Every finding on record at Clarendon Nursing Home

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The Dietary Manager failed to have the appropriate license, certification, or qualifications to function as the Director of Food and Nutrition Services since her start date in August 2025. This failure could place residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition.Findings included: Record review of a current facility employee roster including hire date, indicated the DM's date of hire was 08/01/2025. During an interview on 01/13/26 at 9:05 AM, the ADS stated she had been employed at the facility since August 2025 and was hired as the DM and had been in that role since August. When asked for her certification for DM, she stated she was not certified or enrolled in a class to become certified at this time. During an interview on 01/14/26 at 9:49 AM, the BOM/HR stated that she was responsible for making sure that staff are being trained. She stated the DM was not certified and did not state when her classes will start. The BOM/HR stated that they have a RD who the DM consults with on a regular basis. She stated a negative outcome for not having a trained DM could be malnutrition, choking hazards, and weight loss. In an interview on 01/14/26 at 9:55 AM, the ADM stated the DM was not certified and that BOM/HR was responsible for making sure staff were trained. She stated she thought the DM was supposed to be taking classes and thought she was enrolled but when she asked the BOM/HR person, the ADM stated the DM was not enrolled. She stated a negative outcome for not having a trained DM could be nutritional meals might not be correct. In an interview on 01/15/26 at 10:49 AM, the RD stated that she had been working with the facility since November 2023. She stated that she was not sure if the ADS was certified, but that the ADM would know. The RD stated she consults with the ADS monthly and more if needed. She stated a negative outcome for not having a trained DM could be lack of knowledge on food sanitation and safety. Record review of the facility policy titled Food and Nutrition Services Staff, dated October 2017, included in part: .Policy Statement: The Food Services Department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 3 medication storage areas reviewed to meet the needs of each resident. The facility had 8 inulin medications expired according to the date documented on the bottle/pen of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.Findings included: During an observation on [DATE] at 11:08 AM (with LVN A present) of the facility's medication room noted there were 8 insulins that revealed the following:2-Humulog insulin bottles marked with an open/accessed date of [DATE]. (opened 29 days prior to today's date)1-Novolog insulin bottle marked with an open/accessed date of [DATE]. (opened 46 days prior to today's date)1-Lantus insulin bottle marked with an open/accessed date of [DATE]. (opened 33 days prior to today's date)1-Novolog insulin bottle marked with an open/accessed date of [DATE]. (opened 44 days prior to today's date)1-Humulog insulin pen was not marked with a date it was open/accessed. 1-Humulog insulin pen marked with an open/accessed date of [DATE]. (opened 41 days prior to today's date)1-Lantus insulin pen marked with an open/accessed date of [DATE]. (opened 33 days prior to today's date)LVN A verified all 8 insulins were currently being used for resident treatment. During an interview on [DATE] at 11:14 AM LVN A (the nurse responsible for this shift for administering all injectable medications to include insulin) verified all 8 insulins reviewed had expired. LVN A reported this was a problem and she would immediately dispose of all the expired insulins. LVN A reported the facility had an instruction sheet at the nurses' station containing information on all insulins of when they were to be disposed depending on the type every 28 or 30 days. LVN A reported if an insulin was given that was expired then the resident could have a reaction, or it would not be effective which would affect the residents' condition by raising their blood sugar. During an interview on [DATE] at 9:10 AM the DON reported all insulins should be marked when they are opened with the date they are opened and when they expire which was usually 28 days. The DON reported they have an instruction manual at the nurse's station that gives instructions on all their medications on how they are used and when they should expire to include their insulins. The DON reported she had contacted the Medical Director and the Pharmacy Consultant for additional information but had not heard anything at this time. The DON reported it was the facility policy that each nurse administering any medication was responsible for verifying the medication was viable to administer to include the insulin to include if it was expired. The DON reported that if a medication (especially insulin) was administered was expired then the potency was not what it should be, and the treatment would not be effective. Record review of the facility provided instruction guide titled Insulin Vials PharMerica 6/2021, revealed the following information: Humalog (insulin bottle): Discard after 28 days after opening EVEN IF refrigerated. Novolog (insulin bottle): Discard after 28 days after opening EVEN IF refrigerated. Lantus (insulin bottle): Discard after 28 days after opening EVEN IF refrigerated. Humalog KwikPen (insulin pen): Discard after 28 days after opening . Lantus SoloStar (insulin pen): Discard after 28 days after opening . Record review of the facility provided policy titled Storage of Medications revised [DATE], revealed the following: Policy Statement:The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation:2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safer, and sanitary manner.4. The facility shall not used discontinued, outdated, or deteriorated drugs or biologicals.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses. Findings included:Observation of the pantry on 01/13/26 at 9:10 AM revealed the following:1. (1) clear container that contained what looked like rice, no label or date.2. (1) clear container that contained what looked like flour, no label.3. (3) cans of vegetable soup - cans were dented.During an interview on 01/13/26 at 9:11 AM, the ADS stated that she puts dented cans in a separate area away from food storage. When shown the 3 cans of dented food on the pantry shelves, she immediately removed them from pantry. Observation of the freezer on 01/13/26 at 9:15 AM revealed the following:1. (1) can of lemonade, no label or date.2. (1) box of what looked to be frozen rolls, open to air, dated, no label.3. (6) individual Italian ices, no label or date.4. (1) box of what looked to be guacamole packs, no label or date. Observation of the refrigerator on 01/13/26 at 9:22 AM revealed the following:1. (1) container of what appeared to be yogurt, no label or date.2. (1) opened container of milk - 1/4 full - no date.3. (1) bag of unidentified meat, dated, unable to read label. 4. (1) box containing 8 wrapped packages of margarine, no label or date. 5. (1) Ziploc bag of meat, no label or date. In an interview on 01/13/26 at 11:28 AM, [NAME] C stated she had worked at the facility for 4 days. She stated it was everyone's responsibility to label and date food and if this did not happen, staff would get in trouble and food could be bad or cause residents to get sick. In an interview on 01/13/26 at 11:37 AM, [NAME] D stated she had worked at the facility for almost a year and everyone who worked in the kitchen was responsible for labeling and dating food. She stated a possible negative outcome was food could mold, and residents could become sick or ill from bad food. In an interview on 01/13/26 at 11:43 AM, [NAME] E stated it was everyone's responsibility to label and date food and if this was not happening, residents could get sick or get food poisoning.In an interview on 01/14/26 at 9:41 AM, the ADS stated she had worked at the facility since August 2025 and that it was everyone's responsibility to label and date food and that not doing it could put residents at risk for not receiving correct food or getting sick. Record review of facility policy, titled Food Receiving and Storage dated October 2017, revealed the following information in part:.Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ( use by date). 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). 11. Wrappers of frozen foods must stay intact until thawing.

Based on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 1 (Resident #34) of 15 residents reviewed for behavioral health services.The facility failed to ensure Resident #34's comprehensive care plan included goals and interventions addressing his documented diagnosis of post-traumatic stress disorder.This failure could place residents at risk for diminished quality of life due to the lack of treatment and prevention to maintain resident safety.Findings included:Record review of Resident #34's face sheet dated 01/13/2026 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath),anxiety disorder(feeling panic), bipolar disorder(mood swings), post-traumatic stress disorder, chronic(health condition caused by an extremely stressful event).Record review of Resident #34's last MDS was a quarterly assessment completed 12/18/2025 did not have a BIMS score due to Resident #34 not completing the assessment. In section D0700-Social Isolation- Resident declines to respond. The MDS Assessment further stated his active diagnosis included Post Traumatic Stress Disorder.Record review of Resident #34's care plan latest revision on 01/13/2026 did not mention any goals or interventions related to Resident #34's PTSD. Record review of Resident #34's Trauma Informed assessment dated [DATE] revealed resident had a diagnosis of PTSD. The assessment documented the resident experienced nightmares within the past month of the assessment, frequently on guard and easily startled. The assessment did not include trauma specific guidance or additional information to assist facility staff in providing trauma-informed care.During an interview on 01/13/2026 at 11:20 AM, the MDS LVN stated she and the DON were responsible for updating the care plan with interventions and goals. The MDS LVN stated the absence of trauma informed care measures would be a resident's PTSD may not be addressed. During an interview and observation on 01/13/2026 at 11:25 AM, the DON reviewed Resident #34's care plan and confirmed it did not include goals or care approaches related to the resident's PTSD. The DON stated she and the MDS Coordinator were responsible to ensure care plans were updated and completed with information related to each resident. The DON also stated she was responsible for completing the assessments with residents related to trauma and getting that information in the care plan. The DON stated that a potential negative outcome of not including care approaches and interventions related to resident care would be residents may not get the best care possible.During an observation on 01/14/2026 at 2:00 PM, Resident #34 was in a small group in the activity room, he appeared comfortable in the small group. He did not appear agitated or depressed. He was dressed for the day, sitting in his motorized wheelchair. During an interview on 01/15/2026 at 9:10 AM, LVN B stated she was not aware Resident #34's had PTSD. LVN B stated when time permitted, she reviewed care plans and that it would be beneficial for nursing staff to know what approaches worked best for each resident, including identified triggers. LVN B further stated the DON was responsible for ensuring care plans were updated and completed. During an interview on 01/15/2026 at 9:15 AM, the AD stated documenting care approaches in the care plan assisted her in identifying appropriate activities, resident specific triggers and interventions during activities. She also stated the absence of documented triggers could result in staff inadvertently triggering a resident, which could lead to a negative outcome.On 01/15/2026 at 9:53 AM, a telephone interview with the part time SW was unsuccessful.During an interview and observation on 01/15/2026 at 1:36 PM, Resident #34 reported not feeling well and was observed lying in bed. Resident #34 did not appear depressed or agitated. His room was clean and orderly; his military affiliation flag was hanging near his bed. Resident #34 talked about his time in the military and stated he had PTSD due to events that happened in the military. Because Resident #34 was not feeling well, the interview could not be completed.Record review of Behavioral Assessment, Intervention and Monitoring Policy dated March 2019 reflected the following:.The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial wellbeing in accordance with the plan of care.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #36) of 15 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #36's MDS was accurately coded to reflect he received insulin. This failure could place residents at risk of not receiving necessary care. Findings Included: Record review of Resident #36's admission record dated 01/14/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, mild, with other behavioral disturbance (breakdown of thought process causing disruptive behavior), type 2 diabetes mellitus (inability to process sugar), Anxiety disorder (a group of mental illnesses that cause constant fear and worry), major depressive disorder (mental illness causing sadness due to lack of chemicals in the brain that cause happiness) or (Persistent depressed mood), and cognitive communication deficit (impaired thought processes). Record review of Resident #36's annual MDS assessment revealed a completion date of 11/20/25. Section C (Cognitive Patterns) revealed a BIMS score of 00 which indicated the resident's cognition was severely impaired. Section N0300 & N0350 revealed Resident #36 had received insulin in the last 4 days of the 7-day lookback period. Section N0415 J revealed Resident #36 was not taking insulin. Record review of Resident #36's care plan completed on 11/29/25 revealed Resident #36 was taking insulin for his diabetes.Record review of Resident #36's active order summary report dated 01/15/2026 revealed the following orders: .for blood sugar <60, give 8 ounces of juice with 2 tsp sugar po every 30 minutes until blood sugar is greater than 100. <40 give glucogen 1mg IM and notify MD as needed for hypoglycemia. Semglee Subcutaneous solution Pen-Injector 100 Unit/ML. Inject 10 unit subcutaneously at bedtime related to Type 2 Diabetes Mellites without complications .During an interview on 01/15/26 at 9:41 AM, the MDS LVN stated she had worked at the facility for 10 years and was responsible for completing MDS assessments. She stated she used the RAI manual as her policy when completing MDS assessments. When asked if Resident #36's MDS was correct in section N0415 J, the MDS LVN stated she had never seen including insulin after hypoglycemic before now and she would fix the MDS since he takes insulin. The MDS LVN stated a negative outcome of having inaccurate MDS assessments could be that proper care for residents could be affected and it could also affect their funding.During an interview on 01/15/26 at 9:44 AM, the DON stated that the MDS LVN was responsible for MDS assessments. She stated it would be an issue if a resident was taking insulin and not coded for that on their MDS. The DON stated an inaccurate assessment could affect the funding, continuity of care, and could cause their team to not be on the same page regarding medications. She also stated that an inaccurate MDS could impact care for residents because the care plan was based on the MDS.During an interview on 01/15/26 at 9:51 AM, the ADM stated the MDS LVN was responsible for completing MDS assessments. She stated MDS assessments affected facility funding as well as direct care that a resident received.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed the following: . N0415: High-Risk Drug Classes: Use and IndicationN0415J1. Hypoglycemic (including insulin): Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415J2. Hypoglycemic (including insulin): Check if there is an indication noted for all hypoglycemic medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).Include any of these medications given to the resident by any route in any setting (e.g., at the nursing home, in a hospital emergency room) while a resident of the nursing home.Code a medication even if it was given only once during the look-back period.

Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 4 out of 5 employees (LVN A, CNA B, CNA C and PTA) reviewed for required training. The facility failed to ensure staff were properly trained in Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures and Dementia for 4 of 5 employees (LVN A, CNA B, CNA C, and the PTA) reviewed for training at hire and annually. This failure could place residents at risk of receiving care from individuals who did not have the knowledge and skills to properly provide safety from adverse events or other resident life and health complications. Findings included: Record review of employee records for LVN A reflected LVN A was hired at the facility on 03/18/2022 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 09/24/2023. Record review of employee records for CNA B reflected CNA B was hired at the facility on 06/09/2023 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 02/24/2024. Record review of employee records for CNA C reflected CNA C was hired at the facility on 02/28/2023 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 02/28/2024. Record review of employee records for the PTA reflected the PTA was hired at the facility on an unknown date and had not received any training through the facility, on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since hire. An interview with the BOM/HR on 04/15/2025 at 3:27PM reflected she was unaware LVN A, CNA's B and C, and the PTA were not up to date on their trainings. She stated she had spoken with the corporate office about trainings being provided to the facility staff, but nothing had been done at the corporate level. She stated she had asked the corporate office about the required instructional material of trainings, not the timing of trainings. The BOM/HR stated the PTA did not have trainings for Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, HIV, Restrains, Emergency Procedures, and Dementia on file with the facility because she assumed the PTA had done them through her contracted company. The BOM/HR had not asked the company for verification of the trainings for the PTA prior to hire and was unable to provide the telephone number for the contracted company, so the trainings for the PTA could have been verified. The BOM/HR stated LVN A, CNA B and CNA C should have been trained on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia care through the facility, and could not explain why their training records were not up to date. The BOM/HR stated these trainings were done when an individual was hired and again annually. She stated the negative outcome of caring for residents without training could have been residents received incorrect or incomplete care by the untrained individual. Record Review of undated facility policy for required training reflected the following: There are certain in-service training courses that are required by State such as Blood Borne Pathogens, Restraints, Abuse and Neglect, Slip and Fall, Emergency Preparedness and Resident Rights upon hire and will vary by position and therefore some employees may be required to complete a minimum of courses while others will have a greater amount of training to be completed.

Based on record reviews and interviews the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 2 CNAs (CNA C) reviewed for CNA certification. The facility failed to ensure CNA C's certification was current before allowing her to care for residents. CNA C worked in the facility providing resident care, on a full-time basis, with an expired certification for the months of February and [DATE]. This failure could place residents who received care from CNA C in medical jeopardy, which could lead to the decreased physical, mental, and psychosocial well-being of each resident. Findings included: On [DATE] record review of employee records revealed CNA C's certification expired on [DATE]. An interview with the BOM/HR on [DATE] at 3:27PM revealed she was not aware CNA C's certification had expired. She stated she thought it was the responsibility of CNA C, not herself, to ensure the certification was up to date. CNA C had been on bereavement leave since [DATE] and was not interviewed. An interview on [DATE] at 3:30PM with the Admn., the DON, the ADON, and the BOM/HR revealed the DON was not aware CNA C's certification had expired. The DON stated the last day CNA C worked on the floor was [DATE] due to a death in the family. It was noted at that time, CNA C had been working for 2-months prior to [DATE] with an expired certification. The BOM/HR asked the DON if it was her responsibility to keep up with CNA certifications. The Admn stated it was both the responsibility of the DON and the BOM/HR, along with the employee to ensure all certifications were up to date. The Admn. stated the BOM/HR should have had a system for reviewing employee folders or files to ensure all HR paperwork was up to date. The DON should have had the dates of her employees' certifications and licenses in an electronic file on her computer where it was reviewed monthly. The Admin., the ADON, and the BOM/HR could not identify a negative outcome of having an uncertified CNA caring for residents. The DON stated CNA C had been a CNA for an exceptionally long time and she was competent in her skillset but could not give a negative outcome of CNA C providing care to residents with an expired certification. An interview with the Administrator on [DATE] at 5:27PM reflected monthly in-service trainings did not count as competency training in the aforementioned subjects, due to the fact that monthly in-services did not have a pre- or post-test and had no measure of staff competency but were informational and meant as a refresher course to keep vital information at the forefront of staff decision-making and resident care. There was no facility policy for the review of employee files by the BOM/HR or for the oversight of certificates by the DON.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food service safety. The facility failed to label and date food in the refrigerator, freezer, and pantry. The facility failed to keep food in the refrigerator and freezer sealed. The facility failed to maintain cleanliness in the pantry. The facility failed to store all food at least 6 inches off the floor in the pantry. These failures could put residents at risk of food and pest borne illnesses. Findings Included: An observation of refrigerator 1 on [DATE] at 09:12 AM revealed the following: 1 clear plastic bag open to air containing what appeared to be lunch meat with no label or date. 1 square, opaque, plastic tub with a green lid containing what appeared to be jelly with no label or date. 1 box containing 6 sealed plastic bags of what appeared to be guacamole with brown spots throughout and a date printed on the plastic of [DATE]. 1 square, opaque, plastic tub with a green lid containing what appeared to be slices of cheese with no label or date. 1 resealable plastic bag containing what appeared to be pasta and marinara sauce with no label and a date of ,d+[DATE]. 1 bag of shredded mozzarella cheese in original packaging inside resealable plastic bag with no date and green specks throughout. 1 bag of shredded Parmesan cheese in original packaging inside resealable plastic bag with no date. 1 box of cream cheese, one third full with no date. 1 plastic tub with lid full of stacked sandwiches with no label and no date. An observation of refrigerator 2 on [DATE] at 09:21 AM revealed the following 1 square, opaque, plastic tub with green lid of jalapeno slices labeled and dated ,d+[DATE]-,d+[DATE]. 1 tray with small plastic cups with what appeared to be butter in each one. Covered with plastic wrap. No label or date. 1 opaque, plastic pitcher with red lid containing reddish liquid about ,d+[DATE] inch in bottom and some stuck to sides of pitcher with no label or date. 1 square, opaque, plastic tub with green lid full of whitish substance with no label and no date. 1 large metal bowl covered with plastic wrap full of orange substance with no label no and date. An observation of Freezer 1 on [DATE] at 09:26 AM revealed the following: 1 box of egg patties open to air. An observation of the pantry on [DATE] at 09:27 AM revealed the following: A 5-pound tub of peanut butter with peanut butter smeared all around the outside of the lid and along the bottom edge of the tub in places. 1 5-gallon tub of what appeared to be corn flakes cereal ,d+[DATE] full with no label and no date. 1 5-gallon tub of what appeared to be bran flake and raisin cereal ,d+[DATE] full with no label and no date. 1 5-gallon tub of what appeared to be crispy rice cereal ,d+[DATE] full with no label and no date open to air. 1 5-gallon tub of what appeared to be O-shaped cereal ,d+[DATE] full with no label and no date. 1 5-pound buttermilk biscuit mix in bag with no date. 1 bag of powered sugar half full inside a resealable plastic bag with no date. ,d+[DATE] loaf of bread with best by date of ,d+[DATE]. 1 and ,d+[DATE] bags of hamburger buns with best by date of ,d+[DATE]. 1 shelf full of loaves of bread and bags of large tortillas 3 off the floor. 1 grocery bag containing 12 individual serving size resealable plastic bags containing what appeared to be animal crackers with no label and no date. 1 5-gallon tub ,d+[DATE] full of what appears to be flour with no label and no date 1 resealable gallon-size plastic bag full of what appears to be vanilla wafers with no label and no date. 1 large sealed bag of what appeared to be vanilla wafers with no label and no date. An observation of Freezer 2 on [DATE] at 09:36 AM revealed the following: 1 large bag of what appeared to be tater tots with no label and no date. 1 bag of lumpy whitish substance that appeared to be melted into a solid block on one end with no label and no date. 1 bag of what appeared to be biscuit dough with no label and no date. 1 bag of what appeared to be chicken nuggets with no label and no date. An observation of Freezer 3 on [DATE] at 09:40 AM revealed the following: 2 resealable bags of what appeared to be raw chicken with no label and no date. During an interview on [DATE] at 09:10 AM DM stated she started her job as DM and had zero training. She stated she had her food manager license but had not received dietary management training. She stated the kitchen had been too short-staffed for her to be trained since she started as DM. She stated she had just recently been able to have days off. During an interview on [DATE] at 08:26 AM ADON stated a possible negative outcome of undated, unlabeled food in the kitchen was residents could get some kind of illness or bacteria. She said a possible negative outcome for residents of food in the freezer being left open to air was residents not having a good, decent, proper meal to eat. During an interview on [DATE] at 08:33 AM ADM-IT stated improperly labeled and dated food in the kitchen could result in residents having food poisoning. She stated food open to air in the freezer was just gross and residents might notice the taste of freezer burn or might not eat the food due to dryness and that could result in weight loss. She stated kitchen staff were responsible for ensuring food was labeled and dated and stored correctly. During an interview on [DATE] at 08:39 AM ADM stated food that was not labelled and dated correctly could result in residents being served something that does not need to be served. During an interview on [DATE] at 08:52 AM DON stated food that was not labelled and dated correctly could make residents sick. During an interview on [DATE] at 09:17 AM DM stated she dated food when it came into the kitchen. She stated, I just found out I am supposed to date it when it gets opened. She stated she learned that information during a mock survey. DM stated leftovers were dated by all kitchen staff with two dates, they day they go into the refrigerator and three days later, which is when they are to be thrown away. DM stated food in the refrigerator and in the freezer was to be sealed, no open to air. She stated food in the pantry should not be accessible to pests and the containers should be cleaned if they get dirty. DM stated all staff were responsible for labelling and dating food in the kitchen. She stated she trained her staff regularly one-on-one. DM stated if food was not labelled and dated correctly in the refrigerator or the pantry people can get sick. She stated peanut butter on the outside of the container in the pantry could result in pests. DM stated she did not know food had to be stored at least 6 inches off the floor. Record review of facility policy titled Refrigerators and Freezers and dated 2001 revealed the following: . This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. 'Use by' dates will be completed with expiration dates. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Record review of facility policy titled Food Receiving and Storage and dated 2001 revealed the following: . Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 5. Non-refrigerated foods, . will be stored in a designated 'dry storage' unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) . 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). 11. Wrappers of frozen foods must stay intact until thawing. Record review of US Food and Drug Administration Food Code dated 2022 revealed the following: . Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: . 3) At least 15 cm (6 inches) above the floor.

46534 Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 3 (Resident #2, Resident #26, and Resident #39) of 15 residents reviewed for accidents and hazards. The facility failed to perform quarterly safe smoking assessments on Resident #2, Resident #26, and Resident #39. These failures could place residents at risk of burns and/or injury. Findings Included: Record review of Resident #2's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diffuse traumatic brain injury with loss of consciousness of unspecified duration (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull), lack of coordination, unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body caused by involuntary contraction of the muscles and associated especially with brain disorders such as epilepsy), and parkinsonism (conditions that affect the ability to move and live independently). Record review of Resident #2's Quarterly MDS completed on 08/21/24 revealed the following: Section B: Resident #2's vision was impaired. Section C: Resident #2 had a BIMS score of 15, which indicated intact cognition. Section E: Resident #2 experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality) and displayed behavioral symptoms directed toward others as well as himself. Section GG: Resident #2 had impairment to upper extremities on one side. He required supervision or touching assistance for eating, bathing, lower body dressing, transfers and bed mobility. He required set up or clean up assistance for oral hygiene, personal hygiene, upper body dressing, footwear (removal and application), and walking. He was independent in toileting. Record review of Resident #2's care plan completed on 09/09/24 revealed he was a smoker and required supervision while smoking due to a lack of coordination and impaired cognition. Record review of Resident #2's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 05/04/2019 10/10/2020 05/11/2021 08/11/2021 11/10/2021 07/03/2023 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #2 from 07/03/23 to 10/29/24. Record review of Resident #2's safe smoking assessment dated [DATE] revealed he required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. Record review of Resident # 26's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a serious mental health disease that causes altered perception of reality), bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings), muscle weakness, syncope (dizziness) and collapse, and lack of coordination. Record review of Resident #26's quarterly MDS completed on 10/08/24 revealed the following: Section C: Resident #26 had a BIMS score of 3 which indicated severely impaired cognition. Section E: Resident #26 rejected care and wandered 1-3 days of the 7-day look back period. Section GG: Resident #26 had lower extremity impairment on one side and used a w/c. He required supervision or touching assistance across all ADLs except taking off and putting on footwear and personal hygiene where he required partial/moderate assistance. Record review of Resident #26's care plan completed on 09/10/24 revealed he was at risk for injury while smoking due to poor safety awareness and cognitive impairment. Resident #26 required supervision while smoking. Record review of Resident #26's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 11/17/2022 02/27/2023 07/03/2023 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #26 from 07/03/23 to 10/29/24. Record review of Resident #26's safe smoking assessment dated [DATE] revealed he had cognitive loss, required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. Record review of Resident #39's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, apraxia (difficulty in performing daily tasks), lack of coordination, dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness, ataxia (poor muscle control causing clumsy movements), and need for assistance with personal care. Record review of Resident #39's quarterly MDS completed on 09/12/24 revealed the following: Section C: Resident #39 had a BIMS score of 12 which indicated moderate cognitive impairment. Section E: Resident #39 rejected care 1-3 days during the 7-day look back period. Section GG: Resident #39 required supervision or touching assistance across all ADLs. Record review of Resident #39's care plan completed on 09/11/24 revealed he was at risk for injury while smoking related to a lack of coordination. He required supervision while smoking. Record review of Resident #39's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 04/13/2023 07/03/2023 10/03/2023 01/03/2024 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #39 from 01/03/24 to 10/29/24. Record review of Resident #39's safe smoking assessment dated [DATE] revealed he required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. During an interview on 10/30/24 at 08:28 AM ADON stated DON was responsible for completing safe smoking assessments. She said the assessments were to be completed quarterly on each resident who smoked. She said the safe smoking assessments were stored under the assessment tab in the resident's EHR. ADON stated the assessments were not done quarterly because one safe smoking assessment form was retired and the new one failed to trigger in the system when it was due. She stated a possible negative outcome of not assessing residents for safe smoking on a quarterly basis was the facility would not know if the resident needed special equipment to smoke and the residents might burn themselves. During an interview on 10/30/24 at 08:35 AM ADM-IT stated all charge nurses were responsible for completing safe smoking assessments quarterly on all smoking residents. She said the assessments were kept under the assessment tab in the EHR. ADM-IT said a possible negative outcome of not assessing residents for safe smoking quarterly was, We are a nursing home, and the residents will decline eventually, they could be burned, or they could eat their cigarette. During an interview on 10/30/24 at 08:39 AM ADM stated charge nurses were responsible for completing safe smoking assessments. She said the assessments were supposed to be done quarterly and were kept under the assessments tab in the resident's EHR. She said if assessments were not completed quarterly residents could be unsafe to smoke due to disease progression. During an interview on 10/30/24 at 08:54 AM DON stated the nurses were responsible to complete safe smoking assessments and she and ADON were responsible to ensure the assessments were completed. She stated safe smoking assessments were not done for a period of time because corporate made a new one (safe smoking assessment) and it did not trigger to be done. DON stated safe smoking assessments were to be completed quarterly and were kept in the assessments tab in the resident's EHR. She said a possible negative outcome of not completing safe smoking assessments quarterly was residents might require enhanced supervision or not be able to smoke anymore and the facility would not know. Record review of facility policy titled Smoking Policy and dated 01/15/2021 revealed the following: . A smoking safety evaluation will be completed for all residents who smoke on admission change of condition, and quarterly. Record review of facility policy titled Smoking Policy-Residents and dated 2001 revealed the following: This facility has established and maintains safe resident smoking practices. 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.

Based on observation, interview, and record review, the facility to maintain an effective pest control program so that the facility is free of pests for one of one facility reviewed for environment for 3 out of 3 days. -The facility failed to prevent an infestation of flies and gnats based on observations at varied times over a 3-day period from 10-28-2024 to 10-30-2024. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: During an observation of room [ROOM NUMBER] on 10/28/24 at 09:45 AM with no resident present, observed was a partially eaten tray of food in the room on a bedside table with a meal ticket dated Supper: Sunday 10-27-2024 with Salisbury steak, garlic mash potatoes, and green beans listed on the meal ticket with the noted corresponding food partially eaten on the tray. Also noted were multiple flies and gnats on the tray, curtain, wall, and bed. During an observation and interview on 10/28/24 at 10:00 AM revealed Resident #2 was in his room laying on top of his bed. The resident was observed attempting to keep flies off his person. Five flies were observed to be either on him or his bed. The resident reported that the flies were a problem and verified that they were an issue when he eats. During an observation on 10/28/24 at 10:31 AM revealed four flies were noted on the PPE station outside of room [ROOM NUMBER], one fly on the hallway wall and one fly on the hallway floor. During an observation and interview on 10/28/24 at 10:33 AM revealed Resident #10 was observed in his room lying on top of his bed dressed in sweats and a t-shirt. Noted were several flies on his person and bed and he verified that the flies were an issue especially when he eats. During an interview on 10/28/24 at 11:58 AM LVN A verified that she found the resident tray in room [ROOM NUMBER] Bed B this am and removed it (at 10:07 AM observed by the surveyor). LVN A reported that she was aware that a tray left in a resident's room from the previous evening was an issue and stated, I'm sure you (this surveyor) saw the number of flies that were on that tray. LVN A reported that all trays should be removed from the resident's room within one hour of completing a meal. During the noon meal observation on 10/28/24 the following was revealed: 10/28/24 12:10 PM 2 flies on a table with two residents present. 10/28/24 12:12 PM Resident attempts to shoo fly from his coffee cup. 10/28/24 12:12 PM 5 flies on a table with three residents present. 10/28/24 12:23 PM A resident attempts to shoo a fly from his coffee cup. 10/28/24 12:26 PM A fly landed on a resident's food. 10/28/24 12:27 PM A fly landed on rim of a resident's coffee cup. 10/28/24 12:30 PM A fly landed on a resident's fork. During an observation on 10/28/24 at 02:21 PM revealed Resident #27 was in his bed sleeping on top of his covers. Observed were 5 flies on the resident while sleeping. The resident was observed changing positions several times. During an observation on 10/29/24 at 08:45 AM five flies were noted on the Resident #27's bed. The Resident was not present. During an observation and interview on 10/29/24 at 02:03 PM revealed wound care was performed for Resident #10 who was in his room sitting at the side of his bed. Noted were multiple flies in the room. Before the care started the resident made a statement that something needed to be done about the flies. LVN A reported that she would report the issue to the maintenance supervisor. During an interview on 10/28/24 at 03:03 PM the DON reported that a tray being left out was an issue and that all trays should be picked up within one hour of the meal being completed. The DON reported that it could result in an infestation such as the flies that were noted with this incident. The DON reported that she did not know why the staff did not pick up the tray for this resident the previous evening. The DON verified that staff were supposed to complete rounds every two hours. The DON reported that the Resident in room [ROOM NUMBER] could talk but that he will not make sense with his conversations, he will not remember anything, and he will become verbally aggressive if someone tries to talk to him for any length of time. During an interview on 10/29/24 at 08:48 AM and 08:59 AM this surveyor attempted to interview Resident #22 (the resident assigned to room [ROOM NUMBER]) and he did not respond to introduction or questions. He just starred at this surveyor and then started to become agitated. During an interview on 10/29/24 at 10:30 AM in a resident council meeting 19 of 20 anonymous residents stated the flies in the building bother them. There were loud exclamations and groans following the answer. One of the residents spoke up and said, They drive me crazy flying around my face and my ears all the time. During an interview on 10/29/24 at 02:14 PM LVN A reported that the situation with the flies was horrible mostly due to the resident's behavioral issues especially with urinating and defecating everywhere to include the outside courtyard. LVN A reported that the facility has tried multitude different approaches to deal with the flies and could not get the situation under control. LVN A reported that the flies could cause issues with infections such as with a wound. During an interview on 10/29/24 at 02:49 PM the Maintenance Supervisor reported that the facility has had a second pest control fly service completed outside of the usual monthly pest control service, that he spays with permethrin twice weekly; and he sweeps, and power washes the patio twice weekly due to the resident's constant urination and defecation. He stated the facility was looking into getting and automatic closing door for the patio due to the resident will not close the doors to keep out the flies. He stated the facility has added 12 fly lights, and he has automatic fly sprayers around the facility with food grade spray to address the issue. During an interview on 10/29/24 at 03:16 PM the DON reported that the flies were definitely and issue but that they did not know what they could do that they have not done already. The DON reported they have purchased $3000 dollars' worth of fly lights to increase the current fly lights, they have increased housekeeping hours to hopefully address the incontinence issues, and they were currently pricing the replacement cost of the back patio doors with automatic doors. The DON reported that flies could cause an issue with infection. During an interview on 10/30/24 at 08:31 AM the Administrator reported that all meal trays delivered to resident rooms should be delivered as soon and the kitchen gets them ready, they should be covered, and they should be picked up 1 hour after the meal is completed. The Administrator reported that a meal tray left in the resident's room could result in issues such as flies and bugs. Record review of the facility provided Pest Control Statements revealed the facility received pest control service on the following dates: 8-16-2024 9-25-2024 10-23-2024 Record review of the facility provided policy titled Statement of Resident Rights undated, revealed the following: You have the right to: 1. all care necessary for you to have the highest possible level of health, 2. safe, decent, and clean conditions, Record review of the facility provided policy titled Quality of Life-Homelike Environment undated, revealed the following: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment . 2. The facility staff and management shall maximize . a. Clean, sanitary, and orderly environment. Record review of the facility provided policy titled Food Preparation and Service revised November 2021, revealed the following: Food Distribution and Service: 12. Food that has been served to resident without temperature controls (e.g. trays, snacks, etc.) will be discarded if not eaten withing two hours.

Based on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #43) of 15 residents reviewed for accuracy of assessments. The facility failed to indicate antipsychotic medication and hospice care on Resident #43's MDS assessment. This failure could place residents at risk of not receiving necessary care and/or services. Findings Included: Record review of Resident #43's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, generalized anxiety disorder (inability to control constant worrying), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and intermittent explosive disorder (repeated sudden outbursts of anger). Resident #43's Primary Payer was Hospice Medicaid. Record review of Resident #43's admission MDS with ARD of 08/28/24 and completion date of 08/29/24 revealed the following: Section C: Resident #43 had a BIMS score of 13 which indicated intact cognition. Section E: Resident #43 experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality) and displayed verbal behaviors directed toward others and other behaviors not directed toward others. These behaviors significantly interfered with his care. He rejected care and wandered 1-3 days during the 7-day lookback period. Section N: Resident #43 was not noted to be receiving antipsychotic medication. Question NO450.A of the MDS asked, Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA (Omnibus Budget Reconciliation Act) assessment, whichever is more recent? This question was answered, No - Antipsychotics were not received. Section O: The instructions for Section O stated, Check all of the following treatments, procedures, and programs that were performed on admission, while a resident, and at discharge. The box for hospice was not checked which indicated Resident #43 was not receiving hospice services while a resident. The box for None of the Above was checked indicating Resident #43 was not receiving hospice services while a resident. Record review of Resident #43's care plan initiated 08/19/24 revealed the following focus area initiated on 08/19/24, I am on [name of hospice] hospice, under the care of [name of physician]. Another focus area initiated on 08/29/24 stated, I use antipsychotic medications and listed the name of the medication as well as his diagnosis of intermittent explosive disorder as the reason for the medication. Record review of Resident #43's active orders dated 10/29/24 revealed the following: An order with start date of 08/19/24 to monitor Resident #43 for antipsychotic medication side effects. An order with start date of 08/16/24 to admit Resident #43 to hospice. An order with start date of 08/17/24 for Ariprazole oral tablet 15 MG (Ariprazole) Give 1 tablet by mouth one time a day related to INTERMITTENT EXPLOSIVE DISORDER. Record review of Resident #43's medication administration for August of 2024 revealed he received Ariprazole every day from 08/17/24-08/31/24. During an observation and interview on 10/29/24 at 10:24 AM Resident #43 was seated in his w/c in his room. He stated he was pleased with the care and services he received through hospice. An interview was attempted with MDS LVN on 10/30/24 at 08:17 AM by telephone. She did not answer the call. During an interview on 10/30/24 at 08:24 AM ADON stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN looked at resident charts to determine what medication and care they were receiving before completing the MDS. ADON stated MDS-LVN also gathered information regarding residents during the staff morning meeting. She stated an inaccurate MDS would negatively affect the rates the facility was paid to provide treatment to the resident. She stated that would negatively impact a resident because the facility would not have the funds needed to care correctly for the resident. During an interview on 10/30/24 at 08:31 AM ADM-IT stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN used the RAI as her policy when completing the assessments. ADM-IT stated MDS-LVN runs the medication list to find out what medications a resident is receiving before completing the MDS. She stated she did not think an inaccurate MDS would negatively affect a resident's care because nursing would still take care of the resident as needed. During an interview on 10/30/24 at 08:37 AM ADM stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN reads doctor's orders to assist in MDS completion. ADM stated an inaccurate MDS might result in the resident not receiving proper care plus I don't get the proper money. During an interview on 10/30/24 at 08:50 AM DON stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN looked in resident charts to find which cares and medications they were receiving. She stated an inaccurate MDS could negative impact a resident's care because the plan of care might be incorrect. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . Section N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of . select medications were received by the resident. In addition, two medication sections have been added. The first is an Antipsychotic Medication Review. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look-back period . Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period . Section O SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the last 14 days or since admission/entry or reentry, check Z, None of the above. Hospice care Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA B) of 5 staff observed for resident care. -CNA B did not perform the proper process, wash her hands, change gloves, or place a residents brief properly while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: During an observation on 10/29/24 at 10:59 AM of incontinent care performed by CNA B, CNA B cleaned the resident's rectal area first removing several wipes covered with BM, changed her gloves, used ABHR, placed new gloves, sprayed the resident's rectal area with moisture wipe, then wiped his rectal area with two more wipes. CNA B then picked up the new brief with her contaminated gloves and placed it under the residents. The resident was then rolled to his back. CNA B wiped the resident's penis with one wipe then pulled the new brief in place with her contaminated gloves and secured it. CNA B then removed her contaminated gloves and used ABHR. During an interview on 10/29/24 at 11:34 AM CNA B verified that she did remove her gloves and use ABHR then spray the resident's rectal area with moisture wipe, then use two more wipes to clean his rectal area, and then placed his new brief without removing her gloves or washing her hands. CNA B reported that she should have changed her gloves and washed her hands before putting on the clean brief. CNA B reported that if there had been any sign of feces on her gloves she would have had a problem but she did not see anything on her gloves, so she did not feel that not changing her gloves was an issue. CNA B did verify that she cleaned the resident's rectal area first before cleaning his peri area, that due to the residents having pooped she needed to clean his rectal area first. CNA B reported that she understood and had been instructed that a resident who had a BM was supposed to have that cleaned first before cleaning the peri area. CNA B stated, If you clean the back first when it's got poop you have that cleaned and then you won't get the front dirty. CNA B verified that the DON was the current infection control instructor and that she had been instructed on handwashing and glove changes. During an interview on 10/30/24 at 09:00 AM the DON with the ADON present reported that she expects her staff to complete all incontinent care with cleaning the peri area first then the rectal area before placing the new brief. The DON said this was done to prevent bacteria from the rectal area getting in the urethra and causing a UTI/infection. The DON reported that she also expected that infections could develop with glove changes and handwashing that are not done correctly because bacteria could be introduced. The DON expects glove changes/handwashing and/or sanitizer use frequently, anytime a staff member goes from dirty to clean, and before placing any new supplies such as briefs. The DON reported that if this process was not followed then a resident would be placed at risk for infection due to bacteria that would be on the dirty gloves that could be passed to the hands. The DON verified that she did teach staff on infection control, handwashing, and glove changes and that all direct care staff were instructed on the proper process for incontinent care and when to change gloves and use handwashing or ABHR/sanitizer. Record review of the facility provided policy titled Handwashing/Hand Hygiene revised October 2023, revealed the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene f. before moving from work on a soiled body site to a clean body site on the same resident.

Based on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and hazards. Resident #1 was left alone in the shower, fell , and was injured on 10/13/23. Resident #1 was coded as needing assistance by one staff person for bathing in his MDS completed 08/08/23. This failure could place residents requiring assistance with ADLs in danger of injury. Findings included: Record review of Resident #1's face sheet dated 11-13-23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), personal history of cerebral infarction (stroke), major depressive disorder, muscle wasting and atrophy, vascular dementia with behavioral disturbance (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), anemia (lower than normal amount of healthy red blood cells), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and restlessness and agitation. Record review of Resident #1's Quarterly MDS, completed 08/08/23 revealed a BIMS of 9 which indicated moderately impaired cognition. Section G of the MDS revealed Resident #1 required physical help in part of bathing activity with one-person physical assist. Section G noted Resident #1 utilized a walker. Section GG of the MDS noted Resident #1 required partial to moderate assistance when showering; meaning the staff member lifts or holds trunk or limbs, but provides less than half the effort. Record review of Resident #1's care plan revised on 08/09/23 revealed the following focus areas: I have limited physical mobility r/t Disease Process Muscle Wasting and Atrophy initiated on 10/15/20. I have impaired cognitive function and impaired thought processes with fluctuating cognition r/t Dementia and impaired decision making initiated on 11/19/19. I have the potential for communication problems r/t Difficulty understanding others initiated on 10/16/20. I am at risk for falls because I have a fall risk score of 5 and risk factors such as Gait/balance problems initiated on 10/16/20. Record review of Resident #1's progress notes revealed a note on 10/13/23 at 10:00 PM by LVN A stating CNA B came to tell her Resident #1 was on the floor in the shower room. Resident #1 stated to LVN A, She [CNA B] came and told me to wait and she would help but I thought I could do it myself so I stood up and then I accidentally fell . The note stated the doctor had Resident #1 sent to the hospital for evaluation due to hitting his head and taking a blood thinner. Another note dated 10/14/23 at 02:50 AM revealed an ER nurse contacted LVN A and informed her Resident #1 was ready for discharge and had a closed fracture to his left pinkie finger. Record review of Resident #1's Order Summary Report revealed an order of keep left Pinky finger and third finger wrapped together, if wrap comes off or needs changed d/t being soiled rewrap until follow-up appt on 11/30/23 dated 11/02/23. Record review of Resident #1's Fall Risk assessment dated [DATE] revealed a score of 11 which placed Resident #1 in the high risk for falls category. Resident #1 was noted to have had 1-2 falls in past three months and a balance problem while standing/walking. During an interview on 11/13/23 at 05:22 AM LVN A stated she remembered Resident #1 falling in the shower, but she would need to read her notes to remember specifics. She then looked on her computer at her notes and stated she remembered CNA B had Resident #1 seated in the shower and told him to stay seated while she left to retrieve a washcloth or a towel. LVN A said Resident #1 was a standby assist with showering. She said, He does everything himself, but we only have 3 or 4 residents who are allowed to be in the shower alone. LVN A said after CNA B left Resident #1 sitting in the shower, he tried to stand by himself and fell and hit his head on the wall and the floor of the shower. She stated she and another nurse on duty heard a thump and the two of them reached the shower at the same time CNA B returned to the shower and they saw Resident #1 lying on the floor. LVN A said Resident #1 was able to verbalize to her after the fall that CNA B told him to stay seated, but he thought he could do it himself, so he attempted to stand and he fell . LVN A said after she notified Resident #1's physician about the fall the physician had her send Resident #1 by ambulance to the hospital because he was on blood thinners, and he hit his head. During an interview on 11/13/23 at 05:52 AM CNA B stated she remembered Resident #1 falling in the shower. She said, I told him to wait, I had to get some washrags, but he didn't wait. She said when she left Resident #1 in the shower he was seated but he tried to stand up on his own instead of waiting for her to return. When asked if it was normal for her to leave a resident who required assistance with bathing alone in the shower, she replied, Normally I don't leave them. I told him to sit right there, but he didn't. During an interview on 11/13/23 at 10:23 AM BOM stated it was not at all okay to leave a resident alone in the shower if they required supervision to shower. During an observation and interview on 11/13/23 at 10:37 AM Resident #1 was lying in his bed with his eyes closed. He opened his eyes when his name was called. When asked if he remembered falling in the shower and hurting his finger he nodded, which indicated yes. During an interview on 11/13/23 at 11:48 AM CNA D stated she would never leave a resident who required assistance with showering alone in the shower. She said a possible negative outcome of doing so would be, He would fall. During an interview on 11/13/23 at 11:50 AM CNA E stated he would never leave a resident who required assistance with showering alone in the shower. He said a possible negative outcome of doing so would be, They try to get up and fall. During an interview on 11/13/23 at 12:02 PM CNA F was asked if she would ever leave a resident alone in the shower if the resident required assistance to shower. She said, Oh no ma'am. We're not supposed to do that. They have a chance of falling. Record review of facility policy titled, Falls-Evaluation and Prevention and dated 01/2014 revealed in part: .Intrinsic risk factors for falls include .Gait and balance disorders .Muscular weakness .Confusion .Stroke .Depression .Previous falls .Extrinsic risk factors for falls are part of the resident's environment .The following are typical examples of extrinsic risk factors: . Wet floors . Record review of facility policy titled, Quality of Life - Resident Self Determination and Participation and dated 2016 revealed in part: . 1. Each resident is allowed to choose health care .consistent with his or her interests, values, and assessments .including: . b. Personal care needs, such as bathing methods . 2. In order to facilitate resident choices, the administration and staff: . d. Document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. 4. Residents are provided assistance as needed to engage in their preferred activities on a routine basis. Record review of facility policy titled, Accidents and Incidents - Investigating and Reporting and dated 2017 revealed no information relevant to this investigation.

Based on observation, record review, and interview the facility failed to ensure each resident had the right to formulate an advance directive for 1 (Resident #1) of 6 residents reviewed for advance directives. Resident #1 had a DNR that was signed by the physician in the wrong section and was not dated by the physician. This failure could place residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), personal history of cerebral infarction (stroke) muscle wasting and atrophy, anemia (lower than normal amount of healthy red blood cells), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Resident #1's face sheet noted he was DNR. Record review of Resident #1's Quarterly MDS, completed [DATE] revealed a BIMS of 9 which indicated moderately impaired cognition. Record review of Resident #1's care plan revised on [DATE] revealed the following focus area, I request a code status of DNR initiated on [DATE]. Record review of Resident #1's Order Summary Report dated [DATE] revealed an order for DNR with an order date of [DATE]. Record review of Resident #1's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order form section A revealed Resident #1's printed name, date of birth, signature, and the date [[DATE]] in the correct blanks. The portion of section E titled, Two Witnesses had the required signatures, dates [[DATE]], and printed names of two witnesses. The portion of section E titled Physician's Statement had no information on the signature, date, license #, or printed name blanks. Section F titled Directive by two physicians on behalf of the adult who is incompetent or unable to communicate and without guardian, agent, proxy . contained a signature, printed name, and license number of Resident #1's primary physician but the line for a date was left blank as were the signature, date, printed name, and license number lines for the second physician. During an interview on [DATE] at 10:17 AM LVN C stated a DNR not dated by the physician is not a DNR. When asked if she would refrain from providing CPR to a resident with a DNR that was not dated by the physician, she replied, I mean, you can't it is not a DNR. During an interview on [DATE] at 10:23 AM BOM stated a DNR that was not dated by the physician was not valid. She said a possible negative outcome of having a DNR with no date by the physician was, It would be invalid, and we would have to do CPR on him. During an observation and interview on [DATE] at 10:37 AM Resident #1 was lying in his bed with his walker next to the head of the bed. He had his eyes closed but opened them at the sound of his name. He stated he was not feeling very good due to having COVID (a severe acute respiratory syndrome). When asked if he still wanted to be DNR he looked away and closed his eyes and would not open his eyes or answer any other questions. During an interview on [DATE] at 12:35 PM BOM said of Resident #1's DNR not being dated by the physician, That could have been real bad! She held up a new copy of the DNR that was dated by the physician and said, Now I just have to go get it notarized. During an interview on [DATE] at 01:08 PM Resident #1's emergency contact was asked if she knew if Resident #1 still wanted to be DNR. She replied, Yes. I do know for sure. Record review of the INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER dated [DATE] revealed in part: The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. Record review of facility policy titled, Advance Directives and dated 2001 revealed in part: Advance directives will be respected in accordance with state law and facility policy.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the freezer was free from dirt, debris and rust. Freezer items were not properly stored, labeled, and dated. 2. The facility failed to ensure refrigerator and pantry foods were properly stored, labeled, and dated. 3. The facility failed to ensure general cleanliness was maintained in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 8/29/23 @ 9:10 AM revealed the following: 1. (1) plastic bag of egg omelets, open to air, not in original box, with no label. 2. (1) plastic bag of frozen meat patties, open to air, not in original box with no label. Observation of the kitchen food prep area and the pantry area on 8/29/23 at 9:15 AM revealed the following: 1. A metal rolling rack holding canned foods had food splatters and dirt on the rails holding the canned goods. 2. Crumbs were observed on the front and sides of the industrial toaster and on the stainless-steel table holding the toaster. There were crumbs of food under and behind the toaster. 3. Crumbs were observed on the metal shelf above the kitchen prep table holding the spices. 4. The front and sides of the fryer had food splatters and food debris on the sides of the fryer. 5. There were food crumbs on the lower ledge of the shelves holding clean pans and dishes. 6. A half used jar of grape jelly was on the pantry shelf. The label stated to Refrigerate after opening. 7. A white plastic tub labeled powdered milk had food splatters and dirt on the lid. 8. There were individual sugar packets, cracker packages and food crumbs on the floor under the wire shelving units holding food items in the pantry area. 9. The white Insignia freezer had no handle on the outside of the freezer. The front of the freezer was sticky to the touch. Observations of the kitchen prep area, the pantry area, and the kitchen appliances on 8/30/23 at 8:30 AM revealed there were no changes in the cleanliness in the kitchen. Observations of the kitchen prep area, the pantry, and the kitchen appliances on 8/31/23 at 9:00 AM revealed there were no changes in the cleanliness in the kitchen. In an observation and interview with the DS on 8/31/23 at 8:42 AM, the DS stated she missed the grime and crumbs in the freezer and the pantry. The DM stated she was sorry she missed it and she will get it cleaned. The DS stated she expects all staff to be cleaning daily. The DS stated she does spot checks on a weekly basis. Cleaning practices are standard and should be adhered to. The DS stated she trained the staff on how to clean. The DS stated the consequences of not cleaning the kitchen thoroughly would be food borne illnesses and unsanitary surfaces which could make residents sick. The DS stated the jar of used jelly should have been refrigerated. The DS stated she would throw the opened jelly out and keep it refrigerated from now on. The DS stated the consequences of not refrigerating the jelly according to the instructions would possibly make the residents sick if consumed. She further stated residents could get sick from the food not being covered or refrigerated after being opened. Record Review of the facility policy dated October 2008, titled Sanitation documented: All kitchen areas shall be kept free of litter and rubbish All counters, shelves and equipment shall be kept clean, maintained in good repair and free from breaks corrosion open seams cracks and chipped areas that may affect their use or proper cleaning. All equipment, food contact surfaces and utensils shall be washed to remove soils Kitchen surfaces not in contact with food shall be cleaned on a regular basis. Record Review of the facility policy dated October 2017, titled Food Receiving and Storage documented: All foods in the refrigerator and freezer will be covered, labeled and dated.

Based on interview and record review, the facility failed to develop, implement, and permanently maintain and effective training program for all staff, which includes trainings on abuse, neglect, exploitation, misappropriation of resident property, and dementia management, that is appropriate and effective, as determined by staff for 12 of 15 (ADM, DON, ADON, Dietary Supervisor, Activities Director, MA B, Monitor Tech D, MA E, CNA C, Monitor Tech F, Cook G, and Cook H) employees reviewed for Abuse, Neglect, and Misappropriation training and Dementia training. The facility failed to ensure all staff were trained at time of hire and annually on Abuse, neglect, exploitation, restraints, and falls. This failure could place all residents at risk for abuse, neglect, exploitation, bodily injury, and decline in overall health. Finding include: Record review of employee record for Dietary Supervisor revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 02/28/2023 Record review of employee record for Monitor Tech D revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 08/08/2023 Record review of employee record for Monitor Tech D revealed that there were no trainings listed on an annual basis for this employee. DOH was 08/08/2023 Record review of employee record for CNA C revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 07/18/2023 Record review of employee record for Cook G revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 03/01/2023 Record review of employee record for Cook H revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 02/28/2023 Interview on 08/31/23 at 02:54 PM with BOM who verified that she is responsible for employee orientation, and trainings. Record review of Employee New Hire Packet does reveal a document for the employee to fill out upon completion of training at time of hire. No documentation provided for annual trainings. No policy provided by facility on initial or annual training for employees.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms. Multiple vials of insulin left out on the counter. -The medication refrigerator was not kept at a temperature between 36 to 46 degrees. The facility's failure to ensure drugs and biologicals were stored in accordance with the currently accepted professional principles, this could place all residents receiving medication that have lost integrity to not receive their therapeutic dose. Findings included: 08/29/23 11:59 AM- Per observation of the Medication Storage Room completed with MA A. Noted the temperature monitoring of the refrigerator to be 28-30 degrees on average for the month of August. Noted multiple medications in the refrigerator with instruction no to store below freezing. Noted no expired medications. 1.08/29/23 10:46 AM- Observed LVN B prepare insulin for a resident, after LVN B left 20 bottles of resident insulin on the counter next to the sink at the nurses station out in the open. 2.08/29/23 10:51 AM - Per observation and interview with LVN B who verified that temperature log on the medication room refrigerator from 8-1-2023 from 8-29-2023 has read from 28-30 degrees. LVN B verified that she read the refrigerator temperature this am as 30 degrees. She stated freezing temperature was 32 degrees. In the refrigerator the following medications were observed: *a bottle of Lantus Insulin with instructions to store at 36-46 degrees, *a bottle of Levemir with instruction to store between 36 to 46 degrees, *an opened bottle of TB solution with instruction to store at 35 to 46 degrees, *two open bottles of Influenza Vaccine and 6 unopened bottles of Influenza Vaccine with instruction of store at 36 to 46 degrees, *Engerix-B injection with instructions to store at 36-46 degrees, *Acidophilous with instruction to store unopened container at room temperate and refrigerate after opening, *2 packages of acetaminophen suppository with instructions to store at 68-77 degrees, *4 packages of Zyprexa with instructions to store at room temperature not to exceed 86 degrees, and *3 packages of Respiridol with instructions to store at 36 to 46 degrees. LVN B stated that the refrigerator was to cold and that maybe the thermometers were not correct and needed to be replaced. LVN B stated if medications are not stored properly then they would not be effective in resident treatment and could affect their condition. Observation on 08/29/23 at 11:47 AM, 20 Resident Insulin bottles, 5 insulin pens still on the counter at the nurse's station next to the sink used by staff for handwashing. Observation on 08/29/23 at 12:08 PM, 20 Resident Insulin bottles, 5 insulin pens and insulin testing supplies at the nurse's station next to the sink. Observed 5 staff to include 2 CNA, 1 MA, and 1 Hall Monitor wash their hands at the sink in the nurse's station. Observation on 08/29/23 at 02:04 PM of the nurse's station wash area, observed 20 Resident insulin bottles and 5 insulin pens were not present Interview on 08/29/23 at 03:14 PM , DON and ADON stated they were aware of the thermometer monitoring in the refrigerator and felt that staff were reading the thermometer wrong. Staff stated the current thermometer temperature was 40 degrees but they were aware the temp was below 32 degrees since the first of the month and they could not verify that the medications were not store properly. 08/30/23 09:02 AM- Per interview with the DON and the ADON . The DON stated if medications are not stored at the recommended temperatures, then they will not be therapeutic. The DON stated if the medications in the facility refrigerator did freeze it would destroy the medication and it would not be effective; that would affect the residents care, it could affect the residents blood sugars, and their behavioral issues. ADON agreed with the statement DON had provided above. 08/30/23 09:04 AM- Per interview with the DON and the ADON, the DON reported all medications should be stored safely in a medication care safely. If the medication required refrigeration, then it should be in the refrigerator in the medication room that was locked. The DON stated the insulins that were left on the counter in the nurse's station should not have happened because a resident could access the medication which would result in issues that could affect a residents condition and the medication should have been in the medication carts or in the medication room and locked to prevent access. The ADON agreed with the statement that DON had provided. 08/30/23 10:20 AM- Per interview with LVN B stated all medication should be kept locked up to maintain resident and staff safety. LVN B stated if medications are not kept in a locked secured location, then they can be accessed by resident or staff that are not supposed to have them, that someone would steal the medication. LVN B stated it would not be safe for a resident if they were to access the mediation that was not meant for them and took that medication, that it could affect them and their condition. Record Review of a policy provided by facility, titled Nursing Policy and Procedure, dated March 2012 indicated the following: 2. Only licensed nurse the consultant pharmacist, and those lawfully authorized to administer medication (i.e., medication aides, etc.) are allowed access to medications. 11. Medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 2 of 15 residents (Residents #7 and #16) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan indicating services as follows: 1. Failure to develop person-centered goals reflecting medical needs outside the facility of dialysis for Resident #16 2. Failure to develop person-centered goals reflecting psychosocial needs for activities for Resident #7. These failures could place all residents at risk of receiving care that is substandard, not individualized to the resident, or not meeting the highest practical medical and psychosocial needs. Findings included: Resident #7 Record review of Resident #7's face sheet, dated 8/30/23, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #7's diagnoses included, but not limited to, schizoaffective disorder, anxiety disorder, chronic pain, major depressive disorder, and multiple sclerosis. Record review of Resident #7's BIMS, dated 7/7/23, revealed a score of 15 indicating that the resident was cognitively intact. Record review of Resident #7's care plan, revised on 8/9/23, did not address the resident's activity needs and did not include individualized goals for the residents' psychosocial needs. Resident #16 Record review of Resident #16's face sheet, dated 8/30/2023, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident's diagnoses included but not limited to acute and chronic respiratory failure with hypoxia, type 2 diabetes, end stage renal disease, and heart failure. Record review of Resident #16's MDS, dated [DATE], indicated a BIMS score of 15 indicating that resident was cognitively intact. Record review of resident progress notes indicated that resident attended dialysis on the following days: 8/28/23, 8/23/23, 8/18/23, 8/14/23, 8/11/23, 8/9/23, 8/7/23, and 8/4/23. Record review of Resident #16's care plan, dated 7/19/23, revealed there is no goal related to resident's dialysis treatments. In an interview on 8/31/23 at 9:46 AM, the DON stated she oversaw care plans with the MDS coordinator. Care plans are done every Wednesday based on the MDS nurse assessment. In an interview on 8/31/2023 at 10:10 AM, the DON indicated a negative outcome of not having all needs care planned would be the care team does know what was going on with the residents. Record review of facility policy title Care plans, Comprehensive Person-Centered, revised December 2016, Section 8, Line B states to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Line G states to incorporate identified problem areas. Line L states to identify the professional services that are responsible for each element of care. 48208

Based on observation, interviews, and record reviews, the facility failed to develop and implement a base-line care plan with-in 48 hours for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 1 of 15 residents (Resident #14) whose care plans were reviewed. The facility failed to develop a base-line care plan with-in 48 hours of resident admitting into the facility. This failure could place all residents at risk of receiving care that does not meet the initial goals, medication interventions, services or treatments, or updated information related to re-admitting to the facility after 30 days. Findings include: Record review of Resident #14's face sheet is a 58- year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14's diagnoses included but are not limited to: schizoaffective disorder (depressive type), obsessive-compulsive disorder, anxiety, motor-neuron disease, and aphasia. Record review of Resident #14's MDS, dated [DATE], indicated a BIMS score of 99, indicating cognition could not be measured. Record review of Resident #14's MDS face sheet, undated, indicated resident was discharged on [DATE] and returned to facility on 6/1/2023. Resident #14 was discharged from the facility for 48 days. Record review of Resident #14's MDS face sheet, undated, shows an MDS Entry assessment dated [DATE]. A Quarterly assessment is dated 6/14/2023. Record review of Resident #14's care plan face sheet, undated, indicated Resident #14's initial baseline/comprehensive care plan was initiated 6/28/23. In an interview on 8/31/23 at 9:46 AM, the DON stated she oversaw the care plans with the MDS coordinator. Care plans are done every Wednesday based on the MDS Nurse assessment. The DON stated baseline care plans are completed within 72 hours and a baseline care plan was not required if the resident was out of the facility for more than 30 days. The DON stated that Resident #14 was absent from the facility for more than 30 days and the baseline care plan was missing from their assessments. DON indicated a negative outcome would be a change in the resident's baseline and staff would have not noticed. In an interview on 8/31/2023 at 9:56 AM, MDS Nurse indicated an MDS assessment was opened and completed within 13 days of a resident being admitted . MDS nurse stated DON signed it and MDS nurse places their information in Section X. MDS Coordinator indicated a baseline care plan should be completed immediately once someone returns from being discharged . MDS nurse stated if the resident was out after 30 days, it would be a new baseline care plan. MDS Nurse confirmed there was not a baseline care plan located in Resident #14's chart. MDS Nurse stated that a negative outcome would be the resident does not get the proper care. Record review of facility's policy titled Care Plans, Comprehensive Person-Centered, revised in December 2016, reveals that policy does not cover timeframe dedicated to baseline care plan timeline.

Based on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay for 1 (Resident #60) of 2 residents reviewed for discharge summaries. A. The facility failed to ensure a Discharge Summary for Resident # 60 was completed which included a complete recapitulation of the resident's stay for a resident discharged to another facility. This failure could place residents discharged from the facility at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents, and failure in the continuity of care for residents. The Findings included: Record review of Resident #60's electronic face sheet dated 8/31/23 indicated a [AGE] year-old male admitted on [DATE] with the following diagnoses: Alzheimer's disease, unspecified convulsions, personal history of brain injury, intermittent explosive disorder, diabetes, unspecified mood disorder, dementia, chronic kidney disease, retention of urine and psychotic disorder with delusions. A discharge MDS dated [DATE] documented a BIMS score of 5 out of 15 indicating cognition was severely impaired. A care plan dated 7/11/23 documented Resident #60 was independent in ADLs, required medications to be crushed, had a history of UTI's, had the potential for verbal aggression, physical aggression, and sexually inappropriate behaviors. Record review of Resident #60's physician progress note revealed the last note was dated 6/27/23. Nurses progress note dated 6/28/23 indicated Resident #60's family requested resident to be referred to a facility closer to family. A Nurses progress note dated 7/10/23 documented Resident #60 was accepted to another facility. A Nurses progress note on7/11/23 documented Resident #60 was discharged to another facility. Record review of Resident #60's record indicated there was no Physicians discharge summary in the record. During an interview on 8/31//2023 at 11:27 am the DON stated there was no discharge summary. The DON stated she did not know what happened to it and could not find it. The DON said resident's clinical records, including an accurate discharge summary, were supposed to be forwarded or faxed to the receiving facility in addition to verbal communication. The DON stated the facility did not send any resident paperwork with the resident. The DON stated the consequences of not having a physician discharge summary was if something happened to the resident the facility during the transfer, the facility would be responsible and the receiving facility would not have any history of his care. A policy was requested but never provided.

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse for two of 12 residents (R #2 and #3) reviewed for abuse. The facility failed to develop and implement effective interventions to address R #1's physically aggressive behaviors. R #1 physically assaulted R #2 on [DATE], causing serious bodily injury, and physically assaulted R #3 on [DATE] causing serious bodily injury. This was determined to be past non-compliance that existed from [DATE] and was corrected on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The failure of the facility to intervene after an abusive incident resulted in further abuse and injury. The findings include: A. Resident #1 Review of R #1's undated face sheet reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R #1's Quarterly MDS dated [DATE] reflected: · had adequate hearing and clear speech · understood others and made self-understood · had a BIMs status score of 7 - severely impaired · required supervision for bed mobility, transfers, dressing, and limited assistance for personal care · had no physical behavioral symptoms towards others. Record Review of Resident #1's Nurses' Notes reflected: [DATE] 8:45: Late Entry: Resident was in his room , Resident (#2) a was in the rest room at this time, Resident then became angry and became violent towards Resident (#2), Resident physically assaulted resident (#2) causing bodily injury to resident (#2), Resident then dragged resident (#2) into his room and put him on his bed and closed the curtain to his side and walked out of his room and returned to the dining area, Resident was calm and started eating his breakfast and watching tv, Resident was questioned by staff and the sheriff's department and admitting to the physical assaulting resident (#2). Dr. was notified at this time and ordered to watch resident closely and chart every 1 hr., Dr. ordered injection. Record review of Resident #1's Physician Orders, dated [DATE] reflected Chart 1-hour behavior and where about of resident. Monitor closely keep 2 staff at all times around this resident. Every hour incident reporting. Pharmacy: [MEDICATION NAME] Tablet 1 mg ([MEDICATION NAME]) give 1 mg by mouth every 6 hours as needed for increased anxiety related to [MEDICAL CONDITION]. Start date ,[DATE]//20. [MEDICATION NAME] Solution 5MG/ML ([MEDICATION NAME]) Inject 5 mg IM one time only related to Anxiety Disorder. Record Review of Resident #1's Care Plan, [DATE] reflected the resident had behaviors of sexually inappropriate behavior toward female staff. The facility failed to update the Care Plan with the [DATE] assault on Resident #2. Resident #2 Review of R #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Updated [DIAGNOSES REDACTED]. Review of R #2's Quarterly MDS dated [DATE] reflected: · had adequate hearing and unclear speech · usually understood others and made self-understood · had a BIMs score of 7 - severely impaired · required supervision for bed mobility, transfers, dressing, and limited assistance for personal care · had no physical behavioral symptoms towards others. Review of R #2's Comprehensive Care Plan dated [DATE] reflected no documented physical or verbal aggression towards staff or residents. Record Review of Resident #2's Nurses' Notes reflected: [DATE] 8:44: CNA (A) was answering a call light in resident (#1) room. CNA (A) came upon resident (#2) laying in resident (#1)'s bed with blood all over him. CNA (A) yelled for assistance, staff ran into the room where resident (#2) was lying in bed. Resident was alert and never lost consciousness. The nurse applied pressure to resident (#2)'s right eye where resident has a large hematoma formed with 5+ [MEDICAL CONDITION]. Resident (2) has a two-inch laceration above his eye brow, two cm. laceration below his right eye, after applying pressure bleeding sustained. Resident (#2) did start having some convulsions lasted about 15 seconds x 3 times. Resident (#2) nose swollen about 3= [MEDICAL CONDITION] bleeding was stopped, this nurse applied simple mask O2, 5 liters. Resident (#2) received a laceration right upper lip 2 cm wide and 2 inches long. Resident (#2) has 3-inch hematoma to the left side of the back of his head, scattered multiple small hematomas about the head. Small laceration left side tip of his nose about 1 inch. Resident (#2) right toe nail ripped off. Resident (#2)'s left pupil was reactive and right eye unable to see. Resident O2 on room air saturation was sitting at 88% before applying oxygen. Resident (#2)'s hear rate was 66 beats per minute. Resident (#2) was complaining of pain stated it was his head. EMS arrived in resident's room and took over. Resident (#2) ambulated to gurney with assistance. Resident (#2) was up talking when transported out of facility. [DATE] 12:22: Resident (#2) has multiple fractures on right orbital side of his eye, Resident (#2) has small brain bleed, Resident (#2) sinus cavities completely caved in, Resident (#2) maxilla bone both sides fractured . [DATE] 12:05: Resident (#2) arrived back at facility at 1150, upon arrival resident's vitals were taken and assessment was completed as follows BP ,[DATE], O2 95%, . Resident denies any pain. Resident was placed on isolation due to being admitted to hospital. Assessment was done in that room, resident (#2)'s entire right eye is swollen shut and completely bruised leading to whole cheek being bruised as well due to fx, right jaw is swollen du to fx, laceration to entire right eye brow, there is a slight bruising under left eye, no notable swelling to left eye, small scratch to right temple, slight bruise to entire nose with dried blood still in both nostrils, top lip noticeably swollen and bruised with only slight bruising to bottom lip. Small laceration and bruising to top/crown of head . Review of Resident #2's Hospital records, dated [DATE] reflected: Discharge Diagnosis - Blow out fracture of orbit, closed lamina papyracea fracture, Dementia, Fracture of maxillary sinus, nasal bone fracture, and traumatic intraparenchymal hemorrhage. In an interview on [DATE] at 9:00 AM the SW stated Resident #1 attacked Resident #2 in the bathroom. She stated it was a blood bath. She stated the facility tried to discharge the resident to a mental health hospital, and the state hospital. Neither facility would accept Resident #1 due to his aggressive behaviors. She further stated Resident #1 was placed on one to one supervision for a few days, however the facility could have placed Resident #1 on one to one observations until he was discharged from the facility to prevent further behaviors. She stated the facility previously had Hall Monitors who walked the halls to observe staff. She was not sure what happened to them, however, they have since been rehired. SW stated Resident #2 was moved to another private room, but Resident #1 stayed in his room with his roommate Resident #3. She believed Resident #3 refused to moved rooms. In an interview on [DATE] at 9:14 PM CNA B stated Resident #1was very aggressive towards staff and residents. She felt Resident #1 was a violent aggressive person. He would smile at you one minute and the next minute he would become aggressive. She stated she was not there for the first incident between Resident #1 and Resident #2 but was informed of how awful the incident was. She stated at the time of the incident there were no Hall Monitors. She felt Hall Monitors could have called for help and prevented the incident from escalating to the extent it did. In an interview on [DATE] at 9:21 AM LVN G stated Resident #1 attacked Resident #2 during breakfast time. Resident #2 received his meal tray in his room and everything appeared to be fine. A CNA went down the hall to check on a call light coming from Resident #1 and Resident #3's room. The CNA saw Resident #2 was in Resident #1's bed completely bloody. The CNA alerted staff who ran down to assess the situation. Resident #1 beat Resident #2 badly in the shared bathroom then dragged him to his own bed (resident #1) and continued to beat him. LVN G stated it looked like a slaughter. There was a bloody mess all over the bathroom and bedroom. Resident #1 shut the bed curtain leaving Resident #2 hidden from the hall way. Resident #1 cleaned off the blood from his hands and changed clothes in an attempt to cover up the incident. Resident #2's toe nails were ripped off from being dragged from the bathroom to the bed. It was evident Resident #1 beat Resident #2 in the head. One side of Resident #2's head was swollen immediately, there were lumps on the side of his head, areas of his head were mush. LVN G further stated staff called the Sherriff's and wanted Resident #1 arrested but the Sherriff's department felt he was already in a locked facility and did not arrest him. LVN G stated after the first incident staff initially conducted 15-minute checks on Resident #1 to ensure he did not attack another resident. She stated Resident #1 behavior would change quickly, staff would never know how quick he would react and become aggressive. LVN G stated she was not sure why Resident #1 remained in a room with a roommate after such a terrible incident. She stated at the time of the incident the facility did not have Hall Monitors. She stated the facility previously had Hall Monitors but was unaware of why they no longer worked in the facility. In an interview on [DATE] at 9:31 AM CNA A stated Resident #2 was a very private person who always ate in his room. She passed him his meal tray when Resident #2 said he was going to the bathroom. CNA A did not think much of it at the time. She stated a couple minutes later she call light in the adjoining room (Resident #1 and #3's room) was on. She walked in to the room and noticed Resident #1's bed curtain was drawn closed. She first noticed blood on the floor. She pulled back the curtain and witnessed Resident #2 was curled in a ball. Resident #2 was beaten so bad his face was almost no recognizable. Resident #2 was covered in blood. CNA A stated she believed Resident #2 was dead. She stated his eye was poking out of his head. CNA A felt no resident deserved to be abused like that. She stated Resident #1 had changed his clothes and washed the blood off his hands. Resident #1 walked down to the dining room where he was watching television and laughing. CNA A asked Resident #1 if he had physically abused Resident #2. He responded yes because Resident #2 was sitting on the toilet peeing and he felt that made Resident #2 a homosexual. He admitted to physically assaulting Resident #2, placing him in his (Resident #1) bed. CNA A stated Resident #3 pushed the call light because he woke up and heard something. She felt had he not pressed the call light, Resident #1 would have died . She stated prior to the incident the facility had Hall Monitors. She was not sure why Hall Monitors were not employed at the time of the incident. In an interview on [DATE] at 10:00 AM CNA C stated Resident #1 physically assaulted Resident #2 in the bathroom because he was sitting on the toilet. Another CNA found Resident #2 in Resident #1's bed. She stated there was blood everywhere. Resident #1 beat Resident #2 in the bathroom, dragged him to his bed (Resident #1), and closed the bead curtain so ad to ensure staff would not see Resident #2. She descried Resident #2's as being very bad. Resident #2's eye was swollen, and he was almost not recognizable. CNA C stated it was clear Resident #2 had fallen back and hit his head against the shower control. Resident #1 was severely injured. CNA C stated staff observed Resident #1 more closely after the incident, keeping eyes on him while out of his bedroom at all times. Resident #2 was moved to another hall and isolated from Resident #1. She was unaware as to why Resident #1 was not separated from other residents. In an interview on [DATE] at 12:19 PM LVN H (scheduling coordinator) stated the facility was fully staff and now have hall monitors in place who make rounds daily to observe residents who wander and to redirect residents who have some behavioral concerns. LVN stated Resident #1 physically assaulted Resident #2 because he was sitting on the toilet. Resident #1 called Resident #2 a homosexual because he was sitting and proceeded to beat him in the bathroom. Resident #1 dragged resident #2 to Resident #1's bed and continued to beat him. When Resident #2 was found he was soaked in blood, he had a large hematoma to the left side of his face and his eye was bulging. Resident #2 also had several small lacerations to the back of his head and top of scalp. He had bruising all over his face, and his toes on both feet were peeled back from being dragged. Resident #2's hands, lips, and nose were busted open. It was evident Resident #1's nose was broken. LVN H stated there was blood all over the room, on the door knobs, air conditioner, dresser, floor, bathroom, shower, and shower handles. She said it was clear Resident #2 had fallen back and hit his head on the shower nob. LVN H added one of Resident #2's toe nails was found behind the toilet. Resident #2 started seizing and started to code. Staff pulled the crash cart but fortunately Resident #2 came out of the [MEDICAL CONDITION]. LVN H stated she walked down to the dining room with a CNA to ask Resident #1 if he had beat up Resident #2. Resident #1 replied yes and asked if resident #2 was dead and went back to eating his breakfast. The Physician was immediately notified and immediately prescribed medications to level him out. LVN H added Resident #1 had aggressive behaviors but never to this level. He had never been violent. The facility immediately tried to discharge Resident #1 due to the severity of the physical assault. She stated the first mental health hospital would not accept him. LVN H stated initially the facility put in place one to one monitoring. In an interview on [DATE] at 12:46 PM the ADON stated when she observed Resident #2 after the abuse from Resident #1 it looked like a massacre. Resident #1 admitted to doing it. She stated the facility attempted to discharge Resident #1, however, other facilities would not accept the resident do the severity of the abuse. She stated the facility rehired hall monitors and provided radios for better and quicker communication. Resident #2 was moved to another room and isolated from Resident #1. In an interview on [DATE] at 2:41 PM the DON stated she recalled the incident between Resident #1 and Resident #2. She was aware of the severity of the incident. She stated Resident #2's body was found in bad condition and was sent to the hospital. The DON stated the police were called and several referrals were made in attempt to discharge Resident #1 to another facility. She stated it took a couple weeks for the facility to hire hall monitors and she was able to purchase radios for staff to communicate more effectively. She stated Resident #2 was move to another room with a private bathroom. The DON stated Resident #1 had not previously had violent behaviors. B. Resident #1 Record Review of Resident #1's Nurses' Notes reflected: [DATE] 12:53 AM: at 11:30 PM after being alerted by CNA's when I came upon scene found this resident standing up in aggressive mode holding guitar threatening staff cursing yelling out while his roommate (Resident #3) was lying on the floor after being hit by this resident after talking to resident he put down guitar and yelled you better get him out before I kill him staff was allowed to get roommate up out of room with no further attacks resident asked to stay in room via said nurse resident remains in room monitored via staff et cameras will continue to monitor. Record review of Resident #1's Physician Orders, dated [DATE] reflected Pharmacy: [MEDICATION NAME] Tablet 1 mg ([MEDICATION NAME]) give 1 mg by mouth two times a day related to [MEDICAL CONDITION]. Start date [DATE]. [MEDICATION NAME] Tablet Delayed Release ([MEDICATION NAME] Sodium) Give 250 mg by mouth at bedtime related to Major [MEDICAL CONDITION] Single Episode. Start Date [DATE]. [MEDICATION NAME] Tablet Delayed Release ([MEDICATION NAME] Sodium) Give 500 mg by mouth two times a day related to Major [MEDICAL CONDITION] Single Episode. Start Date [DATE]. [MEDICATION NAME] Capsule 20 Mg (ziprasidone HCI) Give 20 mg by mouth at bed time related to [MEDICAL CONDITION]. Start date [DATE]. [MEDICATION NAME] Capsule 20 Mg (ziprasidone HCI) Give 40 mg by mouth two times a day related to [MEDICAL CONDITION]. Start date [DATE]. [MEDICATION NAME] Tablet 50 mg (QUEtapine [MEDICATION NAME]) Give 50 mg by mouth tow times a day related to [MEDICAL CONDITION]. Start date [DATE]. Review of R #1's Comprehensive Care Plan dated [DATE] reflected: Focus: · I have potential to be physically aggressive related to Dementia, History of harm to others, Poor impulse control, [MEDICAL CONDITION]. Date initiated: [DATE] Interventions/Task: · Followed by Senior Psych Care. Notify me of any escalation in behaviors, ineffectiveness, or side effects of psychiatric medications. · Give me as many choices as possible about care and activities. Monitor me for physically aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. · Monitor/document/report PRN any s/sx of me posing danger to myself and others. · When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Resident #3 Review of R #3's undated face sheet reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R #3's Comprehensive Care Plan dated [DATE] reflected no documented physical or verbal aggression towards staff or residents. Review of R #3's Quarterly MDS dated [DATE] reflected: · had adequate hearing and clear speech · understood others and made self-understood · had a brief interview of mental status score of 10 - moderately impaired · required supervision for bed mobility, transfers, dressing, and extensive assistance for personal care · had no physical behavioral symptoms towards others. Review of Resident #3's Nurses' Notes reflected: [DATE] 02:22: Resident (#3) found in floor of room via staff after being slung down by roommate (resident #1) after roommate trying to go to bathroom, resident (#3) stated roommate called him a punk then he called resident one then resident charged him slung him down then with continued abuse struck him in the head three times stated resident (#1) kept saying he was going to kill him, resident (#3) assisted from floor via staff et assisted to nurses station assessed et treated for [REDACTED].#3) stated that he felt ok that his third digit on his left hand hurt some resident able to move all digits no bruising or swelling noted to area at this time will continue to monitor asleep now without incident. [DATE] 03:11 Late Entry: Received X-ray report. Report as follows. Impacted FX noted at bas of proximal phalanx in index finger . [DATE] 18:31: Resident (#3) continues to refuse to move to a different room made available due to altercation with his roommate, he choose to stay in room, instructed resident on precautions and risk of staying in room, he voiced understanding. Review of Resident #3's X-ray record, dated [DATE] reflected Impacted fracture noted at base of proximal phalanx in index finger. In an interview on [DATE] at 9:00 AM the SW stated just a few days after the initial incident between Resident #1 and Resident #2, Resident #1 got into it with his roommate (Resident #3), he just went crazy on him. He broke his (Resident #3) finger. She stated after the second incident the resident was separated from others and she gathered a referral packet and was able to transfer Resident #1 to the state hospital. She stated it was an ongoing process to get the resident out of the facility. She was not sure why Resident #1 remained in his room with a roommate after the first incident. In an interview on [DATE] at 9:14 PM CNA B stated Resident #1was very aggressive towards staff and residents. She felt Resident #1 was a violent aggressive person. He would smile at you one minute and the next minute he would become aggressive. She stated staff heard commotion coming from down the hall way and when they went to observe the situation they saw Resident #3 on the floor while Resident #1 was above him swinging at him with a guitar. Staff tried to separate the residents, however, Resident #1tried to strike the staff with the guitar. Resident #3 yelled at Resident #1 to stop him from attacking staff. Resident #1 again started trying to attack Resident #3. A nurse was finally able to separate Resident #1 form Resident #3 who sustained a couple abrasions. CNA B stated after the first incident staff checked on the resident regularly but was not sure why he was not isolated from other residents. In an interview on [DATE] at 9:21 AM LVN G stated she was not sure why Resident #1 remained in a room with a roommate after such a terrible incident. In an interview on [DATE] at 9:31 AM CNA A stated a few days after the Incident with Resident #2, Resident #1 attacked his roommate resident #3 and broke his finger. She was unaware as to why Resident #1 was not isolated after such an aggressive incident. She stated Resident #1 and #3 continued to be roommates after the first incident. In an interview on [DATE] at 10:00 AM CNA C stated She was unaware as to why Resident #1 was not separated from other residents after the first incident with Resident #2. Subsequently Resident #1 attacked his roommate Resident #3 a few days later with a guitar causing some abrasions and a fx finger. She stated after the second incident with his roommate. CNA C stated there were resident rooms with private bathrooms that could have been utilized. In an interview on [DATE] at 12:19 PM LVN H (scheduling coordinator) stated they offered Resident #1's roommate, Resident #3 to change rooms but he refused to change rooms. The facility hired hall monitors again to observe the halls for behaviors. Staff were all equipped with walk talkies to communicate more effectively. Subsequently Resident #1 attacked resident #3 in their room with a guitar breaking Resident #3's finger. After the second physical assault by Resident #1 he was discharged to the state hospital. LVN H added the hall monitors were not allowed to touch the resident, they did call for assistance, however, by the time staff arrived, Resident #1 had already attacked Resident #3, knocked him on the floor and hit him with the guitar. LVN H stated the facility previously had Hall Monitors, however, overtime staff had left and the facility did not rehire them until after the incidents. In an interview on [DATE] at 12:46 PM the ADON stated after the incident with Resident #2, Resident #1 remained in his room with his roommate, Resident #3. The ADON stated Resident #3 did not want to change rooms. A few days later Resident #1 attacked Resident #3. Resident #1 pushed Resident #3 to the floor breaking his finger. She stated after the second incident the facility was able to discharge Resident #1 to the state hospital. She stated she was not sure why the facility had not attempted to move Resident #1 to a private room. In an interview on [DATE] at 2:41 PM the DON stated after the first incident Resident #3 was asked if he wanted to move from his room with Resident #1, but he chose not to. The DON stated shortly after Resident #1 had an altercation with Resident #3. The DON added Resident #3 and Resident #1 had always gotten along and never thought there would be an issue. Resident #1 was discharged to the state hospital after the second incident. They have a system in place where they try to send out residents to a facility if they are not able to care for them in the currently building. Review of the facility's undated Abuse, Neglect, Exploitation General Policy, reflected: ABUSE, NEGLECT, EXPLOITATION, PREVENTION STANDARD: This facility has developed and implemented this policy and procedure to prohibit mistreatment, neglect and abuse of all elders and misappropriate of elder property. Abuse means any act or failure to act perfumed intentionally or recklessly that caused or is likely to cause harm to an elder . PURPOSE: To ensure that all elders of this facility will be free of physical, emotional, and sexual abuse, neglectful treatment and misappropriation of funds and resource. The accompanying procedures are employed to assure total staff adherence to this policy. PROCEDURE: . Protection 4 All elders receive protective oversight twenty-four (24) hours a day. The staff is charged with the responsibility to protect elders from abusive staff members, family members and from other elders who might be acting in an aggressive manner. It was determined these failures placed Resident #2 and #3 in an Immediate Jeopardy situation from [DATE] to [DATE] When Resident #1 was discharged from the facility. The facility took the following actions to correct the non-compliance on [DATE]: Observations on [DATE] between 9:00 AM and 4:00 PM, and on [DATE] between 10:00 AM and 5:00 PM revealed Hall Monitors walking the facility hallways observing all residents. The Hall Monitors were equipped with radios and made rounds frequently throughout the facility and on the facility grounds. Direct care staff were observed with and utilizing radios for quicker communication. Staff called for assistance and communicated with each other regularly with the radios. The facility reported both incidents to the appropriate state authority on [DATE] and [DATE]. Record review reflected the facility conducted an internal investigation. Record review reflected the facility was cited for failure to update care plans regarding Resident #1's physical abuse on [DATE]. Review of the facility's In-service training reporter reflected: Abuse and Neglect on [DATE], [DATE], [DATE], [DATE], and [DATE] Assault on staff or residents [DATE] Radio [DATE], and [DATE] Behavior Training [DATE] Interview with staff throughout the investigation revealed staff were trained on abuse and neglect, could identify forms of abuse, were aware of how to intervene with residents who had aggressive behaviors, and were able to identify when and to whom to report abuse and neglect. Two CNAs one LVN on the evening shift, three CNAs and two LVNs on the morning shift, and three CNAs and two LVNs on the afternoon shift were interviewed. Review of Hall Monitor's hire Dates reflected the first hall monitor was hired on [DATE]. In an interview on [DATE] at 10:50 AM Hall Monitor D and E stated they are trained to make rounds daily and watch the halls for any concerns. They focus on the wonderers who can go into different rooms because some Residents typically get upset if they go in to their rooms. They are trained to redirect those wonderers. They also make rounds every hour of the perimeter. They stated there is typically one hall monitor per hall. The facility is composed of two main resident halls. Review of Resident #1's Transfer/Discharge Reported, reflected Resident #1 was discharged to a Psychiatric hospital on [DATE] In an interview on [DATE] at 4:50 PM the NFA and ADON were notified of PNC IJ was Identified.