensive Data Set Minimal Data Set (MDS) assessment, dated November 04, 2022, revealed no BIMS (Brief Interview of Mental Status) score; however, it did indicate that Resident #9's cognitive skills for daily decision-making were severely impaired. A change in condition note dated November 06, 2022, at 16:59 revealed that Resident #9 made multiple attempts to put himself on the ground from his geri (geriatric) chair. The note further revealed that the resident had mats in his room and a helmet on for his safety. The note also revealed that he was restless. A behavioral note dated November 07, 2022, at 0:43 revealed that Resident # 9 made multiple attempts to roll out of his geri chair, rolled around his mat, crawling around his room.A behavioral note dated November 09, 2022, at 1:14 revealed that Resident #9 was restless in bed and crawled around his room. Review of clinical records revealed that Resident #9 obtained a fracture with unknown date; and that, in the facility's investigation no resident interviews were conducted, or the location suspected to have occurred.A Transfer Out note dated November 17, 2022, at 22:25 revealed that resident had an X-ray done on the left hand due to swelling. The note further revealed that he had a fracture of the distal radial metaphysis and new orders for him to be sent out to the hospital for evaluation and treatment. A physician's progress note dated November 18, 2022, at 15:46 revealed that Resident #9's X-ray showed a left distal radius fracture; and that, Resident #9 had fall due to behaviors, and underlying anoxic brain injury. A 5-day investigation dated November 18, 2022, revealed that seven nursing staff members, consisting of Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN), were interviewed. This 5-day investigation further revealed there were no resident that were interviewed as potential witnesses. This 5-day investigation did not indicate where or how the resident fractured the distal radial metaphysis. An interview was conducted on December 12, 2025, at approximately 10:00 AM with the Administrator (Staff #300), who confirmed that he was the facility's abuse coordinator. Staff #300 stated that the residents in the behavioral unit have a diagnosis of Alzheimer's, dementia, and schizophrenia. Staff #300 stated he was not administrator at the time of the incident, however that the residents in this unit have cognition status varieties, for example, some residents are able to hold a conversation, while others are not able to. He then stated that the process during an investigation is to make sure that the residents are safe, conduct interviews with potential witnesses, and staff members who have worked with the residents. Staff #300 stated that the provider, family, and other state agencies would be notified. He then stated that in the behavioral unit, there isn't much interviewing conducted with the resident because of their mental judgment. He further stated that if the residents can hold a conversation and are witnesses to the incident, then they would be interviewed. He then stated that the investigation for this complaint included the staff members and family interviews. He then stated that it seems as though the incident happened in the residents' room, and there was no witness, so that's why residents' interviews were not conducted. He then stated that in their policy, it states that they should interview witnesses, residents, and the person affected. A policy title Abuse: Prevention of the prohibition against was revised in September 2024 and revealed that An interview with the person(s) reporting the incident and an interview with resident(s).

Based on clinical record review, staff interview, the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that on residents Minimum Data Set (MDS) assessment regarding restraints was accurate. The deficient practice could result in inaccurate documentation of the resident's medical history and needs. The census was 109. Findings include:Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrotomy, anoxic brain damage, anxiety, and dementia. A behavioral progress note dated February 13, 2025, indicated that a G-tube was replaced, a new hand mitts and binder placed.A March 4, 2025 behavior note revealed that the resident had been restless and agitated, posey mitts were in place and abdominal binder to protect G-tube site.A Care Plan initiated on May 21, 2025, revealed a focus area for physical restraints documenting the use and the bilateral soft wrist mittens related to traumatic brain injury. This care plan also revealed an intervention placed for the use of a fastened seatbelt in a wheelchair. This care plan revealed an intervention for abdominal support to secure the feeding tube and prevent dislodgement. A physician's order dated August 26, 2025, revealed an order for OK to have a seatbelt while in a wheelchair.A physician's order dated August 26, 2025, revealed an order for removal of bilateral soft wrist mittens every 2 hours for 10 minutes for skin check, check circulation, and range of motion (ROM). An annual IDT (interdisciplinary team) Care Plan Review dated September 2, 2025, included person-centered comprehensive care planning related to restraint, enabling device, safety device. Additional nursing plan of care notes in the review, included to continue with current plan of care, care plan updated. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident's cognitive skills for daily decision-making were severely impaired. The MDS also revealed that the mobility device used by the resident was a wheelchair. The assessment revealed no evidence of restraint use In-chair or out-of-bed for trunk restraints and limb restraints, and no evidence of a trunk restraint used In-bed. A Restraint/Enabling Device / Safety Device Evaluation form dated November 25, 2025. The device recommended portion of the assessment revealed that furniture was removed from the room and his mattresses were on the floor, specialized pro wheelchair with seatbelt, bilateral soft wrist mittens. The evaluation included that the device was considered a restraint, and placed due to the resident unintentionally removing the feeding tube, impaired safety awareness A Treatment Administration Record (TAR) dated December 2025, revealed evidence that bilateral soft wrist mittens and seatbelt were placed as ordered.A December 2, 2025 quarterly IDT Care Plan Review, revealed that the review included person-centered comprehensive care planning related to restraint, enabling device, safety device. Additional nursing plan of care notes in the review, included to continue with current plan of care, care plan updated. However, the review did not include specific changes to the resident's current restraints, or implementing less restrictive restraints.An observation was conducted on December 09, 2025, at 9:13 AM. The resident was observed to be in a reclining wheelchair with bilateral soft mitts, an abdominal binder, and a seat belt. An observation was conducted on December 11, 2025, at 7:02 AM. The resident was observed to be in a reclining wheelchair with a seatbelt and wearing bilateral mittens. An observation was conducted on December 11, 2025, at 11:14 AM in the dayroom. Resident # 9 was observed to be wearing bilateral mitts and had a fastened seat belt in the reclining wheelchair.An observation was conducted on December 12, 2025, at 3:21 PM. While in bed, Resident # 9 was unable to take off his shirt and bilateral soft mitts. An interview was conducted on December 12, 2025, at 9:06 AM with the MDS Coordinator (Staff #313), who stated that the information used to complete the MDS includes assessments, notes, and the Assessment Reference Date (ARD). She then stated for the MDS for the Restraints and Alarms section, Used in chair or out bed for Truck restraints, it was marked Not used and should be marked daily. She further said that the MDS dated [DATE], was inaccurately completed regarding the use of the abdominal binder and bilateral soft mitts. An interview was conducted on December 12, 2025, at 2:49 PM with the Director of Nursing (DON/staff # 301), who stated that the Interdisciplinary Team (IDT) consists of: medical director, unit manager, (MDS) coordinator, wound nurse, and administrator. She further stated that IDT will review the need for restraints. She then stated that Resident #9 had bilateral mites and an abdominal binder because he pulled out his g-tube. She further stated that Resident #9 has a seat belt on while in a wheelchair so that he does not harm himself. She also stated that she would expect the MDS to be accurate. A policy titled, Resident Assessments and Associated Processes, revised or reviewed December 2024, included that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. revealed that it refers to the Long-Term Care Facility Resident Assessment instrument 3.0 User's Manual Version 1.18.22 October 2023. The Centers for Medicare & Medicaid Services' Long Term Care Facility Resident Assessment Instrument (RAI), dated October 2023 revealed that the Federally mandated MDS is the basis for an accurate assessment of nursing home residents.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the state mental health authority was notified of a resident's change in mental condition for one resident (#37). The deficient practice could result in residents not receiving the proper level of care to meet their needs.Findings Include:Resident #37 was admitted to the facility on [DATE] with diagnosis that included atherosclerotic heart disease, bipolar disorder, and colostomy status. A Level 1 Pre-admission Screening and Resident Review (PASARR) dated February 25, 2025 was completed with no referral was necessary for PASARR Level 2. Further review of the PASRR revealed that the Bipolar Diagnosis was not included. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident was congenitally intact. Further review of the MDS revealed no psychiatric or mood disorders and special treatment which included Hospice therapy. A Level 1 PASRR dated April 7, 2025 was completed including the Bipolar Disorder (Manic Depression) diagnosis. An e-mail dated April 14, 2025 from the state mental health authority revealed that Resident #37 met the terminal illness exemption and did not require a Level 2 PASARR due to a terminal illness with life expectancy of less than 6 months and also received hospice care. A Quarterly MDS assessment dated [DATE], revealed a diagnosis of Bipolar disorder with no psychological services, The MDS also revealed that Resident #37 continued to be on Hospice services. A Hospice discharge-transfer summary dated July 21, 2025, revealed that Resident #37 was discharged from hospice care on July 18, 2025 due to extended prognosis. A Nursing Progress note dated August 3, 2025 revealed that Resident #37 was refusing medications the last few days. The progress note goes on to reveal that the Resident became teary eyed that weekend, refusing some meals. Resident # 37 continued to cry and ask why do you treat me like this? It was documented in the Progress note that the nurse had another staff member in the room because resident would make false accusations.A review of the comprehensive care plan initiated on August 4, 2025 revealed that Resident #37 had a potential for a behavior problem related to bipolar disorder, resistive to care, and making false accusations against staff. A Significant Change of Condition MDS assessment dated [DATE], revealed an active diagnosis of Bipolar disorder, no psychological services and no Hospice Care. Multiple medication administration notes on August 13, 2025 revealed that Resident #37 started refusing to take her medication stating If the Holy Spirit wants to heal me he will or I will go home. It was also revealed that the resident's primary care physician was notified and psychological services were notified.An order for psychological services was given on August 13, 2025 for psychological services. A psychiatric note dated August 13, 2025 revealed that Resident #37 did have a urinary tract infection which could be contributing to her recent change in behavior and delusional thinking. A psychiatric note dated August 22, 2025 revealed a recommendation for a mood stabilizer such as lamotrigine to treat bipolar depression which Resident #37 declined.There was no evidence in the resident's clinical records of an updated Level 1 PASARR Screening following being discharged from Hospice on July 18, 2025, or the Significant Change of Condition on August 8, 2025 with unstable behavioral symptoms noted on August 13, 2025. An interview was conducted on December 12, 2025 at 10:12 a.m. with the Social Services Director (Staff # 311) who stated that every patient should have an admission PASSR when they enter and then they continue to monitor changes in behaviors and medications and adjust the care plan as needed. She goes on to reveal that it is the Interdisciplinary team to go over the review of medication and behavior changes and then update then Staff #311 would update PASARR as needed. After reviewing Resident #37's chart Staff #311 stated that a PASARR was done on April 7, 2025 and it was determined that the resident did not need PASARR 2 because she was on hospice. Staff #311 reviewed the chart further and stated that Resident #37 was no longer on Hospice as she was discharged on July 18, 2025. Staff #311 indicated that as a change of condition and stated that she should have resubmitted the PASARR for a change of condition determination. Staff #311 revealed that she did not know what it was not resubmitted for PASARR 2 determination. An interview was conducted with the Director of Nursing (DON/Staff # 301) on December 12, at 1:43 p.m. who stated that all residents get a PASSAR screening done in the hospital when they are admitted and around 30 days into their stay we do another PASARR determination and after that if there no recommendation for a PASARR level 2 we would do one if there is a change of condition. The DON also stated that if we determine there is a change of condition physically or behaviorally then Social Services would resubmit the PSARR with the change of condition for determination of PASARR level 2. The DON reviewed Resident #37's chart and stated the resident was screened on April 7, 2025 and it was determined that the resident did not need PASARR level 2 services because she was considered terminal and on hospice with under 6 months to live. The DON revealed that Resident #37 was no longer under as of July 18, 2025. The DON stated that no longer being on Hospice would be a change of condition in the MDS world. The DON also revealed that it is her expectation is what ever the facilities policy is regarding PASARR submission. Review of a policy titled, Resident Assessment PASRR, reviewed May 2025, revealed that it is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. The policy also revealed that the facility will refer to the state's AHCCCS PASSAR policy. Review of a policy titled, AHCCCS Medical Policy Manual - Pre-admission Screening and Resident Review (PASRR), revealed that a request for PASRR Level 2 evaluation is not required for individuals with a terminal illness and has a life expectancy less than six month, and there is not a current risk to self or others and behaviors/symptoms are stable. The policy also revealed that the facility was required to request Resident Reviews for individuals experiencing a Significant Change in condition as specified in Section 1919(e)(7)(B)(iii) of the Social Security Act. The policy revealed that the facility was required to submit a new Level 1 Screening to AHCCCS or DES/DDD within 14 calendar days after the facility determined through the MDS assessment that there had been a Significant Change in the resident ' s mental condition (42 CFR 483.20). The policy revealed that the submitted documentation would be reviewed to determine if another PASRR Level 2 evaluation was needed.

Number of residents sampled:Number of residents cited: 1Based on observations, record review, staff interviews, review of facility documents, policy, [NAME] Nursing Drug Book, and Medlineplus.gov website, the facility failed to ensure medications for one resident (#14) were administered as ordered by the physician and according to accepted standards of clinical practice. The deficient practice could place residents' safety at risk.Findings include:Resident #14 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, hypoglycemia, and Post-Traumatic Stress Disorder.The care plan dated December 7, 2023, revealed the resident had Diabetes Mellitus. The interventions included diabetes medication as ordered.A physician order dated February 6, 2024 revealed an order for Metformin Hydrochloride (HCL) 500 MG tablet give one tablet by mouth with meals for diabetes. And, another physician order with a revision date of July 16, 2024 revealed an order to OK to crush and combine crushable medications and mix with applesauce/pudding or drink.On December 11, 2025, at 6:20 AM, a medication administration observation was conducted with a Licensed Practical Nurse (LPN/Staff # 468). Staff #468 prepared Metformin 500 milligram (MG) one tablet. Staff #468 crushed the Metformin tablet and mixed it with a spoon of pudding in the medication cup, and then administered the medication to Resident #14 in her room.A review of the Medication Administration Record (MAR) for December 2025, revealed Metformin HCL 500 MG tablet give one tablet by mouth with meals for diabetes with an order date of February 6, 2024 and a scheduled time of 7:00 AM was transcribed in the MAR. Per the MAR, the medication Metformin HCL 500 MG was administered to Resident #14 on December 11, 2025, without a breakfast meal despite an order to give the medication with meals. According to the facility's meal times schedule, the breakfast tray cart for the behavioral unit was scheduled for 7:10 AM.While waiting for additional medication administration observation with Staff #468, an interview was conducted on December 11, 2025 at 6:22 AM with Staff #468. Staff #468 stated that there was only one medication cart in the behavioral unit and the medication storage is shared with the west side unit. He stated that Resident #14 preferred taking her medication with a pudding and her water was located at bedside. Staff #468 stated that he administers medication one hour before and one hour after the schedule time. He said that breakfast trays in his unit are delivered between 7:00 AM to 7:15 AM. An interview was conducted on December 11, 2025, at 11:00 AM with an LPN (Staff #493). Staff #493 stated that a physician order such as give medication with meals meant give medication with meals. He stated that in the computer system for documenting medication, the medications scheduled to give with meals were scheduled according to scheduled meal times, and as long as the resident can eat. He stated that a pudding in a medication cup mixed with the resident's pill was not considered a meal, and he stated that it was just the way the residents take their medication.Another interview was conducted with an LPN (Staff # 482) on December 11, 2025 at 11:38 AM. She stated that a medication with an order to give with meals such as with a medication like Metformin would be given with a meal. She stated that it mostly meant to give with the meal coming, or give it when the meal was getting delivered. She stated that an apple sauce or a pudding with medication could be due to a swallowing issue or due to swallowing a big pill, and the apple sauce or a pudding with the medication was something to take it with.A follow up interview was conducted on December 11, 2025 at 12:28 PM with LPN (Staff #468). Staff #468 stated that an order to give with meals meant to be given with meals such as breakfast, lunch, or dinner. He stated that a spoonful of pudding was not a meal. He stated that regarding Resident #14's Metformin medication to give with meals, he stated that he gave the metformin medication at 7:00 AM, he stated that the common practice for the resident was refusing meals, and today the resident refused breakfast and she received her metformin medication. He stated that he would still administer the resident's Metformin medication for a resident with diabetes who refuses a meal. He stated that he would call a physician to clarify an order if there was a conflict found in the order. He stated that he would generally call the physician if a resident refused to take the medication. He stated that he would not call a physician for Metformin ordered with meals, and would not call the physician because sometimes residents don't take their medication related to their behavior.In an interview conducted on December 12, 2025 at 12:16 PM with the Director of Nursing (DON/Staff # 301). The DON stated that the process and expectation regarding medication administration would be that she expects the nurse to follow the physician's orders, and the process is to follow the physician's orders. She stated that the impact if an order was not followed would depend on the type of the order and the risk for the residents would be possible side effects. The DON stated that the process and expectation for an order with an instruction to give medication with meals meant that nursing staff administer the medication with the meal or directly following a meal. She considered breakfast, lunch, or supper a meal, a spoon of applesauce or a pudding would not be a meal, and a resident receiving their medication with applesauce or pudding would be due to swallowing disorder or a resident's preference, and she would not consider it as a meal. Regarding Resident #14, the DON stated that the order for Metformin was to give with meals.According to [NAME] Nursing Drug Handbook, Metformin is used for management of type 2 diabetes mellitus. Regarding administration and handling, give with meals to decrease gastrointestinal (GI) upset.The medlineplus.gov website last revised on February 15, 2024, Metformin is used alone or with other medications, to treat type 2 diabetes. Metformin helps to control the amount of glucose (sugar) in your blood. It decreases the amount of glucose you absorb from your food and the amount of glucose made by your liver. The regular tablet is usually taken with meals two or three times a day. Metformin may cause side effects such as diarrhea, nausea, stomach discomfort, gas, indigestion, constipation.A review of the facility policy titled Physician Orders, revised in September 2025, revealed that it is the policy of the facility to accurately implement medication orders only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.Another review of the facility policy titled Medication Administration-Oral, revised in September 2025, revealed that it is the policy of the facility to accurately prepare, administer, and document oral medications, and when administering unit doses, identify resident eMAR orders, take vital signs if required, and hold drugs if indicated.

Based on observations, staff interviews, and the facility's policy and procedures, the facility failed to ensure that food items were properly stored and dated to meet safety standards. The deficient practice could result in loss of nutritive value and increase the risk of foodborne illness. Findings include:An initial kitchen observation was conducted on December 9, 2025, at 8:20 a.m. with the Dietary Supervisor (Staff/#308). The following were observed in the walk-in refrigerator:Salad bag opened, exposed to air, and labeled with open and use by dates of 12/6-12/121lb ground beef, without an open or use-by date Employee lunch bag on the shelfBoiled eggs container opened, exposed to air9 unlabeled and undated juice cups1lb bag of green beans opened, exposed to air bag of lettuce opened and exposed to air During a follow-up Kitchen Observation conducted on December 11, 2025, at 6:26 a.m., two sheet cake pans were observed uncovered on the prep counter. A tray line temperature check and observation conducted on December 11, 2025, at 11:46 am revealed the following:12/11/2025 11:40 AM cake dessert- 52 degrees Fahrenheit (F)12/11/2025 11:42 AM cake dessert #2 - 55 degrees F12/11/2025 11:43 AM milk - 46 degrees F12/11/2025 11:43 AM milk #2- 47 degrees F12/11/2025 11:43 AM apple juice - 45 degrees F12/11/2025 11:43 AM diced peaches - 48 degrees F12/11/2025 11:44 AM applesauce - 48 degrees F12/11/2025 11:44 AM watermelon - 48 degrees F12/11/2025 11:45 AM mechanical soft/moist pears - 56 degrees F During an observation conducted on December 11, 2025, at 11:54 AM, a Dietary Aide (Staff #488) was observed placing a personal water bottle on the bottom shelf of the food prep table.An observation of the unit refrigerators was conducted on December 11, 2025, at 1:41 p.m. with (Staff/#308). The unit refrigerator's posted cleaning schedule documented that it was not cleaned on December 10, 2025. Additionally, the fridge contained a paper plate covered with a napkin containing a half-eaten sandwich. (Staff/#308) identified the sandwich as an employee's lunch. Per staff #308, staff stated lunches should not be placed in the unit refrigerators with medications and that they know better. (Staff/#308) noted that the risks of placing personal food in the unit refrigerators is that it can cause cross-contamination. Further observation of the unit refrigerator revealed juice spills located on the shelves and the bottom of the unit refrigerator.An interview was conducted on December 12, 2025, at 1:07 PM with the Dietary Supervisor (Staff/#308). Staff #308 stated that the facility's process for storing food is to label and date all food items and to ensure all food items are properly closed. Staff #308 stated she is responsible for ensuring staff label and date food items. However, there is no set schedule for conducting these observations. Staff #308 stated that she randomly conducts observations of the refrigerator, freezer, and dry storage. Staff #308 stated that the risk of not properly storing or dating food items is that it places residents at risk for food-borne illness from bacterial growth that can cause stomach issues or diarrhea. Staff #308 stated that staff should place their food items in the designated refrigerator for staff located in the break room to prevent cross-contamination. Staff #308 stated that milk should have been at 40 degrees, cold desserts and juices should have been at 42 degrees and under. Per staff #308, the risks of higher temperatures for these foods are bacterial growth, which can cause residents to get sick from it or cause diarrhea. Review of the facility policy titled Food Storage and Date Marking states that sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry, and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination.e. TCS (Time/Temperature Control for Safety) foods should be covered, labeled, and dated if stored and not for immediate use. All foods will be checked to assure that foods (including leftovers) will be consumed by their use-by dates, or frozen (where applicable), or discarded, at the end of the day. Use-by dates for TCS foods are 7 days or less from the prep date.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#10) right to be free from physical abuse from another resident (#8). The deficient practice could result in physical and psychosocial harm.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment. Additionally, the assessment revealed Resident #10 had no hallucinations, no delusions, no inattention, no disorganized thinking, and no altered level of consciousness.Resident #10's care plan was reviewed and revealed no evidence of physical or psychosocial monitoring related to an allegation of physical abuse from another resident.The assessment list of Resident #10's medical record was reviewed and revealed no assessments completed on October 31, 2025, or November 1, 2025.A Behavior Note dated October 31, 2025, revealed Resident #10 went outside with other residents at lunch to eat pizza and sweets. Additionally, the note revealed that Resident #10 went into the main dining area at 2:00 P.M. with other residents from the facility to join in on a Halloween party, and once she came back, she joined others in the common area until the evening. The note revealed Resident #10 was pleasant, cooperative, and did not have any behaviors. There was no evidence of documentation of a resident to resident altercation or assessment of the resident afterward.The clinical record was reviewed and revealed no evidence of change of condition monitoring, no head to toe assessment or other skin assessment, and no documentation regarding a resident to resident altercation on October 31, 2025.A Behavior note dated November 4, 2025, revealed that Resident #10 was in the common area and demanded that the staff get all of management to come talk to her. The note revealed that Resident #10 claimed it was an emergency. The note revealed she was given a chance to calm down on her own. The note revealed no evidence that the facility management met with the resident per her request.A Nursing note dated November 6, 2025, at 2:33 P.M. revealed that a nurse received notification that Resident #10 may have been accidentally struck. The note revealed no evidence of any other details regarding what occurred or when. The note revealed that the nurse attempted to assess the resident, and the resident refused.Regarding Resident #8 (alleged perpetrator):Resident #8 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, violent behavior, schizophrenia, and autistic disorder.A quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 12, indicating moderate cognitive impairment. Additionally, the assessment revealed Resident #8 had no hallucinations, no delusions, no inattention, no disorganized thinking, and no altered level of consciousness.A care plan dated May 8, 2025, revealed Resident #8 had potential for a behavior problem due to verbal aggression. Interventions included to document behaviors, to intervene as necessary to protect the rights and safety of others, and to discuss the resident's behavior and explain why the behavior is inappropriate or unacceptable.A Physician Progress Note dated October 29, 2025 revealed that Resident #8 was currently residing in the behavioral unit of the facility, as she was previously admitted to the hospital for aggressive behavior.A Behavior Note dated October 31, 2025, at 3:49 P.M. revealed that Resident #8 became upset when she returned to the unit from the Halloween party because she was educated that she cannot eat all of her candy at once due to her elevated blood sugars. The note revealed that Resident #8 made accusatory statements toward the staff of a sexual and physical nature, and that Resident #8 was currently in Cares in Pairs and this was unfounded. The note revealed that Resident #8 was not responsive to de-escalation techniques. Also, the note revealed that at that time, the provider ordered intramuscular Ativan injection when all other de-escalation methods were unsuccessful. The note revealed no evidence of a resident to resident altercation or that the resident was assessed for injury afterward.A Psychiatric provider note dated October 31, 2025, at 4:00 P.M. revealed that staff reported that Resident #8 was currently having agitated and aggressive behavior, and that Resident #8 became angry and agitated toward staff and other residents. The note revealed that per staff, Resident #8 began making threatening statements about other residents in the day room. Additionally, the note revealed that the provider overheard Resident #8 make accusatory statements about another resident and threaten to assault the other resident. The note also revealed that per the CNA, Resident #8 struck her while directing Resident #8 away from the other resident. The note revealed that the provider observed Resident #8 push the medication cart into staff repeatedly. Additionally, several attempts were made to calm Resident #8, but attempts were unsuccessful and intramuscular lorazepam injection was ordered.The clinical record was reviewed and revealed no evidence of change of condition monitoring, no head to toe assessment or other skin assessment, and no documentation regarding an incident of a resident to resident altercation on October 31, 2025.A Behavior Note dated November 1, 2025, revealed Resident #8 became upset for no apparent reason and that suddenly, she was yelling out that other residents were talking about her. The note also revealed that Resident #8 attempted to bite the finger of a staff who was trying to help her.A Nursing Note dated November 4, 2025, revealed that Resident #8 was sent to the hospital for further evaluation after the resident reported to nursing staff that she had inserted a pencil in her rectum.A facility Self Report to the State Agency received November 6, 2025, at 2:20 P.M. revealed that two certified nursing assistants (CNAs) called the Director of Nursing (DON / Staff #5) regarding a conversation with a State Surveyor. The report revealed that per the staff's statement, Resident #8 hit Resident #10. Both CNAs stated that they recalled that contact was made while one resident was having psychosis.An interview was conducted on November 6, 2025, at 12:23 P.M. with Resident #8's public fiduciary and power of attorney (POA). The POA stated that she had just had a meeting with Resident #8 the morning of November 6, 2025, to discuss the resident's behaviors. The POA stated that Resident #8 was making allegations against the staff at the facility, and that the POA informed Resident #8 that she needed to tell the truth. Then, the POA stated that herself and Resident #8 discussed the incidents from approximately one week ago, and the POA stated that Resident #8 stated that she got mad at another resident and struck her.A telephonic interview was conducted with a Licensed Practical Nurse (LPN / Staff #29) on November 6, 2025, at 1:07 P.M. Staff #29 stated that she was the unit nurse for Resident #8 and Resident #10 on October 31, 2025. Staff #29 stated that Resident #8 went to activities for a Halloween party and was reported to have been scooping up all the candy. Staff #29 stated that Resident #8 came back to the unit with her hands full of candy, and that Resident #8 became upset when she was told that she could not eat all of the candy at once because of her medical condition. Staff #29 stated that Resident #8 then became agitated and irritated, and her behaviors escalated. Staff #29 stated that Resident #8 was sitting in the day room at a table watching television, with a CNA (Staff #71) and other residents present in the room, and her behaviors escalated as Resident #8 would stand up suddenly and threaten the staff. Staff #29 stated that Resident #8 did hit a staff member that day.A telephonic interview was conducted with a CNA (Staff #71) on November 6, 2025, at 1:20 P.M. Staff #71 stated that on October 31, 2025, Resident #8 was in the common area, and that Staff #71 witnessed Resident #8 hit Resident #10 in the face, and that Staff #71 and another CNA (Staff #82) separated the residents and brought Resident #8 back to her room. Then, Staff #71 stated that he told Resident #8 that she cannot hit other residents, and Staff #71 stated that in retaliation, Resident #8 then threatened that she was going to accuse Staff #71 of raping her. Staff #71 stated that another CNA (Staff #82) was a witness present for the interaction.A telephonic interview was conducted with a CNA (Staff #82) on November 6, 2025, at 1:29 P.M. Staff #82 stated that on October 31, 2025, Resident #8 was in the common area and upset about something. Staff #82 stated that she witnessed Resident #8 walk over to Resident #10 and swing on (Resident #10). Staff #82 stated that Resident #8 hit Resident #10, and as Resident #8 swung her arm at Resident #10, Resident #10 raised her arm to try to defend herself from the strike. Staff #82 stated that she witnessed Resident #8's arm strike Resident #10's raised forearm as she hit her. Staff #82 stated that she immediately went over to separate the residents. Staff #82 stated that she informed the floor nurse (Staff #29) and a charge nurse (Staff #40) about the incident right away.A telephonic interview was conducted with a charge nurse and LPN (Staff #40) on November 6, 2025, at 1:41 P.M. Staff #40 stated that on October 31, 2025, she heard that Resident #8 tried to hit Resident #10. Staff #40 stated that she heard that Resident #8 was swinging at people, but that Staff #40 did not know for certain if Resident #8 had hit Resident #10. Staff #40 stated that she did not complete an assessment of the residents after the incident. Staff #40 also stated that she did not do an incident report, and that Staff #40 believed that the floor nurse (Staff #29) had reported the incident to the unit manager (Staff #53). A telephonic interview was conducted on November 6, 2025, at 1:57 P.M. with a behavioral unit manager and LPN (Staff #53). Staff #53 stated that he was notified by the CNAs that Resident #8 hit Resident #10, but that he could not specify when he heard, who specifically informed him, or any other details of the incident. Staff #53 stated that he believed he was not at the facility when it happened. Staff #53 stated that he could not remember if he notified the abuse coordinator (Staff #90) of the incident. Staff #53 stated that he did not know if a nurse assessed the residents for injury after the incident. Also, Staff #53 stated that he did not complete an incident report regarding the incident.An interview was conducted with the Assistant Director of Nursing and LPN (Staff #30) on November 6, 2025, at 2:17 P.M. Staff #30 stated that if there is an allegation of abuse, the expectation is to notify the Administrator immediately. Staff #30 stated that if staff witnessed an alleged incident of physical abuse between residents, then she would expect staff to de-escalate the situation, to ensure the residents are safe, and to perform a head to toe assessment of the residents to assess for injury. Additionally, Staff #30 stated that facility staff do an investigation of the incident and document the investigation. Staff #30 stated that she was not informed of a resident to resident incident between Resident #8 and Resident #10.An additional telephonic interview was conducted on November 6, 2025, at 2:22 P.M. when the behavioral unit manager (Staff #53) called the surveyor and stated that he had heard about the incident between Resident #8 and Resident #10 after the fact on November 3, 2025. An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 2:26 P.M. who approached the surveyor and stated that he had just received a call from Staff #53 about an allegation of resident to resident abuse on October 31, 2025. The Administrator stated that Staff #53 did not inform him of the incident previously, and that the Administrator had just found out about the allegation at that time of the call with Staff #53.An interview was conducted with the Director of Nursing (DON / Staff #5) on November 6, 2025, at 2:30 P.M. Staff #5 stated that Staff #53 had called her and informed her that Resident #8 was having severe behaviors, and that Resident #8 had bitten Staff #71, but she was not informed about the resident to resident altercation between Resident #8 and Resident #10.An additional telephonic interview was conducted with an LPN (Staff #29) on November 6, 2025, at 2:40 P.M. Staff #29 stated that on October 31, 2025, the CNAs informed her that Resident #8 hit Resident #10. Staff #29 stated that she was told by the CNAs that Resident #8 and Resident #10 were in the common area, and Resident #8 became agitated, and the staff were unable to calm her down. Staff #29 stated that then, Resident #8 approached Resident #10 who was in her wheelchair, and hit Resident #10. Staff #29 stated that she believed it was just one strike. Staff #29 stated that after the CNAs told her, that she went to Resident #10 and asked her what happened, and that Resident #10 stated that Resident #8 hit her in the side of the face. Staff #29 stated that she asked Resident #10 if she was ok, and Staff #29 did not see any visible marks on the side of Resident #10's face, but Staff #29 did not do a full assessment of the resident. Staff #29 stated that she did not do a progress note or incident report regarding the incident.An interview was conducted with an LPN (Staff #3) on November 6, 2025, at 3:34 P.M. Staff #3 stated that if staff were to witness a resident hitting another resident, that he would expect staff to first separate the residents and ensure their safety, then to interview witnesses and residents to determine what happened, and to notify the abuse coordinator of the incident. Additionally, Staff #3 stated that he would also inform the DON, the ADON, the resident's family if applicable, and the provider, and that he would complete an incident report.An interview was conducted with Resident #10 on November 6, 2025, at 3:58 P.M. Resident #10 stated that the past weekend, Resident #8 was very angry and punched Resident #10 in the left side of her face, and that directly after, Staff #71 pulled Resident #8 off of her. Resident #10 stated that the punch from Resident #8 caused her pain. Resident #10 also stated that she did not feel safe with Resident #8 in the facility.An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 4:07 P.M. Staff #90 stated his understanding of abuse is taking advantage of someone in some way, and that there are different types of abuse including physical, emotional, sexual, and neglect. Staff #90 stated that if there is an allegation of abuse, that he would expect staff to immediately notify him, ensure the residents are safe, to separate the residents, and that then the DON or himself would initiate an investigation into the incident. Staff #90 stated that he could not state directly what happened between Resident #8 and Resident #10, because the investigation and interviews were ongoing.An additional interview was conducted with the DON (Staff #5) on November 6, 2025, at 4:18 P.M. Staff #5 stated that if there was an allegation of physical abuse between residents, that she would expect staff to notify herself or the Administrator (Staff #90) immediately. Additionally, Staff #5 stated that staff are expected to keep the residents separated, assess for any injuries and treat with first aid if necessary, and to document in the medical record in a change of condition notification and in an incident report. Regarding the incident between Resident #8 and Resident #10, Staff #5 stated that the investigation had just started and interviews were ongoing, and that Resident #10 stated that Resident #8 had hit her. Staff #5 declined to state directly if the incident between Resident #8 and Resident #10 was considered physical abuse, but Staff #5 did state that if a resident walked over and struck another resident in the face, that it would not be appropriate.Review of the facility policy titled Abuse: Prevention and Prohibition Against, revised September 2024, revealed it is the policy of the facility that each resident has the right to be free from abuse. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to develop and implement policies and procedures to prevent physical abuse of a resident (#10) from another resident (#8). The deficient practice could result in physical and psychosocial harm.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment. Additionally, the assessment revealed Resident #10 had no hallucinations, no delusions, no inattention, no disorganized thinking, and no altered level of consciousness.A Behavior Note dated October 31, 2025, revealed that Resident #10 went into the main dining area at 2:00 P.M. with other residents from the facility to join in on a Halloween party, and once she came back, she joined others in the common area until the evening. The note revealed Resident #10 was pleasant, cooperative, and did not have any behaviors. There was no evidence of documentation of a resident to resident altercation.The clinical record was reviewed and revealed no evidence regarding a resident to resident altercation on October 31, 2025.Regarding Resident #8 (alleged perpetrator):Resident #8 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, violent behavior, schizophrenia, and autistic disorder.A quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 12, indicating moderate cognitive impairment. Additionally, the assessment revealed Resident #8 had no hallucinations, no delusions, no inattention, no disorganized thinking, and no altered level of consciousness.A care plan dated May 8, 2025, revealed Resident #8 had potential for a behavior problem due to verbal aggression. Interventions included to document behaviors, to intervene as necessary to protect the rights and safety of others, and to discuss the resident's behavior and explain why the behavior is inappropriate or unacceptable.A Behavior Note dated October 31, 2025, at 3:49 P.M. revealed that Resident #8 became upset when she returned to the unit from the Halloween party because she was educated that she cannot eat all of her candy at once due to her elevated blood sugars. The note revealed that Resident #8 was not responsive to de-escalation techniques. Also, the note revealed that at that time the provider ordered intramuscular Ativan injection when all other methods were unsuccessful. The note revealed no evidence of a resident to resident altercation.A Psychiatric provider note dated October 31, 2025, at 4:00 P.M. revealed that staff reported that Resident #8 was currently having agitated and aggressive behavior, and that Resident #8 became angry and agitated toward staff and other residents. The note revealed that per staff, Resident #8 began making threatening statements about other residents in the day room. Additionally, the note revealed that the provider overheard Resident #8 make accusatory statements about another resident and threaten to assault the other resident.The clinical record was reviewed and revealed no evidence of documentation regarding a resident to resident incident on October 31, 2025.A facility Self Report to the State Agency received November 6, 2025, at 2:20 P.M. revealed that two certified nursing assistants (CNAs) called the Director of Nursing (DON / Staff #5) regarding a conversation with a State Surveyor. The report revealed that per the staff's statement, Resident #8 hit Resident #10. Both CNAs stated that they recalled that contact was made while one resident was having psychosis.An interview was conducted on November 6, 2025, at 12:23 P.M. with Resident #8's public fiduciary and power of attorney (POA). The POA stated that she had just had a meeting with Resident #8 the morning of November 6, 2025, to discuss the resident's behaviors. The POA stated that Resident #8 was making allegations against the staff at the facility and that the POA informed Resident #8 that she needed to tell the truth. Then, the POA stated that herself and Resident #8 discussed the incidents from approximately a week ago, and the POA stated that Resident #8 stated that she got mad at another resident and struck her.A telephonic interview was conducted with a Licensed Practical Nurse (LPN / Staff #29) on November 6, 2025, at 1:07 P.M. Staff #29 stated that she was the unit nurse for Resident #8 and Resident #10 on October 31, 2025. Staff #29 stated that Resident #8 went to activities for a Halloween party and was reported to have been scooping up all the candy. Staff #29 stated that Resident #8 came back to the unit with her hands full of candy, and that Resident #8 became upset when she was told that she could not eat all of the candy at once because of her medical condition. Staff #29 stated that Resident #8 then became agitated and irritated, and her behaviors escalated. Staff #29 stated that Resident #8 was sitting in the day room at a table watching television, with a CNA (Staff #71) and other residents present in the room, and her behaviors escalated as Resident #8 would stand up suddenly and threaten the staff. Staff #29 stated that Resident #8 did hit a staff member that day.A telephonic interview was conducted with a CNA (Staff #71) on November 6, 2025, at 1:20 P.M. Staff #71 stated that on October 31, 2025, that Resident #8 was in the common area and that Staff #71 witnessed Resident #8 hit Resident #10 in the face, and that Staff #71 and another CNA (Staff #82) separated the residents and brought Resident #8 back to her room. Then, Staff #71 stated that he told Resident #8 that she cannot hit other residents, and Staff #71 stated that in retaliation, Resident #8 then threatened that she was going to accuse Staff #71 of raping her. Staff #71 stated that another CNA (Staff #82) was a witness present for the interaction.A telephonic interview was conducted with a CNA (Staff #82) on November 6, 2025, at 1:29 P.M. Staff #82 stated that on October 31, 2025, Resident #8 was in the common area and upset about something. Staff #82 stated that she witnessed Resident #8 walk over to Resident #10 and swing on (Resident #10). Staff #82 stated that Resident #8 hit Resident #10, and as Resident #8 swung her arm at Resident #10, Resident #10 raised her arm to try to defend herself from the strike. Staff #82 stated that she witnessed Resident #8's arm strike Resident #10's arm as she hit her. Staff #82 stated that she immediately went over to separate the residents. Staff #82 stated that she informed the floor nurse (Staff #29) and a charge nurse (Staff #40) about the incident right away.A telephonic interview was conducted with a charge nurse and LPN (Staff #40) on November 6, 2025, at 1:41 P.M. Staff #40 stated that on October 31, 2025, she heard that Resident #8 tried to hit Resident #10. Staff #40 stated that she heard that Resident #8 was swinging at people, but that Staff #40 did not know for certain if Resident #8 had hit Resident #10.A telephonic interview was conducted on November 6, 2025, at 1:57 P.M. with a behavioral unit manager and LPN (Staff #53). Staff #53 stated that he was notified by the CNAs that Resident #8 hit Resident #10, but that he could not specify when he heard, who specifically informed him, or any other details of the incident.An interview was conducted with the Assistant Director of Nursing and LPN (Staff #30) on November 6, 2025, at 2:17 P.M. Staff #30 stated that she was not informed of a resident to resident incident between Resident #8 and Resident #10.An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 2:26 P.M. who approached the surveyor and stated that he had just received a call from Staff #53 about an allegation of resident to resident abuse on October 31, 2025. The Administrator stated that Staff #53 did not inform him of the incident previously, and that the Administrator had just found out about the allegation at that time of the call with Staff #53.An additional telephonic interview was conducted with an LPN (Staff #29) on November 6, 2025, at 2:40 P.M. Staff #29 stated that on October 31, 2025, the CNAs informed her that Resident #8 hit Resident #10. Staff #29 stated that she was told by the CNAs that Resident #8 and Resident #10 were in the common area, and Resident #8 became agitated, and the staff were unable to calm her down. Staff #29 stated that then, Resident #8 approached Resident #10 who was in her wheelchair, and hit Resident #10. Staff #29 stated that she believed it was just one strike. Staff #29 stated that after the CNAs told her, that she went to Resident #10 and asked her what happened, and that Resident #10 stated that Resident #8 hit her in the side of the face.An interview was conducted with Resident #10 on November 6, 2025, at 3:58 P.M. Resident #10 stated that the past weekend, Resident #8 was very angry and punched Resident #10 in the left side of her face, and that directly after, Staff #71 pulled Resident #8 off of her. Resident #10 stated that the punch from Resident #8 caused her pain. Resident #10 also stated that she did not feel safe with Resident #8 in the facility.An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 4:07 P.M. Staff #90 stated his understanding of abuse is taking advantage of someone in some way, and that there are different types of abuse including physical, emotional, sexual, and neglect. Staff #90 re-stated that he first learned of the allegation of physical abuse between Resident #8 and Resident #10 from the phone call with the unit manager (Staff #53) today. Staff #90 stated that he could not state directly what happened between Resident #8 and Resident #10, because the investigation and interviews were ongoing.An additional interview was conducted with the DON (Staff #5) on November 6, 2025, at 4:18 P.M. Staff #5 stated that if there was an allegation of physical abuse between residents, that she would expect staff to notify herself or the Administrator (Staff #90) immediately, because they are required to report the allegation of abuse to mandated entities within 2 hours. Additionally, Staff #5 stated that staff are expected to keep the residents separated, assess for any injuries and treat with first aid if necessary, and to document in the medical record in a change of condition notification and in an incident report. Regarding the incident between Resident #8 and Resident #10, Staff #5 stated that the investigation had just started and interviews were ongoing, and that Resident #10 stated that Resident #8 had hit her. Staff #5 declined to state directly if the incident between Resident #8 and Resident #10 was considered physical abuse, but Staff #5 did state that if a resident walked over and struck another resident in the face, that it would not be appropriate.Review of the facility policy titled Abuse: Prevention and Prohibition Against, revised September 2024, revealed it is the policy of the facility that each resident has the right to be free from abuse. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking. Regarding the prevention of abuse, the facility policy revealed that the facility will act to protect and prevent abuse and neglect from occurring within the facility by: identifying, correcting and intervening in situations in which abuse is more likely to occur, to include validating that the facility has deployed the correct number of competent staff on each shift to meet the needs of the residents. Additionally, prevention of abuse included identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating and physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to report an allegation of physical abuse of a resident (#10) immediately and within 2 hours to mandated entities. The deficient practice could lead to ongoing abuse of a resident resulting in physical and psychosocial harm.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment.A Behavior Note dated October 31, 2025, revealed Resident #10 went outside with other residents at lunch to eat pizza and sweets. Additionally, the note revealed that Resident #10 went into the main dining area at 2:00 P.M. with other residents from the facility to join in on a Halloween party, and once she came back, she joined others in the common area until the evening. The note revealed Resident #10 was pleasant, cooperative, and did not have any behaviors. There was no evidence of documentation of a resident to resident altercation.Regarding Resident #8 (alleged perpetrator):Resident #8 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, violent behavior, schizophrenia, and autistic disorder.A quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 12, indicating moderate cognitive impairment.An Behavior Note dated October 31, 2025, at 3:49 P.M. revealed that Resident #8 became upset when she returned to the unit from the Halloween party because she was educated that she cannot eat all of her candy at once due to her elevated blood sugars. The note revealed no evidence of a resident to resident altercation.The clinical record was reviewed and revealed no evidence of documentation regarding an incident of a resident to resident altercation on October 31, 2025.A facility Self Report to the State Agency received November 6, 2025, at 2:20 P.M. revealed that two certified nursing assistants (CNAs) called the Director of Nursing (DON / Staff #5) regarding a conversation with a State Surveyor. The report revealed that per the staff's statement, Resident #8 hit Resident #10. Both CNAs stated that they recalled that contact was made while one resident was having psychosis.A telephonic interview was conducted with a CNA (Staff #71) on November 6, 2025, at 1:20 P.M. Staff #71 stated that on October 31, 2025, that Resident #8 was in the common area and that Staff #71 witnessed Resident #8 hit Resident #10 in the face, and that Staff #71 and another CNA (Staff #82) separated the residents and brought Resident #8 back to her room. Then, Staff #71 stated that he told Resident #8 that she cannot hit other residents, and Staff #71 stated that in retaliation, Resident #8 then threatened that she was going to accuse Staff #71 of raping her. Staff #71 stated that another CNA (Staff #82) was a witness present for the interaction.A telephonic interview was conducted with a CNA (Staff #82) on November 6, 2025, at 1:29 P.M. Staff #82 stated that on October 31, 2025, Resident #8 was in the common area and upset about something. Staff #82 stated that she witnessed Resident #8 walk over to Resident #10 and swing on (Resident #10). Staff #82 stated that Resident #8 hit Resident #10, and as Resident #8 swung her arm at Resident #10, Resident #10 raised her arm to try to defend herself from the strike. Staff #82 stated that she witnessed Resident #8's arm strike Resident #10's arm as she hit her. Staff #82 stated that she immediately went over to separate the residents. Staff #82 stated that she informed the floor nurse (Staff #29) and a charge nurse (Staff #40) about the incident right away.A telephonic interview was conducted with a charge nurse and LPN (Staff #40) on November 6, 2025, at 1:41 P.M. Staff #40 stated that on October 31, 2025, she heard that Resident #8 tried to hit Resident #10. Staff #40 stated that she believed that the floor nurse (Staff #29) had reported the incident to the unit manager (Staff #53). A telephonic interview was conducted on November 6, 2025, at 1:57 P.M. with a behavioral unit manager and LPN (Staff #53). Staff #53 stated that he was notified by the CNAs that Resident #8 hit Resident #10, but that he could not specify when he heard, who specifically informed him, or any other details of the incident. Staff #53 stated that he could not remember if he notified the abuse coordinator (Staff #90) of the incident.An interview was conducted with the Assistant Director of Nursing and LPN (ADON / Staff #30) on November 6, 2025, at 2:17 P.M. Staff #30 stated that if there is an allegation of abuse, the expectation is to notify the administrator immediately. Staff #30 stated that she was not informed of a resident to resident incident between Resident #8 and Resident #10.An additional telephonic interview was conducted on November 6, 2025, at 2:22 P.M. when the behavioral unit manager (Staff #53) called the surveyor and stated that he had heard about the incident between Resident #8 and Resident #10 after the fact on November 3, 2025, and that Staff #53 stated he did not report it to the Administrator because he believed it had already been reported already. An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 2:26 P.M. who approached the surveyor and stated that he had just received a call from Staff #53 about an allegation of resident to resident abuse on October 31, 2025. The Administrator stated that Staff #53 did not inform him of the incident previously, and that the Administrator had just found out about the allegation at that time of the call with Staff #53. The Administrator stated that he would be starting a facility self-report regarding the incident at this time.An interview was conducted with the Director of Nursing (DON / Staff #5) on November 6, 2025, at 2:30 P.M. Staff #5 stated that Staff #53 had called her and informed her that Resident #8 was having severe behaviors, and that Resident #8 had bitten Staff #71, but she was not informed about the resident to resident altercation between Resident #8 and Resident #10.A telephonic interview was conducted with an LPN (Staff #29) on November 6, 2025, at 2:40 P.M. Staff #29 stated that on October 31, 2025, the CNAs informed her that Resident #8 hit Resident #10. Staff #29 stated that she was told by the CNAs that Resident #8 and Resident #10 were in the common area, and Resident #8 became agitated, and the staff were unable to calm her down. Staff #29 stated that then, Resident #8 approached Resident #10 who was in her wheelchair, and hit Resident #10. Staff #29 stated that she believed it was just one strike. Staff #29 stated that after the CNAs told her, that she went to Resident #10 and asked her what happened, and that Resident #10 stated that Resident #8 hit her in the side of the face. Staff #29 also stated that she informed Staff #40 and Staff #53 of the incident because they were the charge nurses.An interview was conducted with an LPN (Staff #3) on November 6, 2025, at 3:34 P.M. Staff #3 stated that if there is an allegation of abuse, that staff are to notify the abuse coordinator / Administrator (Staff #90) immediately, but definitely within 2 hours.An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 4:07 P.M. Staff #90 stated his understanding of abuse is taking advantage of someone in some way, and that there are different types of abuse including physical, emotional, sexual, and neglect. Staff #90 stated that if there is an allegation of abuse, that he would expect staff to immediately notify him. Additionally, Staff #90 stated that he is required to report all allegations of abuse to mandated entities within 2 hours, including to the local police, to the State Agency, to Adult Protective Services (APS), and to the ombudsman. Staff #90 re-stated that he first learned of the allegation of physical abuse between Resident #8 and Resident #10 from the phone call with the unit manager (Staff #53) today.An additional interview was conducted with the DON (Staff #5) on November 6, 2025, at 4:18 P.M. Staff #5 stated that if there was an allegation of physical abuse between residents, that she would expect staff to notify herself or the Administrator (Staff #90) immediately, because they are required to report the allegation of abuse to mandated entities within 2 hours. Regarding the incident between Resident #8 and Resident #10, Staff #5 stated that the investigation had just started and interviews were ongoing, and that Resident #10 stated that Resident #8 had hit her.Review of the facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised September 2024, revealed it is the policy of the facility that each resident has the right to be free from abuse. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Additionally, all alleged violations involving abuse are reported to the Administrator of the facility, the State Agency, and Adult Protective Services.Review of the facility policy titled Reporting Reasonable Suspicion of a Crime, revised September 2024, revealed staff must report a suspicion of a crime to the State Survey Agency and at least one local law enforcement entity within a designated time frame by e-mail, fax or telephone. The individual does not need to determine which local law enforcement entity to report a suspicion of crime, but must report to at least one local law enforcement entity that has jurisdiction over the location of where the crime occurred.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to immediately assess residents (#8 and #10) after an allegation of physical abuse, and failed to investigate the allegation according to facility policy. The deficient practice could result in physical and psychosocial harm of a resident.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment.Resident #10's care plan was reviewed and revealed no evidence of physical or psychosocial monitoring related to an allegation of physical abuse from another resident.The assessment list of Resident #10's medical record was reviewed and revealed no assessments completed on October 31, 2025, or November 1, 2025.A Behavior Note dated October 31, 2025, revealed Resident #10 went outside with other residents at lunch to eat pizza and sweets. Additionally, the note revealed that Resident #10 went into the main dining area at 2:00 P.M. with other residents from the facility to join in on a Halloween party, and once she came back, she joined others in the common area until the evening. The note revealed Resident #10 was pleasant, cooperative, and did not have any behaviors. There was no evidence of documentation of a resident to resident altercation or assessment of the resident afterward.The clinical record was reviewed and revealed no evidence of change of condition monitoring, no head to toe assessment or other skin assessment, and no documentation regarding a resident to resident altercation on October 31, 2025.A Nursing note dated November 6, 2025, at 2:33 P.M. revealed that a nurse received notification that Resident #10 may have been accidentally struck. The note revealed no evidence of any other details regarding what occurred or when. The note revealed that the nurse attempted to assess the resident, and the resident refused.Regarding Resident #8 (alleged perpetrator):Resident #8 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, violent behavior, schizophrenia, and autistic disorder.A quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 12, indicating moderate cognitive impairment.An additional Behavior Note dated October 31, 2025, at 3:49 P.M. revealed that Resident #8 became upset when she returned to the unit from the Halloween party because she was educated that she cannot eat all of her candy at once due to her elevated blood sugars. The note revealed that Resident #8 was not responsive to de-escalation techniques. The note revealed no evidence of a resident to resident altercation or that the resident was assessed for injury afterward.The clinical record was reviewed and revealed no evidence of change of condition monitoring, no head to toe assessment or other skin assessment, and no documentation regarding an incident of a resident to resident altercation on October 31, 2025.A facility Self Report to the State Agency received November 6, 2025, at 2:20 P.M. revealed that two certified nursing assistants (CNAs) called the Director of Nursing (DON / Staff #5) regarding a conversation with a State Surveyor. The report revealed that per the staff's statement, Resident #8 hit Resident #10 on November 1, 2025. Both CNAs stated that they recalled that contact was made while one resident was having psychosis.Review of the State Agency database conducted November 12, 2025, revealed no evidence that the facility submitted a 5-day investigation report for an allegation of abuse between Resident #8 and Resident #10 on October 31, 2025.A telephonic interview was conducted with a Licensed Practical Nurse (LPN / Staff #29) on November 6, 2025, at 1:07 P.M. Staff #29 stated that she was the unit nurse for Resident #8 and Resident #10 on October 31, 2025. Staff #29 stated that Resident #8 went to activities for a Halloween party and was reported to have been scooping up all the candy. Staff #29 stated that Resident #8 came back to the unit with her hands full of candy, and that Resident #8 became upset when she was told that she could not eat all of the candy at once because of her medical condition. Staff #29 stated that Resident #8 then became agitated and irritated, and her behaviors escalated. Staff #29 stated that Resident #8 was sitting in the day room at a table watching television, with a CNA (Staff #71) and other residents present in the room, and her behaviors escalated as Resident #8 would stand up suddenly and threaten the staff. Staff #29 stated that Resident #8 did hit a staff member that day.A telephonic interview was conducted with a CNA (Staff #71) on November 6, 2025, at 1:20 P.M. Staff #71 stated that on October 31, 2025, that Resident #8 was in the common area and that Staff #71 witnessed Resident #8 hit Resident #10 in the face, and that Staff #71 and another CNA (Staff #82) separated the residents and brought Resident #8 back to her room. Then, Staff #71 stated that he told Resident #8 that she cannot hit other residents, and Staff #71 stated that in retaliation, Resident #8 then threatened that she was going to accuse Staff #71 of raping her. Staff #71 stated that another CNA (Staff #82) was a witness present for the interaction.A telephonic interview was conducted with a CNA (Staff #82) on November 6, 2025, at 1:29 P.M. Staff #82 stated that on October 31, 2025, Resident #8 was in the common area and upset about something. Staff #82 stated that she witnessed Resident #8 walk over to Resident #10 and swing on (Resident #10). Staff #82 stated that Resident #8 hit Resident #10, and as Resident #8 swung her arm at Resident #10, Resident #10 raised her arm to try to defend herself from the strike. Staff #82 stated that she witnessed Resident #8's arm strike Resident #10's arm as she hit her. Staff #82 stated that she immediately went over to separate the residents. Staff #82 stated that she informed the floor nurse (Staff #29) and a charge nurse (Staff #40) about the incident right away.A telephonic interview was conducted with a charge nurse and LPN (Staff #40) on November 6, 2025, at 1:41 P.M. Staff #40 stated that on October 31, 2025, she heard that Resident #8 tried to hit Resident #10. Staff #40 stated that she heard that Resident #8 was swinging at people, but that Staff #40 did not know for certain if Resident #8 had hit Resident #10. Staff #40 stated that she did not do an assessment on the residents after the incident. Staff #40 also stated that she did not do an incident report. A telephonic interview was conducted on November 6, 2025, at 1:57 P.M. with a behavioral unit manager and LPN (Staff #53). Staff #53 stated that he was notified by the CNAs that Resident #8 hit Resident #10, but that he could not specify when he heard, who specifically informed him, or any other details of the incident. Staff #53 stated that he believed he was not at the facility when it happened. Staff #53 stated that he did not know if a nurse assessed the residents for injury after the incident. Also, Staff #53 stated that he did not complete an incident report regarding the incident.An interview was conducted with the Assistant Director of Nursing and LPN (Staff #30) on November 6, 2025, at 2:17 P.M. Staff #30 stated that if there is an allegation of abuse, the expectation is to notify the administrator immediately. Staff #30 stated that if staff witnessed an alleged incident of physical abuse between residents, then she would expect staff to de-escalate the situation, to ensure the residents are safe, and to perform a head to toe assessment of the residents to assess for injury. Additionally, Staff #30 stated that facility staff do an investigation of the incident and document the investigation. Staff #30 stated that she was not informed of a resident to resident incident between Resident #8 and Resident #10.An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 2:26 P.M. who approached the surveyor and stated that he had just received a call from Staff #53 about an allegation of resident to resident abuse on October 31, 2025. The Administrator stated that Staff #53 did not inform him of the incident previously, and that the Administrator had just found out about the allegation at that time of the call with Staff #53.An interview was conducted with the Director of Nursing (DON / Staff #5) on November 6, 2025, at 2:30 P.M. Staff #5 stated that Staff #53 had called her and informed her that Resident #8 was having severe behaviors, and that Resident #8 had bitten Staff #71, but she was not informed about the resident to resident altercation between Resident #8 and Resident #10.An additional telephonic interview was conducted with an LPN (Staff #29) on November 6, 2025, at 2:40 P.M. Staff #29 stated that on October 31, 2025, the CNAs informed her that Resident #8 hit Resident #10. Staff #29 stated that she was told by the CNAs that Resident #8 and Resident #10 were in the common area, and Resident #8 became agitated, and the staff were unable to calm her down. Staff #29 stated that then, Resident #8 approached Resident #10 who was in her wheelchair, and hit Resident #10. Staff #29 stated that she believed it was just one strike. Staff #29 stated that after the CNAs told her, that she went to Resident #10 and asked her what happened, and that Resident #10 stated that Resident #8 hit her in the side of the face. Staff #29 stated that she asked Resident #10 if she was ok, and Staff #29 did not see any visible marks on the side of Resident #10's face, but Staff #29 stated that she did not do an assessment of the resident. Staff #29 stated that she did not do a progress note or incident report regarding the incident. Staff #29 also stated that she informed Staff #40 and Staff #53 of the incident because they were the charge nurses. Staff #29 stated that no other nurses assessed the residents after the incident because Staff #29 was the only nurse there.An interview was conducted with an LPN (Staff #3) on November 6, 2025, at 3:34 P.M. Staff #3 stated that if staff were to witness a resident hitting another resident, that he would expect staff to first separate the residents and ensure their safety, then to interview witnesses and residents to determine what happened, and to notify the abuse coordinator of the incident. Additionally, Staff #3 stated that he would also inform the DON, the ADON, the resident's family if applicable, and the provider, and that he would complete an incident report.An interview was conducted with Resident #10 on November 6, 2025, at 3:58 P.M. Resident #10 stated that the past weekend, Resident #8 was very angry and punched Resident #10 in the left side of her face, and that directly after, Staff #71 pulled Resident #8 off of her. Resident #10 stated that the punch from Resident #8 caused her pain. Resident #10 also stated that she did not feel safe with Resident #8 in the facility.An interview was conducted with the Administrator (Staff #90) on November 6, 2025, at 4:07 P.M. Staff #90 stated that if there is an allegation of abuse, that he would expect staff to immediately notify him, ensure the residents are safe, to separate the residents, and that then the DON or himself would initiate an investigation into the incident. Staff #90 stated that an investigation would entail interviewing witnesses or those near the situation to determine what occurred. Staff #90 re-stated that he first learned of the allegation of physical abuse between Resident #8 and Resident #10 from the phone call with the unit manager (Staff #53) today. Additionally, the Administrator stated that the required timeframe for submitting a completed investigation of an abuse allegation to the State Agency is 5 business days.An additional interview was conducted with the DON (Staff #5) on November 6, 2025, at 4:18 P.M. Staff #5 stated that if there was an allegation of physical abuse between residents, that staff are expected to keep the residents separated, assess for any injuries and treat with first aid if necessary, and to document in the medical record in a change of condition notification and in an incident report. Regarding the incident between Resident #8 and Resident #10, Staff #5 stated that the investigation had just started and interviews were ongoing, and that Resident #10 stated that Resident #8 had hit her.Review of the facility policy titled Abuse: Prevention and Prohibition Against, revised September 2024, revealed it is the policy of the facility that each resident has the right to be free from abuse. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. All allegations of abuse will be promptly and thoroughly investigated by the Administrator or his/her designee. The investigation will include the following: an interview with the person(s) reporting the incident; an interview with the resident(s); interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; a review of the resident's medical record; an interview with staff members (on all shifts) who may have information regarding the alleged incident; interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; an interview with staff members (on all shifts) having contact with the accused employee; and a review of all circumstances surrounding the incident. Regarding protection of residents, if an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: respond immediately to protect the alleged victim and integrity of the investigation; examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increase supervision of the alleged victim and residents; make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; protect the involved persons from retaliation; and provide emotional support and counseling to the resident during and after the investigation, as needed.Review of federal regulation 42 C.F.R., revealed that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: S483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. S483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. S483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident.Review of the facility policy titled Incidents and Accidents, revised September 2024, revealed that should an accident/incident occur, the resident will be provided immediate attention by a licensed nurse, who will notify medical provider, family member, EMS, etc. as appropriate. Render immediate assistance. Do not move the victim until he/she has been examined for possible injuries. Licensed nurse will assess the resident including vital signs, neuro checks if needed, complaints of pain and location, and determine if treatment or additional care is needed, including accessing the EMS system. Licensed nurse will notify medical provider for residents, and obtain orders for further treatment or diagnosis as deemed necessary by the provider.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to report an allegation of sexual abuse of one resident (#10) to mandated entities within 2 hours. The deficient practice could result in ongoing abuse, leading to physical and/or psychosocial harm of a resident. Past non-compliance was identified for this citation:These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of November 17, 2025 and three were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction. The facility conducted an in-service regarding Abuse Prevention and Reporting Policy (documentation was included at the time of the request), to include immediate separation of residents, safety, assessment of involved parties, timely notifications and documentation. The facility also conducted a full-house resident questionnaire to ensure no residents observed or felt resident-to-resident abuse. All residents reported feeling safe in the facility with no abuse concerns identified. Grievance logs, 24-hour reports and documentation will be review four times a week for the next four weeks and the monthly. Staff will follow abuse prevention and reporting policy, until compliance is met and ensure all allegations of abuse are addressed properly. Any issues observed will be followed up on immediately and 1 on 1 education will be provided. -Findings include:Resident #10 was admitted to the facility on [DATE], with diagnoses that included myoneural disorder, other toxic encephalopathy, dysphagia, ataxia, and post-traumatic stress disorder.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) assessment score of 15, indicating intact cognition. Additionally, the assessment revealed Resident #10 had no hallucinations or delusions.A physician order dated August 26, 2025, indicated for a chest x-ray for leukocytosis.An additional physician order dated October 1, 2025, indicated for a stat chest x-ray for shortness of breath.A Nursing Note dated October 16, 2025, revealed that Resident #10 was discharged from the facility to the hospital.A police report initiated October 18, 2025, revealed that Resident #10 (alleged victim) reported that an unknown male that conducted x-rays allegedly committed sexual abuse by touching Resident #10's breast, while she was receiving medical care at the facility. The report additionally revealed that a description of the male was provided by Resident #10, and that Resident #10 stated that she had reported the allegation to a nurse at the facility, and that the nurse stated that the alleged perpetrator had left the building. The report also revealed that a police officer assigned to the case arrived at the facility on October 23, 2025, and discussed the case with the Assistant Director of Nursing (ADON / Staff #12). The report revealed that Staff #12 identified the x-ray technician as the possible perpetrator, and additionally provided police with information about Resident #10's room number and previous roommate. Additionally, Staff #12 provided information to the police that the only dates that Resident #10 had received x-rays were August 27, 2025, and October 1, 2025. The report revealed that Staff #12 spoke with her boss (Administrator / Staff #66), who would be in the office the following day to assist with any video footage needed. The report revealed that on October 24, 2025, the police officer returned to the facility to meet with Staff #66, and that the police officer was notified that Staff #66 was out of state, and that the video camera footage that was requested was not available.Review of the facility's list of self-report incidents revealed no evidence of an allegation of sexual abuse of Resident #10.Review of the State Agency database revealed no evidence that the facility submitted a self-report for an allegation of sexual abuse of Resident #10.An interview was conducted with Resident #10's former roommate on November 17, 2025, at 9:46 A.M. The roommate stated that a detective came and talked to her in October 2025, and asked her if she had witnessed anything between Resident #10 and an x-ray technician.An interview was conducted with a Licensed Practical Nurse (LPN / Staff #29) on November 17, 2025, at 9:56 A.M. Staff #29 stated that if she saw or heard any allegation of abuse of a resident, that she would first ensure the resident is safe, then report the allegation immediately to the abuse coordinator (Staff #66). Staff #29 stated the importance of immediately reporting an allegation of abuse is to protect against continued abuse of a resident, and that witnesses may have memory problems, so staff would need to act right away to take witness statements.An interview was conducted on November 17, 2025, at 10:00 A.M. with an LPN and ADON (Staff #12), who stated that if staff see or hear an abuse allegation, the expectation is to first ensure the safety of the resident, and then to contact Staff #66 immediately. Staff #12 stated if staff cannot reach Staff #66, then the process would be to report the allegation immediately to the Director of Nursing (DON / Staff #47), who would then contact Staff #66 on his other phone number. Staff #12 stated that there is a 2-hour timeframe in which the facility must report allegations of abuse to the State Agency and other mandated entities. Staff #12 stated that if a staff member touched a resident's genitals without a medical reason to do so then that could be considered sexual abuse. Staff #12 stated that in October, police came to the facility and informed Staff #12 that Resident #10 had made a statement that someone from an x-ray company had sexually assaulted Resident #10 while she was a resident at the facility. Staff #12 stated that the police talked to Staff #12 first. Then, Staff #12 stated that she gave the police Staff #66's phone number, and then police talked to Staff #66.An interview was conducted with the Administrator (Staff #66) on November 17, 2025, at 10:07 A.M. Staff #66 stated that if staff were to see or hear an allegation of abuse, that he would expect staff to first make sure residents are safe, then to immediately notify Staff #66 of the allegation. Additionally, Staff #66 stated that there is a 2-hour timeframe in which the facility is required to report an allegation of abuse to the State Agency, to the ombudsman, and to police. Staff #66 stated that he did not know of any abuse allegations regarding Resident #10. Staff #66 also stated that there were no investigations regarding an abuse allegation of Resident #10. Staff #66 stated that he was not aware of any police contacting him regarding an allegation of abuse of Resident #10.An interview was conducted with the DON (Staff #47) on November 11, 2025, at 10:47 A.M. Staff #47 stated that the police came to the facility sometime during the timeframe of October 18-25, 2025, and requested video camera footage for particular hallways. Staff #47 stated she was not informed by the police or by any other staff of any allegation of abuse. Staff #47 stated that no video camera footage was provided because most of the video cameras are fake, and that the real video cameras were not working. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation, revised September 2024, revealed that it is the policy of the facility that each resident has the right to be free from abuse. This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the facility. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately.Review of the facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment, revised September 2024, revealed that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that all alleged violations involving abuse are reported immediately but not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Additionally, the policy revealed to ensure that all alleged violations involving abuse are reported to: the Administrator of the facility, the State Survey Agency, and Adult Protective Services (as appropriate).

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to investigate an allegation of sexual abuse of one resident (#10). The deficient practice could result in ongoing abuse, leading to physical and/or psychosocial harm of a resident. Past non-compliance was identified for this citation:These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of November 17, 2025 and three were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction. The facility conducted an in-service regarding Abuse Prevention and Reporting Policy (documentation was included at the time of the request), to include immediate separation of residents, safety, assessment of involved parties, timely notifications and documentation. The facility also conducted a full-house resident questionnaire to ensure no residents observed or felt resident-to-resident abuse. All residents reported feeling safe in the facility with no abuse concerns identified. Grievance logs, 24-hour reports and documentation will be review four times a week for the next four weeks and the monthly. Staff will follow abuse prevention and reporting policy, until compliance is met and ensure all allegations of abuse are addressed properly. Any issues observed will be followed up on immediately and 1 on 1 education will be provided. -Findings include: Resident #10 was admitted to the facility on [DATE], with diagnoses that included myoneural disorder, other toxic encephalopathy, dysphagia, ataxia, and post-traumatic stress disorder.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) assessment score of 15, indicating intact cognition. Additionally, the assessment revealed Resident #10 had no hallucinations or delusions.A physician order dated August 26, 2025, indicated for a chest x-ray for leukocytosis.An additional physician order dated October 1, 2025, indicated for a stat chest x-ray for shortness of breath.A Nursing Note dated October 16, 2025, revealed that Resident #10 was discharged from the facility to the hospital.A police report initiated October 18, 2025, revealed that Resident #10 (alleged victim) reported that an unknown male that conducted x-rays allegedly committed sexual abuse by touching Resident #10's breast, while she was receiving medical care at the facility. The report additionally revealed that a description of the male was provided by Resident #10, and that Resident #10 stated that she had reported the allegation to a nurse at the facility, and that the nurse stated that the alleged perpetrator had left the building. The report also revealed that a police officer assigned to the case arrived at the facility on October 23, 2025, and discussed the case with the Assistant Director of Nursing (ADON / Staff #12). The report revealed that Staff #12 identified the x-ray technician as the possible perpetrator, and additionally provided police with information about Resident #10's room number and previous roommate. Additionally, Staff #12 provided information to the police that the only dates that Resident #10 had received x-rays were August 27, 2025, and October 1, 2025. The report revealed that Staff #12 spoke with her boss (Administrator / Staff #66), who would be in the office the following day to assist with any video footage needed. The report revealed that on October 24, 2025, the police officer returned to the facility to meet with Staff #66, and that the police officer was notified that Staff #66 was out of state, and that the video camera footage that was requested was not available.Review of the facility's list of self-report incidents revealed no evidence of an allegation of sexual abuse of Resident #10.Review of the State Agency database revealed no evidence that the facility submitted a 5-day investigation report for an allegation of sexual abuse of Resident #10.An interview was conducted with Resident #10's former roommate on November 17, 2025, at 9:46 A.M. The roommate stated that a detective came and talked to her in October 2025, and asked her if she had witnessed anything between Resident #10 and an x-ray technician. The roommate also stated that facility staff did not ask her any questions related to the allegation.An interview was conducted with a Licensed Practical Nurse (LPN / Staff #29) on November 17, 2025, at 9:56 A.M. Staff #29 stated that if she saw or heard any allegation of abuse of a resident, that she would first ensure the resident is safe, then report the allegation immediately to the abuse coordinator (Staff #66). Staff #29 stated the importance of immediately investigating an allegation of abuse is to protect against continued abuse of a resident, and that witnesses may have memory problems, so staff would need to act right away to take witness statements.An interview was conducted on November 17, 2025, at 10:00 A.M. with an LPN and ADON (Staff #12), who stated that if staff see or hear an abuse allegation, the expectation is to first ensure the safety of the resident, and then to contact Staff #66 immediately. Staff #12 stated that if a staff member touched a resident's genitals without a medical reason to do so then that could be considered sexual abuse. Staff #12 stated that in October, police came to the facility and informed Staff #12 that Resident #10 had made a statement that someone from an x-ray company had sexually assaulted Resident #10 while she was a resident at the facility. Staff #12 stated that the police talked to Staff #12 first. Then, Staff #12 stated that she gave the police Staff #66's phone number, and then police talked to Staff #66.An interview was conducted with the Administrator (Staff #66) on November 17, 2025, at 10:07 A.M. Staff #66 stated that if staff were to see or hear an allegation of abuse, that he would expect staff to first make sure residents are safe, then to immediately notify Staff #66 of the allegation. Then, Staff #66 stated that he starts the investigation process, and that would include to suspend a staff member if one was identified as an alleged perpetrator, to start interviewing residents and anyone else identified as a possible witness, and to try to get an understanding of what happened. Staff #66 stated that he did not know of any abuse allegations regarding Resident #10. Staff #66 also stated that there were no investigations regarding an abuse allegation of Resident #10. Staff #66 stated that he was not aware of any police contacting him regarding an allegation of abuse of Resident #10.An interview was conducted with the DON (Staff #47) on November 11, 2025, at 10:47 A.M. Staff #47 stated that the police came to the facility sometime during the timeframe of October 18-25, 2025, and requested video camera footage for particular hallways. Staff #47 stated she was not informed by the police or by any other staff of any allegation of abuse. Staff #47 stated that no video camera footage was provided because most of the video cameras are fake and that the real cameras were not working. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation, revised September 2024, revealed that it is the policy of the facility that each resident has the right to be free from abuse. This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the facility. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. Regarding investigation, the policy revealed that all identified events are reported to the Administrator immediately. All allegations of abuse will be promptly and thoroughly investigated by the Administrator or his/her designee. The investigation will include the following: an interview with the person(s) reporting the incident, an interview with the resident(s), interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; a review of the resident's medical record, an interview with staff members (on all shifts) who may have information regarding the alleged incident, interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident, an interview with staff members (on all shifts) having contact with the accused employee; and a review of all circumstances surrounding the incident. To the extent there is evidence that could be used in a criminal investigation, staff will immediately notify the Administrator or his/her designee. Staff are not to tamper with or destroy any such evidence at any time. At the conclusion of the investigation, the Facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred. The investigation, and the results of the investigation, will be documented.Review of the facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment, revised September 2024, revealed that in response to allegations of abuse, the facility will ensure that, after receipt of a report of possible abuse, steps are immediately taken to protect the identified resident(s), to ensure that the results of all investigations are reported within five (5) working days of the incident to the Administrator and to the State Survey Agency, and to ensure that, if the alleged violation is verified, appropriate corrective action is taken.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an allegation involving abuse and neglect was documented completely in the clinical record for one resident (#11). The deficient practice could result in incomplete documentation in resident medical records and continued violation of resident rights.Findings include: Resident #11 was admitted to the facility on [DATE], with diagnoses that included pathological fracture of the right humerus, muscle weakness, dysphagia, systolic heart failure, hypotension, hypertensive heart disease, secondary malignant neoplasm of the liver, intrahepatic bile duct, lung, and brain, anxiety disorder, hyperlipidemia, anemia, and gastroesophageal reflux disease.A Medicare-5 Day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment.A care plan focus initiated on September 12, 2025, revealed the resident was resistant to care related to her anxiety.A care plan focus initiated on September 12, 2025, revealed the resident had the potential for a behavior problem related to anxiety, evidenced by refusing care, yelling at staff, and hitting staff.A care plan focus initiated on September 12, 2025, revealed the resident had the potential to demonstrate physical behaviors related to anxiety, and that she hit and spat at staff. Review of Resident #11's clinical record revealed no evidence of documentation regarding an allegation of abuse by a staff member. A telephonic interview was conducted on September 15, 2025, at 11:03 a.m. with a Registered Nurse (RN/Staff#14) who stated that if an allegation of abuse were made to him, he would need to do a progress note with a time stamp, what was witnessed, who he notified, and what immediate interventions they had as per facility policy. An interview was conducted on September 15, 2025, at 11:24 a.m. with a Licensed Practical Nurse (LPN/Staff#21) who stated that if an allegation of abuse were made to him, he would need to document it in the progress notes as per facility policy. The LPN stated that the progress note would need to detail the time the incident happened, verbal allegations that came from the patient, what was said, what actions were taken, and who was notified. The LPN stated that it was important to document allegations of abuse in the clinical record to trace down patterns or record historical evidence of allegations of abuse to make sure they have full documentation for legal reasons. The LPN further stated that the risk of not documenting allegations of abuse in the clinical record could be that if there was an allegation that did occur and was not documented, they would not be able to further prevent other incidents or prove that the incident occurred, and abuse may continue. An interview was conducted on September 15, 2025, at 11:49 a.m. with the Director of Nursing (DON/Staff#48) who stated that her expectation of staff in documenting allegations of abuse in the clinical record would be to notify administration before documenting an incident. The DON stated that she would expect staff to document allegations of abuse in the progress notes, complete a Change of Condition, and management would update the care plan. The DON stated that the progress notes would need to detail what happened, the psychosocial well-being of the resident, what they were doing for the resident, and who was notified. The DON stated that an example statement of her expectation, which would be patient reports an allegation of abuse against family, staff, or other resident, administrator aware, family and physician notified, followed by any interventions they put in place. The DON stated that she did not put a progress note in the clinical record about the allegations against the nurse, and there is no documentation specifically about the incident in the clinical record. The DON further stated that a progress note would have been expected in this situation, and it did not meet her expectations regarding the actual incident and allegations. A review of a policy titled, Documentation and Charting, was conducted in October 2024 and revealed that it is the policy of the facility to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, as well as the progress of the resident's care. The policy also revealed that the facility would provide nursing service personnel with a record of the physical and mental status of the resident, and a legal record that protects the resident, physician, nurse, and facility.

Base on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to monitor and ensure that resident (#34) was administered pain and psychotropic medications as per the orders and medications were left with the resident unsupervised. The deficient practice could result in the pain and anxiety not being managed. Findings include: Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included post traumatic disorder, anxiety, major depression, low back pain, and chronic pain syndrome. The care plan dated May 26, 2023 revealed that the resident is on pain medication therapy related to pain. Interventions included to administer medication as ordered. Review of the care plan dated May 29, 2023 revealed that the resident is on anti-anxiety mediation due to anxiety as evidenced by restlessness. Interventions included to give anti-anxiety medications as ordered by the physician. The minimum data set (MDS) dated [DATE] included that the resident's memory is okay and she is able to make decisions independently. The order summary revealed: -April 10, 2024, Gabapentin capsule 400 mg give 2 capsules by mouth every 6 hours for neuropathy. Hold from October 11, 2024 to October 14, 2024. -April 12, 2024, Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg (Oxycodone) give 1 capsule by mouth two times a day for pain. -April 14, 2024, monitor behavior every shift for anti-anxiety episodes as evidenced by target behavior, restlessness. -June 14, 2024, Oxycodone HCl oral tablet 15 mg (Oxycodone HCl) give 1 tablet by mouth every 6 hours for pain. Hold from October 11, 2024 to October 14, 2024. -July 31, 2024, Alprazolam tablet 0.5 mg give one tablet orally every 12 hours for anxiety as evidenced by restlessness. -October 27, 2024, Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg give 1 capsule by mouth one time only for pain for one day. The medication administration record (MAR) dated October 27 2024 revealed: -Oxycodone HCl oral tablet 15 mg (Oxycodone HCl) give 1 tablet by mouth every 6 hours for pain was administered at 6:00 a.m. -Gabapentin capsule 400 mg give 2 capsules by mouth every 6 hours for neuropathy was administered at 6:00 a.m. -Alprazolam tablet 0.5 mg give 1 tablet orally every 12 hours for Anxiety as evidenced by restlessness was not administered at 8:00 a.m. -Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg (Oxycodone) give 1 capsule by mouth two times a day for pain was not administered at 8:00 a.m. -Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg give 1 capsule by mouth one time only for pain for one day was administered at 3:15 p.m. A behavior note dated October 16, 2024 by a licensed practical nurse (LPN/staff #48) revealed that the resident was compliant with taking her medications, but requires observation due to losing them or dropping her medications on herself. A progress note dated October 27, 2024 by a (RN/staff #33) revealed that the nurse received a report that the resident takes her medications in pudding. The nurse brought the resident her morning medications that contained controlled substances in pudding; the resident became immediately agitated that the medications weren't separated into a separate cup and threw them on the floor. The nurse informed the resident that controlled substances would not be re-pulled. The resident subsequently refused all care from the nurse, including afternoon medications, and removed her supplemental oxygen in protest. The nurse informed the Assistant Director of Nursing (ADON) and the medical doctor. The medical doctor stated that he would come and see the resident. A progress note dated October 27, 2024 by (RN/staff #33) revealed that the physician cleared a one-time dose of pain medication for the resident. A behavior note dated October 29, 2024 by a (LPN/staff #42) revealed that the resident was compliant with taking her medications and appeared to be in a positive mood. She was watched while taking her medications to make sure that did not drop or hide anything. An interview was conducted on November 1, 2024 with (RN/staff #33), who stated that he had provided care for resident #33 on prior occasions. He went to her room to administer her morning medications between 8:00 and 9:00 a.m. He stated that he received a report that the resident receives her medication in pudding, but she wanted to see the medications, so she could identify them and choose which medications that she wanted to take, but they were already dissolving, so they were not recognizable. He stated that the resident told him that she is usually given her medication on the side with the pudding and he told the resident that was fine, but he could not pull the narcotics again, so she would have to take the medications in the pudding. He stated that a certified nursing assistant (CNA/staff 8#) was in the resident's room when he left to get the resident some water, but the resident normally takes the medications just with pudding, and when he returned the CNA told him that the resident had thrown the pudding with the medications on the floor, so he had to throw it all away. He stated that he did not know if the resident was allowed to take her medication without supervision, but based on his training, he is supposed to watch the resident take the medication to verify that it was taken and to ensure that the resident doesn't aspirate. He stated that once the medications were on the floor, he told the resident that she would have to wait until the next time that the medications were scheduled to be administered and this included the pain and anti-anxiety medication. He stated that there is a risk of continued pain and withdrawal when pain medications are not administered as ordered, and there is a risk of agitation if anti-anxiety medications are not administered as per orders. He thought that the pain medication and anti-anxiety medication was due again sometime in the evening. He stated that he didn't contact the physician right away, but continued to monitor the resident, and around mid afternoon, the resident complained of pain, removed her oxygen, became aggressive and was still upset about not receiving her medications in the morning. He stated that he contacted the physician around 1:00 p.m.; the physician was in the facility and told him that he would come by and see the resident. He stated that it is not within his purview to decide if a resident should get medication or not and the normal process would be to call another nurse to witness the medications being thrown away and pull more pain and anti-anxiety medication for the resident, but the medication had dissolved, so another nurse would not be able to identify the medications to witness that the medication was thrown away. He stated that he did not contact the ADON or DON because he was the charge nurse that day. During a second interview with (RN/staff #33) conducted on November 1, 2024 at approximately 11:15 a.m., he reviewed the medication administration record (MAR) dated October 2024 and stated that the resident refused all medications on the morning of October 27, 2024 when he wouldn't pull another Xtampza ER oral capsule for pain and Alprazolam for anxiety. He stated that the resident did not receive any medication on the morning of October 27, 2024, and if he documented that the resident did receive a medication, it is a documentation error. An interview was conducted on November 1, 2024 with a certified nursing assistant (CNA/staff #8), who stated that the resident's call-light was on and she was walking towards the resident's room when she heard raised voices. She stated that she could hear (RN/staff #33) and the resident were both yelling, so she didn't go into the room. Staff #33 came out of the room and said, I am not dealing with her anymore, and then the pudding cup with the medications came flying out of the room into the hallway and landed on the floor. She cleaned up the pudding on the floor and when she went into the resident's room, the resident told her that she doesn't take her medications like that and kept asking to speak with the charge nurse, but the charge nurse had called off that day, so (RN/staff #33) was the acting charge nurse. The resident was upset throughout the day and there wasn't anyone there to help the resident with her problem. The resident was asking to talk to someone throughout the day. An interview was conducted on November 1, 2024 at 12:25 p.m. with resident #33, who stated that she takes her medication with yogurt/pudding because she has trouble swallowing them. She stated that the nurse brought her medications in the yogurt and she was not able to identify the medications and told staff #48 that she needed to see the pills to make sure that she was getting the right medications, and he told her that he was not pulling the medications again. He left the yogurt with the medications on her table and walked out of the room, so she threw the cup of yogurt with the medications out the door into the hallway. She stated that the nurse normally waits until she takes the medications before leaving the room. She stated that she asked the nurse to call her doctor. An interview was conducted on November 1, 2024 at 12:49 p.m. with the Director of Nursing (DON/staff #1), who stated that resident #34 is not allowed to take medication unsupervised because she has a history of pocketing medications. She stated that the resident was given her pain medication that afternoon and received her evening medications. She stated that (RN/staff #33) should have followed the process when medication is wasted; he could have called a nurse from another hall to witness him throwing the medications away. She stated that staff #33 should have also notified the physician right away about the resident not getting her medications to make sure that there were no issues, but the resident has other orders for pain medication, so the resident did not go without pain medication. The facility policy, Professional Standards states that it is the policy of this facility that services provided by the facility meet professional standards of quality and be provided by qualified persons in accordance with each resident's care plan. The facility policy, Self-Administration of Medications states that if a resident desire to participate in self administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status.

Based on review of documentation, photographs, staff interviews, and the facility policy and procedure, the facility failed to provide services in accordance with professional standards of practice for one resident (#1). The deficient practice could result in appropriate services not being identified and provided to residents. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified fracture of thoracic vertebrae 5 and 6, subsequent encounter for fracture with routine healing , hypertension, and hypotension. The order summary revealed an order for aspirin tablet chewable 81 milligram (mg) one tablet by mouth one time a day for clotting prevention dated January 16, 2024; ticagrelor oral tablet 90 mg one tablet by mouth for clotting prevention dated January 16, 2024, the order discontinued and request for stop date not provided; and ticagrelor oral tablet 90 mg give one tablet by mouth every 12 hours for coronary artery disease (CAD) dated January 19, 2024, the order was discontinued and request for stop date not provided. Review of the care plan did not reveal a plan for hypertension, coronary artery disease, or the use of anticoagulants. The minimum data set (MDS) assessnebt dated January 22, 2024 included a brief interview for mental status score of 12 indicating moderate cognitive impairment. Review of a weekly skin evaluation dated January 30, 2024 did not reveal any new skin issues. Documentation dated February 3, 2024 at 12:27 p.m. revealed that a licensed practical nurse (LPN/staff #244) sent pictures of the resident's left foot/lower leg and the left knee/thigh to the physician stating that everyone said this was new bruising; the resident was on an acetylsalicylic acid (aspirin) and ticagelor. Documentation revealed at 12:30 p.m., the physician stated to get an X-ray of the knee and foot; to hold the aspirin (acetylsalicylic acid) for two days; and, check for blood clotting factors to include PT (prothrombin time), PTT (partial thromboplastin time), INR (international normalized ration) with CBC (complete blood count) in the morning. There was no mention that the left leg was cool to the touch. Documentation dated February 3, 2024 at 1:23 p.m. revealed that (LPN/staff #244) sent a second message to the physician stating that a registered nurse (RN/staff #92) stated that the resident was not really eating or drinking, and resident had a peripheral (IV), and asked if the physician would like to start fluids. The documentation revealed at that at 1:24 p.m. the physician responded stating to give the resident a liter of .9 normal saline at 60 milliliter (mL)/hour. There was no mention that the left leg was cool to the touch. A progress note dated February 3, 2024 at 2:02 p.m. revealed that resident #1's left leg from the upper thigh area to the toes was cool to the touch and red blotchy in appearance; pulses were present; flushed foley with red tinged urine flowing; physician notified and orders received for IV fluids at 60 mL/hr and X-ray ordered for knee and ankle. The order summary revealed an order dated February 3, 2024, x-ray left knee and foot one time only for bruising and swelling for one day and completed February 4, 2024. The order summary revealed an order dated February 4, 2024, PT/INR, PTT, CBC in the morning for bruising for one day and discontinued February 5, 2024. A progress note dated February 4, 2024 at 6:46 a.m. revealed that the resident was admitted to the hospital intensive care unit for a myocardial infarction, stroke, and blood clots in the bottom left extremity. A progress note dated February 5, 2024 at 10:50 a.m. revealed that the resident passed away in the morning at the hospital. The medication administration record (MAR) dated February 2024 revealed: -January 16, 2024, Aspirin tablet chewable 81 mg give one tablet by mouth one time a day for clotting prevention was administered February 1, 2, and 3, 2024. -January 19, 2024, Ticagrelor oral tablet 90 mg give one tablet by mouth every 12 hours for coronary artery disease (CAD) was administered February 1, 2, and 3, 2024. -February 3, 2024, x-ray left knee and foot one time only for bruising an swelling for one day was completed on February 3, 2024. -February 4, 2024, PT/INR, PTT, CBC in the morning for bruising for one day and was not completed due to the resident being transferred to the hospital. An interview was conducted on April 2, 2024 at 9:34 a.m. with a registered nurse (RN/staff #92), who stated that when she is assessing a resident for pedal pulses and femoral pulses in the lower extremities, she compares the color, temperature, and pulse in both extremities to identify differences between the two. She asks the resident if he or she is experiencing tingling or numb sensations. She stated that a white color in the skin indicates hypoxia, a lack of oxygen, and a red, blue, purplish color indicates perfusion. She stated that when she assessed resident #1's left and right lower extremities on February 3, 2024, there was a difference in temperature and color. The left extremity was cooler to the touch and a purple blotchy color. She observed that the higher up the thigh, the more purplish the blotchiness. She stated that it is best practice to use a scale from 1 to 4 when assessing the intensity of the pulse, 1 being faint and 4 indicating a bounding pulse. She stated that using a scale to assess intensity allows her to determine if there was a difference or a change in pulse intensity, which may indicate a problem, but she did not use the scale to assess the resident and therefore, did not did not determine a baseline for pedal pushes, so she could not really assess a change in condition. She stated that she checked that a pedal pulse was present and continued to check every hour until the X-ray technician arrived, but she did not document the assessments in the progress notes. Staff #92 reported to the charge nurse (LPN/staff #244) and staff #244 contacted the physician. An interview was conducted on April 2, 2024 at 11:06 a.m. with (LPN/staff #244), who stated that she was notified by a certified nursing assistant (CNA) that the resident had new bruises on the left leg. She stated that she assessed the resident's left leg and observed there was new bruising around the knee and on the dorsal side of the foot, but the red/purplish discoloration could have been mottling, which would have indicated a lack of blood flow. Then she stated that she thought the blotchy discoloration and not mottling. She stated that if mottling was present, pedal pulses would need to be checked and the facility doesn't use the intensity scale to assess pedal pulses, they only check that a pedal pulse is present. Then she stated that she did not remember if the left leg was cool to the touch, blotchy in color, or if staff #92 was present during the assessment. Then she stated that the left leg was warm to the touch. She stated that she did not document her assessment and told staff #92 to complete the documentation. She stated that she contacted the physician to report new bruising around the knee and dorsal side of the left foot and the physician ordered an X-ray and to hold the blood thinners for three days. She stated that staff #92 should have told her that the resident's left leg was cool to the touch because she thought that the resident had bruising from an unknown injury, but did not report the injury of unknown origin to the Director of Nursing or the state agency. She stated that she was later told that the resident had blood clots in the lower extremities. An interview was conducted on April 2, 2024 at 12:42 p.m. with the Director of Nursing (DON/staff #7), who stated that if a resident's leg was cool from the thigh to the toe, it was an expectation that the pedal pulse is checked. She stated that the facility does not use an intensity scale when checking the pedal pulse, the staff just check that the pulse is present. She stated that a lack of a pulse or a weak pulse can indicate a lack of blood flow to the area. She stated that the physician should have been notified if the the left leg was cool to the touch and a cooler extremity could indicate a decrease in blood flow. The facility policy, Change of Condition dated July 2023 states that it is the policy of this facility that all changes in resident condition will be communicated to the physician and documented. Nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that changes in resident #491 condition will be communicated to the physician. The deficient practice could result in delayed treatment. Findings include: Resident #491 was admitted on [DATE], with diagnoses of traumatic hemorrhage of cerebrum without loss of consciousness, wedge compression fracture of T11-T12 vertebra, fracture of the lower end of right radius and lower end of right ulna, dementia, essential primary hypertension, and atrial fibrillation. Record review dated September 8, 2023, revealed the following orders: aspirin 81 mg give one tablet by mouth one time a day for CVA prophylaxis, Lisinopril oral tablet 2.5 mg give one tablet by mouth one time a day for hypertension, and Amiodarone HCL oral tablet 200 mg give two tablets by mouth every 12 hours for atrial fibrillation for 7 days then give one tablet by mouth one time a day for atrial fibrillation for 23 days. Record review dated September 8, 2023, revealed resident had a hypertension care plan with a goal to remain free of complication related to hypertension. The interventions included to give anti hypertensive medications as ordered, to monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness, to monitor for and document any edema and notify MD, to monitor/document abnormalities for urinary output and report significant changes to the MD, to monitor/document/report to MD as needed any signs and symptoms of malignant hypertension such as headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (Dyspnea), and to monitor/record medication side effects and report to MD as necessary. On September 11, 2023, Interdisciplinary Team (IDT)-Brief Interview for Mental Status (BIMS) record revealed resident score was 0.0, a severe cognitive impairment. The Minimum Data Set (MDS) dated [DATE] revealed resident have a memory problem for short- and long-term memory; resident cognitive skills for daily decision making is severely impaired; resident required extensive assistance for bed mobility, transfer, dressing, eating, toilet use, personal hygiene; and resident required total dependence for bathing. During the review of vital signs, record review revealed the resident had a systolic blood pressure that ranges from 112 millimeter of mercury to 168 millimeters of mercury, and a diastolic blood pressure ranges from 68 millimeter of mercury to 89 millimeters of mercury since admission, except on September 17, 2023 at 07:29, record revealed the resident had a one-time episode of a blood pressure of 168/110. A physician progress note dated September 17, 2023 at 10:20 AM revealed, Patient lying in bed and no apparent distress. Seeing at around 9:50 AM. Not as talkative today. Appears comfortable. Blood Pressure: 168/110 September 17, 2023 at 7:29 AM. History of atrial fibrillation-on Amiodarone. On aspirin. Remains sinus on auscultation. Occasionally has an extra beat but remains in sinus. Follow up with cardiology. Hypertension-BP elevated. Monitor - on Lisinopril. During the review of vital signs, record review revealed the resident had a pulse rate that ranges from 54 beats per minute regular rate to 98 beats per minute regular rate since admission. But on September 18, 2023 at 6:36 AM, record revealed the resident had a new onset irregular pulse rate of 115 beats per minute. During the review of vital signs, record review revealed the resident had a respiration rate that ranges from 16 breaths per minute to 22 breaths per minute since admission. But on September 18, 2023 at 6:36 AM, record revealed the resident had respiration of 26 breaths per minute. There was no evidence found in the clinical record that the resident's physician was notified of the resident's blood pressure reading of 168/110 on September 17, 2023 at 7:29 AM. There was no evidence found in the clinical record that the resident physician was notified of the resident's new onset irregular heart rate of 115 beats per minute on September 18, 2023 at 6:36 AM, and there was no evidence in the clinical record that the resident's physician was notified regarding resident's status on September 18, 2023 upon entering the patient's room this morning during shift report the patient was seen breathing heavily, ADON was called into the room. Oxygen saturation were reading at 97%. Frequent checks were provided to the patient and the daughter was called and left a VM (voice message). Record review revealed on September 18, 2023 at 8:20 AM, therapy and CNA walked in the room and the patient was seen unresponsive, no pulse felt and patient is a DNR. During an interview with a Certified Nursing Assistant (CNA/staff #62) conducted on December 7, 2023 at 10:08 AM, the CNA stated that if there is a vital sign that looks too high or low, she will tell the nurse right away. She stated that they used a sheet that they grab every day and has section for blood pressure, respiration, and incontinent, and once the sheet is filled out with vital signs, she makes a copy and gives it to the nurse like for instance if she is done with room [ROOM NUMBER], she goes to the printer and make a copy and gives it to the nurse. The nurse has a copy by 7:00 AM and at the latest probably 7:30 AM. If low or high, she will retakes it again with same blood pressure cuff, and she will let the nurse know, and then the nurse will tell her to take with a manual blood pressure cuff just to make sure it is accurate reading. The vital signs that she takes are temperature, pulse, respiration, blood pressure and oxygen. Therapy does the height and weight. An interview was conducted on December 7, 2023 at 10:20 AM with a Licensed Nursing Assistant (LNA/Staff #92). Staff #92 stated that LNA is same thing as CNA with fingerprint. She stated that she takes vital signs right away, and writes/put it all in the sheet and then enters it in the system. If too high or too low, She stated that sometimes she rechecks it and sometimes the nurses do it. By 6:30 or 7:00 AM, the vital signs are entered in the system. Another interview was conducted on December 7, 2023 at 10:30 AM with a Licensed Practical Nurse (LPN/Staff #48). Staff #48 stated that admission nurses handles new patient, and then she gets report from them. The CNAs takes vital signs first thing in the morning before medication pass and the CNA gives us a copy of the paper of the residents' vital signs. Full set of vital signs are given to the nurse. She stated that she will go ask what happen if one of the vital signs is missing. Most part, the CNAs are pretty much on top of taking vital signs. Then, she stated that she will take the blood pressure for follow up, if they could not get it. Most part, the CNA will let me know if its high or low. If high or low, she will recheck it first, double check, then check what orders are in place, then she will let the provider know. An interview was conducted with the Director of Nursing (DON/Staff #170) on December 7, 2023 at 10:50 AM. The DON stated that the process for rehab patient is we get their vital signs every day and as needed. If there is a bad vital sign, the CNA notifies the nurse. It depends on the vital signs, usually the nurse or the CNA retakes them. If it is a high blood pressure, the nurse will check if there is a medication ordered and then the nurse will give the medication. If there is a new onset, then they are to notify the provider. Sometimes the provider will say, thanks for letting me know with no new orders or might order. If there is no new order, we might get vital signs the next shift to make sure nothing is significantly change. If on change of condition documentation, then vital signs are taken twice-day shift and night shift. Get the vital signs on day shift between 7:00 AM-9:00 AM and night shift between 7:00 PM-9:00 PM. Sometimes patients are on medication that requires us to check vitals. For change of condition, first admitted patients to establish baseline vital signs. If patient is on any type of change in condition, it will trigger the nurse to obtain vital signs at least twice a day. Some patient requires vital signs three times a day per insurance. The facility policy on Change of Condition Reporting, revised July 2017 and reviewed October 2023, included that all changes in resident condition will be communicated to the physician. For Acute Medical Change, any sudden or serious change in a resident's condition manifested by marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. Nurse will be documented in the licensed progress notes as soon as possible after resident needs have been met. For Routine Medical Change, unusual signs and symptoms will be communicated to the physician promptly. Routine changes are minor changes in physical and mental behavior that are not life threatening. The licensed nurse is responsible for notification of the resident's condition to the physician. Document resident change of condition and response in the resident's medical record and update the residents Care Plan, as indicated. For follow-up, the licensed nurse responsible for the resident will continue assessment and documentation.

Based on clinical record review, interviews, facility documentation, health plan documentation, review of the State Agency (SA) database, and facility policies, the facility failed to ensure one resident (#1) was free from physical and psychosocial abuse and the facility failed to prevent further abuse for the residents after staff were made aware of an allegation of potential staff to resident abuse. The sample size was 3 residents. As a result, the Conditions of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The resident census was 106. The deficient practice could result in further resident abuse. Findings include: On August 5, 2021 at 1:12 pm, the Condition of IJ was identified. The administrator (staff #21), Director of Nursing (DON/staff #38), and clinical resource nurse (staff #46) were informed of the facility's failure to initiate and follow abuse policies and procedures in investigating and assessing an allegation of abuse for one resident (#1). Specifically, staff were informed that an interview with the resident revealed notification to two staff members of an allegation of abuse on July 19, 2021. Interviews with both staff members revealed the resident had notified them of the incident and the staff members had discussed the incident with the administrator on July 19, 2021. After this report, the alleged perpetrator was allowed to continue to work the rest of her shift and was able to work with the resident as well as other residents. Additionally, the allegation was not reported to all required entities, and the allegation was not investigated until the facility was notified by the SA of the allegation. The clinical resource nurse presented a removal plan on August 5, 2021 at 2:34 pm. The facility was informed at 3:05 pm that the removal plan needed to be revised to included removal of information that showed the facility was not aware of the incident until July 29, 2021. The plan also needed to be revised to show a tentative date of completion for training, include law enforcement in the agencies to be notified of abuse allegations, establish a process to include non-interviewable residents in screening residents for potential abuse concerns, and include a process to document that all residents have been interviewed. A revised removal plan was presented by the facility on August 5, 2021 at 3:30 pm. This removal plan was accepted. The plan included the following corrective actions: -The resident was no longer residing at the facility. -The alleged perpetrator (staff #3) was immediately suspended on 8/4/2021. -Education was immediately initiated on 8/4/2021 by all of the Assistant Directors of Nursing (ADONs) to staff regarding reporting of abuse to include abuse prevention and re-initiated immediately upon notification of IJ, all staff from all departments to be educated by 8/11/21, and any staff member not receiving this education by this date, will need to receive the education prior to working their next scheduled shift. -Education was immediately provided on 8/5/2021 at 1:35 p.m. to the administrator and DON by the clinical resource nurse on reporting alleged violations of abuse, neglect, exploitation or mistreatment to include; immediately removing alleged perpetrator from premises, reporting allegation to administrator, the SA, Adult Protective Services (APS), Ombudsman, and law enforcement and to immediately initiate an investigation. -The administrator and DON and Operations Manager (OM) were suspended on 8/5/2021 pending investigation. -Resident interviews for all interviewable residents initiated on 8/4/2021 and re-initiated on 8/5/2021 immediately following notification of IJ to ensure residents feel safe, have not experienced or witnessed abuse, and feel comfortable reporting it to staff if it does occur. Will provide education on process of reporting issues to any staff member. Non-interviewable residents will have a skin assessment completed to identify any new or unusual skin issues. The responsible parties of the non-interviewable residents will be contacted to ask if they have visited recently and have any unusual behaviors or concerns regarding their care. -All residents have the potential to be affected by this practice. At 3:35 p.m. on August 5, 2021, the facility was notified that the concerns related to abuse also resulted SQC. Multiple observations were conducted on August 6, 2021 of implementation of the plan of correction. Staff in-services were being completed and staff interviewed were knowledgeable regarding abuse allegation identification, investigation, and reporting. As there were no additional concerns identified, the condition of IJ was removed on August 6, 2021 at 10:10 a.m. Specifics regarding resident #1: -Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial admission record dated July 16, 2021 included that the resident was alert, oriented to time, place, and person and was able to follow simple commands. The record included that the resident was continent of urine and bowel without urgency. The resident used a walker as an assistive device and had muscle weakness in both upper and lower extremities, but did not have any weight bearing limitations. A skin integrity section included that the resident had intact skin but had multiple discolored areas on her upper and lower extremities. There were no further details on these discolored areas and no mention of any bruising on the resident's chest. The record included that the resident had anxiety at times. A fall risk evaluation dated July 16, 2021 included the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A functional performance evaluation dated July 16, 2021 included the resident required substantial/maximum assistance (the helper does more than half the effort) for toileting. Review of the facility staffing assignment sheet for July 16, 2021 revealed that two Certified Nursing Assistants (CNAs/staff #73 and staff #3) were both assigned to the area that included the resident's room for the evening shift. A report for Activities of Daily Living (ADL) revealed that on July 16, 2021 at 9:59 pm, toileting was performed and the resident required extensive one person physical assistance. This was documented as complete by a CNA (staff #73). Review of the report for ADLs revealed no documentation of the other CNA (staff #3) providing care to the resident on July 16, 2021. Review of the facility staffing assignment sheet for July 19, 2021 revealed that staff #3 was again assigned to the area that included the resident's room from 6:00 am to 10:00 pm. A social services assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact and a Patient Health Questionnaire (PHQ-9) score of 10 indicating moderate depression. The assessment included the resident did not have a history of trauma. Review of a nursing note dated July 20, 2021 included the resident had no new skin conditions. A case manager note dated July 22, 2021 included that therapy informed case management that the resident really wanted to go home. A discharge Minimum Data Set (MDS) dated [DATE] included that the resident's short-term memory was ok. The MDS did not include a long-term memory assessment. The assessment included the resident was independent in making decisions regarding daily life, no evidence of acute change in mental status, and did not reject evaluation or care. The MDS included the resident required supervision for bed mobility, transfers, walking in the room, and toilet use. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note included that the resident appeared to be a little anxious. Per the clinical record, the resident was discharged from the facility on July 23, 2021. Review of the clinical record revealed no documentation that the resident had any falls in the facility. There were no fall assessments or any documentation to show that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, there was no documentation to show that the resident had bruising on her chest upon admission. Review of facility documentation revealed no evidence that the facility reported any incidents of abuse or neglect regarding the resident to the SA or to APS until after they were notified of an allegation by the SA on July 29, 2021. Also, there was no evidence that the facility investigated any incidents of abuse or neglect regarding the resident until after the SA informed the facility of the allegation. There was no evidence that an abuse allegation regarding this resident was reported to the SA or that investigation results were provided to the SA until August 5, 2021. Further review of the SA database revealed that the facility had not reported any incidents or provided any completed investigations for any resident since September 2017. Review of the facility's investigation, submitted August 5, 2021, revealed that the SA called the facility to discuss an allegation of staff to resident abuse on July 29, 2021. The allegation was noted to be regarding both physical and verbal abuse and included that during a transfer in the bathroom, a staff member shoved the resident while in the restroom and when assisting her back into her wheelchair and the staff member called her a rich [OBSCENITY] . The investigation included that the resident did not report an allegation of abuse while in the facility and that the facility only became aware when the SA called on July 29, 2021 to discuss the allegation. The investigation included that the alleged perpetrator could not be identified due to no description being provided and that when the facility called the resident, she would not provide any information. The facility was unable to substantiate the allegation. Further review of the investigation revealed that multiple staff members and residents had been interviewed regarding this incident and none of them reported any abuse or neglect concerns. There was no evidence that the resident's prior roommate (resident #5), who was still residing in the facility, had been interviewed regarding this incident. The report included that staff members who worked on the unit where the resident resided were interviewed, however, there was no evidence that staff #3, who had worked with the resident when she was in the facility, had been interviewed. Review of an email provided by the resident's health plan included a statement that the administrator was made aware on July 28, 2021 of the allegation of abuse on July 16, 2021. The email included that the administrator reported to the health plan that the incident was the result of a fall in the bathroom and was quickly addressed and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on August 3, 2021 at 2:20 pm with a Registered Nurse Case Manager (RNCM/health plan staff #79) for the resident's health plan. She stated that the resident informed her office on July 26, 2021 of an allegation of abuse that occurred when she was a resident at the facility. She stated the resident did not report directly to the facility for fear of retaliation because the resident had already informed two staff members and the CNA was still allowed to care for her. She stated the facility administrator (staff #21) was contacted on July 28, 2021 and informed of the allegations. She stated the administrator stated the resident had fallen in the bathroom and that's where she sustained her alleged injuries. An interview was conducted on August 3, 2021 at 3:00 pm with the DON (staff #38) and the administrator (staff #21). The administrator stated the facility was not made aware of any allegation of abuse towards the resident until the SA called them on July 29, 2021. The administrator stated that the health plan contacted him on Wednesday (July 28, 2021) and informed him that some resident concerns had already been presented to him by the OM (staff #26). The administrator said that the concerns were related to a medication administration issue, a request to change rooms because her roommate was keeping her up at night, and some concerns about some bruising. He stated that she had a fall in the hallway during the first night in the facility but he was not aware of any allegations against a staff member. The DON stated that the resident had bruises all over her body from a fall prior to admission which would make it difficult to identify if there were any new bruises. She stated that that they were unable to identify a date, time, location, or staff member during their investigation of an allegation of abuse. A phone interview was conducted on August 4, 2021 at 8:15 am with the resident. She stated that on July 16, 2021 around 8:00 pm, she needed to go to the bathroom. She stated that she had difficulty walking related to her increased weakness and required assistance to go to the bathroom. She said she pushed her call light and waited for 20 minutes; when staff did not come, she pushed the button again and waited another 20 minutes. She said that at this time, she became fearful that she was going to wet the bed. She said she needed to get someone's attention quickly so she used her roommate's wheelchair to go out into the hallway to get help. She said that once in the hallway, she heard staff yelling and complaining about being short staffed. She said she waved down an African American CNA with short tight curly hair (who was later identified to be staff #3). She informed the CNA that she had been trying to get help for the last 40 minutes. She said the CNA approached her swiftly, spun her around in the wheelchair while grabbing her shoulder. She said the CNA hit the wall with the wheelchair when they entered the room. As the interview with the resident continued, the resident was audibly upset and was heard crying on the phone. She said that the CNA wheeled her into the restroom where there was a sink and toilet. She said the CNA ran her into the wall, causing her to lift up slightly in the wheelchair, hitting her chest on the grab bar. She said that the CNA was complaining when she requested to go to the sink to wash her hands and brush her teeth. She said that when the CNA moved her toward the sink, she rammed her chest into the sink edge. She said the CNA then returned her to her bed and left. She said she could hear the CNA call her a white rich [OBSCENITY] in the hallway. She said this incident happened only a few hours after her admission and she was afraid to call for help or to even leave her bed. She said she could not sleep, hid from staff #3, and cried from that day until she reported the incident to staff on July 19, 2021. She said that she noticed bruising across her chest the following morning. The resident continued by saying that on Monday, July 19, 2021 she reported this incident to two staff members, the OM (staff #26) and an Occupational Therapist (OT/staff #110). She stated that both staff members were informed that the person who had abused her was providing her care that day (July 19, 2021). She stated she was never interviewed by the DON or administrator about the incident. She further said that she did not have any falls while in the facility. Review of clinical records revealed that at the time of the alleged incident, the resident's roommate was resident #5. An interview was conducted on August 4, 2021 at 10:47 am with resident #5. She stated that she was resident #1's roommate for a while and that a CNA took resident #1 to the bathroom on July 16, 2021 and closed the door behind her. Resident #5 described the CNA as an older African American with short curly hair. She said that she did not know what was being said, but she did hear the tone and pitch of the conversation rise higher while they were in the bathroom. She said that after resident #1 went back to bed and the CNA left, the resident told her what happened in the bathroom. She said that resident #1 told her that she was assaulted in the bathroom. She said she did not have any more information because she did not want to get anyone into trouble. She said that she was not interviewed about the incident until August 3, 2021. On August 4, 2021 at 12:20 pm, the DON (staff #38), administrator (staff #21), and clinical resource nurse (staff #46) were notified that the CNA involved in the abuse allegation was identified to be staff #3. The DON said that the CNA would be suspended. An interview was conducted on August 4, 2021 at 12:45 pm with an OM (staff #26). He stated that he met the resident on Monday, July 19, 2021 at around 4:30 pm. He stated the resident informed him at that time of concerns with her roommate and concerns she had with a CNA. He stated the resident told him that a CNA was rude/snippy with her and that while in the hallway, the CNA called her a rich white woman. He said that he did not know the CNA's name, but the resident described her as an African American with short black hair. He said that this was not enough information to identify who the CNA was. He stated that he felt that because the staff member did not use a bad word, he would not call this abuse. He stated the resident was chuckling about it because she said she is not rich. He stated the resident told him everyone has bad days. He stated he did not need to report it as abuse because it is not considered abuse when a staff member is rude or snippy or if they do not use bad language towards residents. He stated that he did inform the administrator on Monday, July 19, 2021 that the resident had an issue with a staff member. An interview was conducted on August 4, 2021 at 2:55 pm with the DON (staff #38) and the administrator (staff #21). The administrator stated the OM and the OT both informed him of the issues with the resident. The administrator stated that when the OT had informed him, he told the OT that the OM had already spoke with him about the resident having concerns with her care. The administrator stated he did not know what CNA the resident was having issues with and it did not seem like a big issue at the time. The administrator stated he should have looked further into the allegation. The DON stated that there was only one African American CNA working the evening of July 16, 2021 and that CNA has short, dark curly hair. The DON confirmed that the CNA was staff #3. During a continued interview with the DON and administrator, the DON stated there is no documentation of the resident falling while in the facility and all of the resident's bruising was identified on admission from a fall at home. An interview was conducted on August 5, 2021 at 8:55 am with a CNA (staff #3). She stated she remember working on July 16, 2021 but did not remember much about it. She stated she does not remember giving any direct care to the resident that night and that she does not remember any resident wheeling herself out into the hallway. She stated she was in the room a couple of times that night to care for resident #5 (resident #1's roommate), but that resident #1 did not require any assistance. She stated resident #1 was totally independent for her care and toilet needs. She stated she was never in the bathroom with resident #1 during her stay at the facility. In an interview on August 5, 2021 at 10:35 am with a CNA (staff #73), she stated she might have cared for the resident but she does not remember. She stated she did not know what rooms she was caring for on July 16, 2021. She stated she does not remember ever taking the resident to the bathroom and she does not remember any resident coming out into the hallway looking for help. An interview was conducted on August 5, 2021 at 11:00 am with an OT (staff #110). She stated that the resident was alert and oriented. She said she met with the resident on Monday, July 19, 2021 between 3:30 to 4:30 pm. She stated in that meeting, the resident told her of the allegations of abuse from a CNA that cared for her on July 16, 2021 and was caring for her on that day (July 19, 2021). She said that the resident reported that a CNA had said mean things to her including calling her a rich b word. She said that the resident told her that a bruise across her chest was from the grab bar in the bathroom and that this injury was caused by the CNA. She said that the resident had bruises on her extremities prior and that these were caused by fall prior to admission. She said that the resident described the CNA as an older African American woman with tight curly hair. She said she knew who the CNA was based on the description provided and that it was staff #3. She stated the administrator and DON were not in the building so she sent the administrator a text message. She stated that the message included the resident's concerns with the CNA. She stated that the response from the administrator included that he would speak to the resident. She stated that the facility did not interview her about the alleged abuse until August 4, 2021. A review of the labor hours report for July 2021 included that staff #3 clocked in at 5:47 am and clocked out at 10:26 pm on July 19, 2021. The allegation of abuse was reported by the resident between 4:00 to 4:30 pm on July 19, 2021, meaning that staff #3 continued to work with the resident for approximately 6 hours after the allegation was made. An interview was conducted on August 6, 2021 at 8:22 am with a clinical resource nurse (staff #46). She stated the facility is unable to provide the text messages between the OT and the administrator as they had been deleted. In an interview on August 6, 2021 at 8:50 am with the interim Director of Nursing/Clinical Market Leader (staff #10), a clinical resource nurse (staff #46), and a regional Executive Director (ED/staff #79). All three staff stated that they were not aware that the SA had no record of any reportable events since September 2017 including any abuse or neglect allegations, misappropriation of property allegations, or reports of injuries of unknown origin. They said they were not aware when the last reportable event was sent to the SA. The resident rights policy regarding reporting alleged violations of abuse, neglect, exploitation or mistreatment, revised May 2021, included that the facility will ensure that all violations of abuse, neglect, exploitation or mistreatment are reported within two hours to the administrator, the SA, and APS as appropriate. The policy included that the results of all investigations are reported within 5 working days to the administrator and to the SA. The facility's abuse prevention policy, revised May 2021, included it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. The facility will [MEDICATION(S)] to prevent abuse and neglect from occurring within the facility by supervising staff to identify and correct any inappropriate or unprofessional behaviors. The facility will assist staff in identifying abuse, neglect, exploitation of residents, and misappropriation of resident property. This includes identifying the different types of abuse including mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to bruises, skin tears and injuries of unknown source and sudden or unexplained changes in behaviors or activities (e.g., fear of a person or place, feeling of guilt or shame, etc.). Continued review of the policy included that all identified events are reported to the administrator immediately, that all allegations of abuse and neglect will be promptly and thoroughly investigated by the administrator or his/her designee. The policy included that the investigation will include the following: -An interview with the person reporting the incident; -An interview with the resident; -Interviews with any witnesses to the incident including the alleged perpetrator; -Interviews with staff members on all shifts who may have information regarding the alleged incident; -Interviews with other residents to whom the accused employee provides care; -Interviews with staff members on all shifts who have had contact with the accused employee. -Examination of the resident by a licensed nurse if allegation involves physical or sexual abuse of which the findings of the examination shall be recorded in the resident's clinical record. This includes a psychosocial assessment if needed; -Results of the investigation will be documented. The policy further included that if an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the facility will take steps to respond immediately to protect all residents from physical and psychosocial harm during and after the investigation. The facility will increase supervision of the alleged victim and other residents and make room or staffing changes if needed to protect the residents. The policy included that the victim will be protected from retaliation, and the facility will provide emotional support and counseling to the resident during and after the investigation, as needed. The policy included that if the alleged abuse involves an employee, the facility will immediately remove the employee from the care of any resident and suspend the employee during the investigation.

Based on observation, clinical record review, staff interviews and review of facility policy and procedure, the facility failed to provide care and treatment to prevent a pressure ulcer for one resident (#168). Findings include: Resident #168 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission nursing assessment dated [DATE], which documented the resident's skin was "Clean and intact skin." There was no documentation of any pressure ulcers upon admission. The Braden Scale for predicting pressure ulcer risk dated March 20, 2013, documented that the resident was at mild risk of developing a pressure ulcer. Physician admission orders [REDACTED]. Review of the interim care plan dated March 21, 2013, revealed a goal that the resident would have no impaired skin integrity through the next review. Approaches included a pressure reducing device to bed and wheelchair, encourage resident to float heels in bed, and encourage and assist the resident to turn and reposition every one to two hours. According to the Minimum Data Set (MDS) admission assessment dated [DATE], under Section M Skin, the resident was assessed to be at risk for pressure ulcers, however, no pressure ulcers were present. Review of the weekly skin integrity action tool revealed that the resident's skin was dry and intact on March 21 and March 28, 2013. Further review of the clinical record revealed there was no consistent documentation that the resident's heels were floated while in bed, nor documentation that the resident was turned and repositioned every one to two hours, as care planned. Review of the weekly skin integrity action tool revealed the resident's skin was dry and intact on April 3, 2013. A comprehensive care plan dated April 4, 2013, identified a problem of a potential for pressure ulcers related to impaired mobility and dementia. The goal included that the risk for skin breakdown would be minimized through the next review. Approaches included to encourage the resident to turn and reposition at least every two hours and for a pressure redistributing device to bed and wheelchair. This care plan did not include to float the resident's heels in bed, as previously care planned. The weekly skin integrity action tool dated April 11, 2013, documented the resident's skin was dry and intact. Review of the April 2013 Treatment Record revealed the resident's heels were to be floated at all times, however, the order was written as an "FYI." Continued review of the clinical record revealed there was no consistent documentation that the resident's heels were floated from April 1 through April 16, as care planned. According to the weekly pressure sore record dated April 17, 2013, the resident now had a pressure ulcer to the right heel, which measured 1.8 centimeter (cm) x 1.5 cm. The documentation included the wound had no drainage, there was zero percent granulation tissue or necrosis, no tunneling/undermining, and the the edges were hard. The assessment did not include a stage of the pressure ulcer, nor if the wound was open or closed. The note documented that the physician was notified, however, there were no wound treatment orders until two days later. Review of the actual impaired skin care plan updated on April 18, included a pressure ulcer to the right heel and the stage was unable to be determined. A physician's orders [REDACTED]. Review of a pressure ulcer care plan revealed it was updated on April 19, to reflect an unstageable wound on the left heel (per staff the left heel was in written in error and the wound was on the right heel). A goal included for no further breakdown, no complications related to the wound and that it would show signs of healing by the next review date. The approaches included a dietary consultation and an Airdyne mattress. A Braden Scale assessment dated [DATE], continued to identify the resident as being at mild risk, despite having an unstageable pressure ulcer to the right heel. A physician's orders [REDACTED]. Dietary notes indicated a consultation was completed on April 23, 2013, with no suggested changes to the resident's care. The next wound assessment was done nine days later on April 26, 2013. Per the weekly pressure sore record the wound measured 1.8 cm x 1.5 cm, with no drainage, no odor, no tunneling, the wound bed had zero percent granulation tissue, and the surrounding skin was hard. The note further included that there was no change in the wound. A nurse's note dated April 26, 2013, documented an unstageable area to the right lateral heel with a brown scab at the base of the wound. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The order now included the resident's heels were to be floated at all times. A nurse's note dated April 30, 2013, documented the right heel pressure ulcer was covered with slough, had an odor and the skin surrounding the wound was macerated. The note further documented that the heels were elevated on a pillow at all times and that the resident was on an Airdyne mattress. According to the weekly pressure sore record dated April 30, 2013, the wound was unstageable measuring 1.2 cm x 1.5 cm, with purulent (puss) drainage and odor, and the skin surrounding the wound edges were shallow with diffuse maceration. The documentation also included the wound had zero percent granulation tissue and had 100 percent necrotic tissue. The note indicated that the wound had worsened and the physician was called. A physician's orders [REDACTED]. The order also included to apply a thin layer of skin barrier cream to the edges of the wound. A nurse's note dated May 2, 2013, documented a conversation with a hospice certified nursing assistant (CNA) who stated the wound on the resident's heel had been present since she was at another long term care facility. The note further documented that the nurse who did the admission assessment was so focused on the resident's bottom that she may not have looked well at the resident's heels. However, there was no clinical record documentation to support that the right heel pressure ulcer was present upon admission, nor any documentation on the multiple weekly skin assessments that were completed from March 21 through April 16, of any pressure ulcer to the right heel. On May 8, 2013, documentation on the weekly pressure sore record revealed the wound was unstageable and measured 1.2 cm x 1.5 cm, with purulent odorous drainage and was 100 percent necrotic. A nursing note dated May 9, 2013, indicated that the resident's heels were floated at all times and that the resident had the Airdyne bed. Per the weekly pressure sore record dated May 16, 2013, the right heel wound measured 1.2 cm x 1.4 cm and had purulent drainage with no odor. The wound bed was described as 100 percent necrotic tissue and the edges of the wound were shallow with diffuse maceration. The note indicated there was no change in the wound. Per the weekly pressure sore record dated May 24, 2013, the right heel wound measured 1.0 cm x 1.2 cm, had purulent drainage and no odor, had 100 percent necrotic tissue, and the surrounding skin was macerated. The note indicated the wound had improved. A wound observation was completed on May 30, 2013 at 1:30 p.m. with licensed staff. The wound bed was pink with no necrotic tissue. The wound was not measured at this time. An interview was conducted with a Certified Nursing Assistant (CNA) on May 30, 2013. The CNA stated when the residents are showered the CNAs look at their skin from head to toe and if they notice any unusual areas on the resident's skin they report it to the nursing staff. An interview was conducted with a licensed practical nurse on May 30, 2013. The nurse stated that when a CNA reports to them that there might be a problem with the resident's skin, the nurse would go and assess that specific area of skin. She stated that the nursing staff rely on the CNAs to let them know if there is a problem area on a resident's skin. An interview was conducted with the Director of Nursing (DON) on May 30, 2013. The DON stated that she would have expected the nursing staff to complete a head to toe assessment which included visualizing the resident's skin from head to toe. The facility policy and procedure regarding pressure sore monitoring guidelines stated "It is the goal of the facility to maintain skin integrity. A resident who has developed a pressure sore will receive necessary treatment and services to promote healing, prevent infection and prevent new sores from developing...that the goal of the facility was to maintain skin integrity...to prevent further complications during the wound healing process...Upon identifying a pressure sore...weekly head to toe skin assessments...the licensed nurse will perform the following procedures...Complete or update Braden Scale Assessment...The accuracy of the Braden Scale assessment will be confirmed weekly for 4 weeks following admission by an interdisciplinary team during the weight and skin condition review meeting."

Based on closed clinical record review, facility and hospital documentation, staff interviews, and policy review, the facility failed to provide one resident (#261) with the appropriate drinking device for hot liquids to prevent an accident resulting in actual harm, and failed to ensure safety measures were in place to prevent falls. Findings include: Resident #261 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Regarding the burns sustained from a hot beverage Review of the resident's clinical record revealed a comprehensive care plan regarding activities of daily living (ADL's) that documented the resident required assistance with activities of daily living, including eating. Review of a hot beverage safety evaluation dated January 11, 2012, included that the resident may require set up assistance, while consuming hot beverages. Also noted under the comment section was that set-up was provided for the resident at all meals. A quarterly minimum data set (MDS) assessment dated [DATE], documented the resident was able to eat independently without assistance. Another hot beverage safety evaluation was completed on March 22, 2012, which noted the resident was now unable to consume hot beverages safely independently. Per the assessment, the resident required supervision while consuming hot beverages. This evaluation noted that the resident's care plan was updated regarding her need for assistance with hot beverages. However, further review of the comprehensive care plans revealed there were no specific interventions for the need to provide assistance with hot beverages. Review of the nurse's notes dated March 26, 2012, revealed the resident was screaming in the assisted dining room, as she had spilled coffee on herself. The resident was found to have slight redness on her abdomen, left breast and left lower arm. Review of facility documentation dated March 26, 2012, revealed the resident had sustained first degree burns. An intervention included for the use of a sippy cup for hot beverages. A physician's orders [REDACTED]. The order also included for Silvadene twice a day for 48 hours to the resident's abdomen, left breast, and left lower arm. A quarterly MDS assessment dated [DATE], documented the resident required limited assistance with eating. Review of the nurse's notes dated September 23, 2012, included the resident was sitting in the dining room after breakfast when she asked for hot tea. A staff member gave her the hot tea and the resident spilled the tea on her upper thighs and her lap. The physician was notified and ordered Silvadene until healed. Review of facility documentation dated September 23, 2012, revealed the resident was in the assisted dining room when a student certified nursing assistant (CNA) yelled out that the resident spilled tea on herself. Nurse's notes dated September 23, 2012, documented the resident had numerous large fluid-filled blisters noted on both of her upper thighs with slight redness surrounding these areas. A second entry noted that the resident complained of pain related to the blisters and was medicated. The blisters were noted to be large and raised, however, there were no measurements documented. The note also included that the CNA's were counseled to make sure that sippy cups were used for hot beverages for this resident. A nurse's note dated October 2, 2012, included the resident was being discharged to another facility. The note included the burn to the resident's right thigh measured 5 centimeters (cm) x 5 cm. The upper left thigh was noted to have a reddened area. In an interview with a registered nurse (RN) at 9:10 a.m. on May 30, 2013, she stated a student CNA was feeding the resident and asked for hot tea. She said the student CNA got her a cup of hot tea and did not use a sippy cup for the tea. She stated the student should have provided the resident with a sippy cup for the tea, since this was an intervention being used for this resident. She stated that this resident was weak and needed assistance with all of her ADL's. She stated that the burns sustained on this resident's thighs were severe. She stated that when there are students in the facility, their instructor trains the students to look at meal tickets before feeding residents to see if they have any special needs, such as sippy cups for hot beverages. She further stated that the student should have been assigned to a CNA and that when assigned with a student, the CNA should stay with the student to be sure that the residents get what they need for meals. In an interview with the RN instructor of the student CNAs at 9:45 a.m. on May 30, 2013, she stated that when instructing the students she tells them that they are to read the diet slips for each resident when feeding. She further stated that the students are assigned to a facility CNA on a 1:1 basis and that the students can feed people on their own, but they have a facility CNA that is responsible for them. She further stated that a student is not allowed to feed a resident who has special risks, such as a resident who may be at risk for choking. An interview was conducted at 12:15 p.m. on May 30, 2013, with a CNA who assists residents in the assisted dining room. She stated that she will read the dietary slip to know if a resident has a special need, such as a sippy cup. She stated that when students are in the facility, she will teach them to look at the dietary slip before serving a meal. She further stated that she stays with the student as much as she can to make sure they are doing the job right. During an interview with the Director of Nursing (DON) at 8:30 a.m. on May 31, 2013, she stated that the hot tea incident happened on a weekend and that the resident was in the assisted dining room when she was given a cup of hot tea that she spilled on herself causing burns. The DON stated that the resident was not given a sippy cup for the tea. She stated that someone likely did not realize the resident needed a sippy cup for hot beverages and instead gave her a regular cup. She further stated that when students are in the building, they are under the direction of a facility CNA that they are assigned to and that they should not be putting anything in front of the resident without a facility CNA watching them. She further stated that the students are instructed to read diet cards so they are familiar with any special needs that residents may have. Regarding the fall out of the wheelchair Review of the clinical record revealed the resident had a history of [REDACTED]. A care plan for the potential for falls identified that the resident was at risk, due to a history of falls, impaired mobility, impaired cognitive status, poor judgement, poor safety awareness, and an inability to use the call light or ask for assistance. Interventions included to assist with transfers and ambulation as needed, analyzing previous falls to determine if any patterns can be addressed, and encourage use of proper foot wear and assistive devices. The care plan did not include that the resident tended to lean forward, nor were there any interventions in place to address this behavior. Review of the clinical record revealed that a fall risk assessment dated [DATE], which noted the resident was at high risk for falls and had multiple falls in the past. Continued review of the clinical record revealed that a mobility screening was completed on January 11, 2012. The screening noted that the resident was dependent in her level of assistance and required the nursing staff to lift more than 25 pounds of the resident's weight. Also, it noted that the resident's level of cooperation and comprehension was unpredictable. Review of the nursing notes revealed that the resident was attempting to get out of bed several times on January 6, 2012. Review of the physician's orders [REDACTED]. Nurses notes dated January 25, 2012, included the resident fell from the bed. The fall mats were not in place beside her bed. No injuries were noted. Review of facility documentation revealed that the resident sustained [REDACTED]. A CNA was noted to be taking over for the evening CNA when she transferred the resident off the toilet and put her in her wheelchair. The CNA began pushing the resident's wheelchair toward her bed, when the resident leaned forward and fell on the floor. According to a nurse's note dated March 1, the resident sustained [REDACTED]. A physician's orders [REDACTED]. Review of the hospital documentation revealed that the resident was diagnosed with [REDACTED]. In an interview with a CNA at 9:15 a.m. on May 30, 2013, she stated that she was the CNA who was pushing the resident's wheelchair when the resident fell . She stated that most of the time this resident required total care at night and that the incident occurred at night. She stated that she got the resident into her wheelchair and told a family member who was present to get in front of her, because the resident did not have the foot pedals on her wheelchair and it would be safer to have her there in front. She stated the family member did not do this. She stated that she started wheeling the chair toward the resident's bed and the resident fell . She said that she thought the resident had leaned forward and lost her balance, falling out of the chair. She further stated that the resident did lean forward sometimes to the point of being unsafe. She also stated that the resident's foot pedals were usually on the wheelchair and that they should have been on the night of the fall. She stated that everyone knew to use the foot pedals for this resident, as she was a tall lady and her feet would tend to drag on the floor. She said that when someone was to have foot pedals, it might be in the resident's care plan or it could be through verbal communication. She stated that in this case, neither of these things happened and staff just knew to use the pedals for this resident. She stated that she knew to use the foot pedals because the resident did not move around on her own and her feet hit the ground so she knew that using the foot pedals would be safer. She stated that after the fall, they used the foot pedals on her chair all the time. During an interview with a licensed practical nurse (LPN) at 10:00 a.m. on May 30, 2013, he stated that this resident was a known fall risk and that he remembered the resident falling a few times during her stay in the facility. He stated that the resident would try to get up out of bed or out of her wheelchair often and was not able to safely do so. He stated that she would lean out of her wheelchair a lot, especially when she was going from the bathroom to her bed. He stated that the normal procedure in the facility was to put the foot pedals on almost every resident's wheelchair in the facility. In an interview with the DON at 8:10 a.m. on May 31, 2013, she stated that the only thing she could conclude about the fall was that the foot pedals were not on the wheelchair. She stated that maybe the foot pedals should have been on the chair for the short distance from the bathroom to the bed, but that normally the resident was good about lifting her feet while in the wheelchair. She stated that the facility will communicate special needs such as foot pedals through communication or by care planning. She further stated that she did not remember if the resident was prone to leaning out of her wheelchair. In an interview with an LPN at 9:15 a.m. on May 31, 2013, she stated that she remembers that this resident would attempt to transfer herself a few times and would lean forward and to the edge of her wheelchair, which put her at risk for falls. She stated that this resident had poor safety awareness. An interview was conducted with a CNA at 9:30 p.m. on May 31, 2013, who stated that the resident would often try to stand up out of her wheelchair and was often leaning from the wheelchair trying to pick items up off the floor. She stated that when leaning and trying to get up, the resident was at high risk for falls. She stated that because this resident was a fall risk, she would make sure that the foot pedals were on and she would keep a close watch on the resident. Review of a fall prevention policy noted that the facility will identify residents at risk for falls and develop interventions in place to prevent falls.