Every finding on record at Diversicare of Brookhaven

Based on observation, interview and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to foods not dated, staff touching the garbage can lid and then touching clean dishes, touching food that is ready to eat with hands, staff touching their face then touching the food thermometer, placing used water pitchers back on the shelf with clean dishes during two (2) of (2) kitchen observations.Findings include:A review of the facility's policy, Handwashing Procedure for Dining Services, undated, revealed .situations that require hand hygiene.After handling soiled equipment or utensils.After.touching your.face.A review of the facility's policy, Food Storage: Cold Foods, revised 2/2023 revealed, .Procedures.5. All foods will be stored.labeled and dated.On 01/05/2026 at 10:08 AM, observation during an initial tour of the kitchen revealed Refrigerator #2 contained one (1) cup of what the Dietary Manager (DM) revealed to be thickened milk with no label or date. The DM acknowledged the unlabeled and undated milk in the refrigerator. The DM affirmed that the milk was not poured that morning. The DM reported that the milk should have been labeled and dated by the person who poured it to ensure it is used within a safe timeframe.On 1/07/2026 at 9:53 AM, during a second observation and interviews of the kitchen revealed during the food preparation the cook removed her gloves, lifted the garbage can lid with her bare hands, threw the glove in the garbage can and proceeded to remove clean dishes from the dishrack and place them in various shelves and drawers in the kitchen. The cook laid her hand across the top of each piece of cornbread with the spatula underneath as she lifted it from the cooking pan to be moved to another pan for the food service line. The [NAME] touched her mouth with her hand and proceeded to touch the thermometer used to check the temperature of the food. The Dietary Aide (DA) used two water pitchers to fill glasses, then placed the used pitchers back on the shelf with clean dishes. The [NAME] acknowledged touching the garbage can with her hand and then putting up the dishes. The [NAME] also acknowledged touching the cornbread with her hands to remove it from the pan and touching her mouth and proceeding to touch the thermometer. The [NAME] affirmed that she should have washed her hands and not touched the bread with her hands. The [NAME] stated the purpose of maintaining sanitation in the kitchen is to prevent the spread of germs. The DA acknowledged during an interview that she placed the pitchers back on the shelf with clean dishes. The DA stated the purpose of maintaining clean dishes is to prevent infection. The DM acknowledged the poor hand hygiene displayed by the kitchen staff and the placing of used dishes back among clean dishes. The DM stated the purpose of maintaining sanitary practices in the kitchen is to keep the elderly from getting sick and to keep down pathogens. The DM stated the staff has been in-serviced recently and will be in-serviced again. On 01/08/2026 at 9:50 AM, during an interview the Administrator acknowledged the unlabeled and undated milk as well as the unhygienic practices during the lunch service. The Administrator noted the importance of maintaining sanitary conditions in the kitchen is to prevent the spread of germs. The Administrator noted she expects the kitchen staff to adhere to the professional standards for sanitation.

Based on observation, interviews, record reviews and facility policy the facility failed to obtain a physician order for oxygen (02) before administrating for one (1) of two (2) residents reviewed for oxygen. Resident #27Findings include:A record review of the facility's Oxygen Guideline policy with an update of 8/1/24, revealed medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided in accordance with a healthcare provider's order and in accordance with acceptable standards of practice .On 01/05/2026 at11:32 AM, in an observation of Resident #27 in bed eating lunch. Resident #27 has O2 flowing at 2 milliliters (ml).On 01/07/2026 at 8:20 AM, an observation of Resident #27 in bed oxygen flowing at 2ml.On 01/08/26 at 12:18 PM, in an interview, the Director of Nursing (DON) stated they do not have standing orders. She stated we call the Nurse Practitioner (NP) for all orders. She confirmed oxygen is a medication and should not be given without physician order.Record review of the admission Record revealed Resident #27 was initially admitted on [DATE] with diagnoses that included unspecified asthma.A record review of Resident #27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicates the resident is cognitively intact.Record review of the Order Summary Report with active orders as of 1/6/26 revealed there was not a physician order for oxygen.

Based on observation, interviews, record reviews and facility policy review the facility failed to develop a comprehensive care plan regarding Post Traumatic Stress Disorder (PTSD) and for the use of oxygen (O2) therapy for two (2) of 20 care plans reviewed. Resident #2 and Resident #27.Findings include:A record review of the facility policy Care Plan with an effective date of October 2021 revealed Care plans will be developed for all patients and residents based upon the Resident Assessment Instrument (RAI) manual guidelines .On 1/6/25 at 1:30 PM, in an interview Resident #2 stated she was in the Army for 34 years. She stated she fought in a war and that triggered her PTSD. She was very vague and would not talk much about it. She was talkative about other things. No behavior noted during interview.On 01/07/2026 at 2:40 PM, in an interview with Licensed Practical Nurse (LPN) # 1 stated residents have schizophrenia and get confused at times. She stated she is aware of PTSD and that should be on the care plan. On 01/08/26 at 12:18 PM, during an interview the Director of Nursing (DON) stated that the comprehensive care plan should contain details of PTSD, so staff will be aware when providing care. She stated this may help Resident #2 to calm down and let staff know what to avoid while providing care. On 01/08/26 at 12:34 PM, in an interview with Registered Nurse (RN) #1/Minimuum Data Set (MDS) nurse stated that the care plan is developed so that staff can use it while providing care. She stated the triggers for PTSD should be included in the care plan, it makes staff aware of the triggers of her PTSD. A record review of Resident #2's admission Record revealed an admission date of 9/17/25 with diagnoses that included of Dementia in other diseases classified elsewhere, unspecified severity, with Mood Disturbance and Post-traumatic stress disorder, chronic which included an onset date of 9/16/25.A record review of the comprehensive care plans revealed a care plan for PTSD had not been developed. A record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/25 revealed a Brief interview of Mental Status (BIMS) score of 9 which indicates moderate cognitive impaired.Resident #27A record review of Resident #27's comprehensive care plan revealed there was not a care plan developed for oxygen usage.On 01/05/2026 11:32 AM, in an observation of Resident #27 in bed eating lunch. Resident #27 had O2 flowing at 2 milliliter (ml)/hour.On 01/05/26 at 11:35 AM, an interview with RN #2 confirmed that Resident #2 was receiving 02 at 2ml/minute. On 01/08/26 at 12:18 PM, during an interview the DON stated they do not have standing orders. She confirmed oxygen is a medication and should not be given without physician order. She stated the care plan should include oxygen so staff will know how to check saturation and tubing. She stated the care plan is used by all staff and should be correct. On 01/08/26 at 12:34 PM, in an interview with RN#1 care plan nurse stated if it is not on the physician orders there will not be a care plan developed. She stated it was not ordered. She stated all staff use care plans to give care.Record review of the admission Record revealed Resident #27 was initially admitted on [DATE] with diagnoses that included unspecified asthma.A record review of Resident #27's MDS with an ARD of 11/25/25 revealed a BIMS score of 14 which indicates the resident was cognitively intact.Record review of the Order Summary Report with active orders as of 1/6/26 revealed there was not a physician order for oxygen.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure infection control practices were followed during medication administration for one (1) of three (3) residents observed for medication pass (Resident #52).Findings include:Record review of the facility policy Handwashing/Hand Hygiene with an effective date of 11/1/2017 revealed .2. All team members shall follow the handwashing/hand hygiene procedures.8. Single use disposable gloves should be used.b. When anticipating contact with blood or body fluids; and C. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions .On 01/07/2026 at 8:10 AM, an observation of medication administration for Resident #52 was conducted with Licensed Practical Nurse (LPN) #1. During this time, the nurse was observed administering a nasal spray, an inhaler, and a lidocaine patch. LPN #1 entered the resident's room and placed the medications on the bedside table without disinfecting the surface or applying a barrier to prevent contamination. At 8:12 AM, LPN #1 administered the nasal spray without wearing gloves, followed by the inhaler and the topical lidocaine patch-again without wearing gloves or performing hand hygiene between administrations. At 8:18 AM, LPN #1 placed the used inhaler and nasal spray back into the unit's general medication cart without disinfecting them prior to storage.On 01/07/2026 at 8:20 AM, during an interview LPN# 1 confirmed she should have worn gloves to give the topical patch, but stated she did not know she was supposed to wear gloves when giving nasal sprays or inhalers. She then stated that she doesn't usually use a barrier when giving medications, but that they would help prevent cross contamination from occurring along with performing hand hygiene when changing between different routes of medication administration. She confirmed that items should not be placed on a resident's table and then back into a common area such as the medication cart without being disinfected first to prevent cross contamination.On 1/8/2026 at 10:48 AM, during an interview the Director of Nurses (DON) revealed that LPN# 1 should have performed hand hygiene, then placed gloves on before performing the inhaler medication administration, then changed gloves and completed hand hygiene before giving the nasal medication and then performed hand hygiene and changed gloves again prior to giving a transdermal patch. She noted that each medication required gloves to be worn to prevent infection. She stated that prior to sitting the resident's medications on the bedside table, it should have been disinfected. She further confirmed that items shouldn't be taken into a room, sat on a contaminated surface and then placed back in the medication cart without being disinfected properly.Record review of Resident 52's January 2026, Medication Administration Review (MAR) revealed medication administrations on 1/7/25 by LPN #1 as follows: 1).Azelastine-fluticasone 137-50 micrograms/actuation (mcg/act) 1 spray in both nostrils one time a day for allergic rhinitis. 2). Lidocaine 4% patch apply to affected area topically one time a day, remove after twelve hours. 3). Symbicort Inhalation Aerosol 160-4.5mcg/act 2 puff inhale orally twice a day.Record review of the admission Record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease.Record review of Resident 52's Minimum Data Set (MDS) with an Assessment Reference date of 12/23/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.

Based on observation, interview, record review and facility policy review the facility failed to provide activities and invitations to activities to meet the residents' psychosocial needs for one (1) of 17 residents sampled. Resident # 19 Findings include:A review of the facility's policy, Resident Rights and Quality of Life Policy, with an effective date of March 13, 2020, revealed, .A patient or resident has a right.To receive services in a center environment that is.comfortable with adequate space for activities.A review of the facility's Recreation Services Assessment dated 12/29/25 revealed the resident listed several activities that he would enjoy including Bingo.During an interview on 1/05/2026 at 11:15 AM, Resident #19 revealed he was new to the facility. The resident stated he was not interested in group activities but would like to participate in one-on-one activities. The Resident stated he has not been offered any opportunities for activities since moving into the facility.On 01/06/2026 at 9:40 AM, during an observation the Activities Supervisor (AS) walked from room to room inviting residents to the 10:00 AM activity. The AS walked past Resident #19's room without addressing the upcoming activity with him.On 01/06/2026 at 1:30 PM, an observation revealed the AS walked to and from multiple rooms on the hall to invite residents to 2:00 PM Bingo. The AS was observed to walk past Resident #19's room without addressing the upcoming Bingo activity. On 01/06/2026 at 2:45 PM, an interview with the resident confirmed he was not invited to any activity for the day. The resident stated he would have enjoyed playing bingo at 2:00 PM. The resident noted he would not be at the facility long because he is there for rehab, but he would like to be invited to activities.On 01/08/2026 at 9:21 AM, an interview with the AS acknowledged that she did not invite Resident #19 to activities that were tailored to meet his psychosocial needs. The AS noted that the purpose of encouraging residents to stay active, motivated and around people and to keep them cheerful. The AS noted she will improve her efforts to invite all the residents to activities and to document her efforts.During an interview on 01/08/2026 at 9:28 AM, the Administrator acknowledged that the resident has not received invitations to activities that were enjoyable to him. The Administrator affirmed the importance of keeping the residents engaged in activities. The Administrator noted that she will engage other staff to assist with inviting the residents to activities to ensure all residents are encouraged to join. A record review of the facility's admission Record revealed the facility admitted the resident on 12/23/25 with diagnoses including Chronic Obstructive Pulmonary Disease.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/25 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact.

Based on observation, interview, facility policy review, and record review, the facility failed to revise the comprehensive care plan to reflect ongoing behavioral concerns and physical aggression for one (1) of three (3) sampled residents (Resident #1). Findings Include:A policy review of the facility's Care Plan policy dated 10/21 revealed culturally component goals and interventions for mood, behaviors, history of trauma, cognitive concerns. should be added to the comprehensive care plan .On 11/24/25 at 11:29 AM, in a phone interview, Certified Nursing Assistant (CNA) #1 stated Resident #1 had been physically abusive toward her on multiple occasions, including hitting, kicking, and grabbing her. She reported the behavior to the Nursing Home Administrator and was moved off the resident's hall.On 11/24/25 at 12:18 PM, Resident #1 was observed calm in bed, oriented to two domains, intermittently providing appropriate responses.On 11/24/25 at 12:30 PM, CNA #2 stated she had witnessed Resident #1 become aggressive with CNAs.On 11/24/25 at 12:53 PM, Resident #3, the roommate of Resident #1, stated he had observed Resident #1 hit CNAs.On 11/24/25 at 1:00 PM, CNA #3 stated that Resident #1's verbal and physical aggression was directed toward CNAs and confirmed being struck herself.On 11/24/25 at 5:35 PM, Registered Nurse #1 stated she was aware of the behavior concerns but had not witnessed them herself. She stated behavior concerns should be reflected in the care plan, which is used by all staff to direct care.On 11/24/25 at 5:47 PM, CNA #4 stated she uses the care plan to guide her care provision.On 11/24/25 at 5:55 PM, the Interim Director of Nursing confirmed that the Kardex, used by CNAs, is based on the comprehensive care plan. She stated behavior issues must be included in the care plan to guide all staff.A record review of Resident #1's admission Record revealed an admission date of 9/30/25 with diagnoses including cerebral infarction, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety.A record review of progress notes revealed behavioral incidents including:10/12/25 - Combative behavior toward CNA; 10/18/25 - Slapped a CNA in the face and kicked her in the chest; 10/20/25 - Slapped a CNA in the face and pulled her hair down and punched her in the face; 10/18/25 - Hit a nurse in the abdomen; 11/02/25 - Punched a CNA with a closed fist.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 10/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitive intactness. The MDS with ARD 10/24/25 coded for physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others.A record review of the comprehensive care plan revealed no documentation of person-centered goals and interventions to address Resident #1's repeated verbal and physical aggression toward staff.

Based on observation, interview, record review, and policy review, the facility staff failed to handle and transport linens in accordance with accepted standards in order to provide hygienically clean linens and prevent the spread of infection for one (1) of five (5) observations and failed to follow appropriate infection control practice for management of drainage system associated with indwelling catheter within accepted standards of practice for one (1) of six (6) sampled residents, Resident #4.Record review of Facility History revealed the facility was cited 6/04/25 at level D for F880 for infection control due to improper handling of clean linen, therefore the scope and severity was increased to E.Findings include:Policy review of the facility policy titled, DESCRIPTION OF STEPS IN THE LAUNDRY PROCESS, Revision Date 10/25/16, revealed the policy stated, Soiled Linen containers or barrels should be on each Nursing unit stored in a soiled area so that nursing can deposit soled linen.it is very important to properly transport and store soiled linens to prevent the spread of infection. To do so, all soiled linen and clean linen must be covered during transportation and while being stored.On 10/21/25 at 12:25 PM observation and interview with Resident #4 revealed resident's room smelled strongly of urine and there was a six (6) square foot area of the floor under and next to the resident's bed that was covered in urine which was dripping from a blue plastic urine bag cover. The resident said that the prior night shift (11:00 PM 10/20/25 through 7:00 AM 10/21/25) nor the 10/21/25 day shift staff had emptied his urine collection bag. The resident stated that he had received treatment for urinary tract infection during his stay at the facility.On 10/21/25 at 1:03 PM during an interview, C.N.A. #5 stated that she had not noticed that resident #4's urine collection bag was full or overflowing on 10/21/25 or that there was urine under and beside his bed when she was in his room prior at 12:25 PM on 10/21/25. She confirmed that she had been in Resident #4's room and removed his lunch tray and then clocked out for lunch; she stated that she did not smell urine in Resident #4's room because, I can't really smell.On 10/21/25 at 12:40 PM observation and interview with the Administrator revealed she confirmed that Resident #4's room smelled like urine and that there was approximately seven (7) square feet of the floor beneath and beside the resident's bed that was covered with urine, and the urine collection bag/bag cover were overflowing with urine dripping onto the floor. On 10/21/25 at 12:45 PM observation revealed the uncovered catheter urine collection bag was lying on the floor next to Resident 4's bed along with the blue plastic urine collection bag cover, both were full to overflowing with urine. There was urine covering an eight square foot area of the floor beneath and next to the resident's bed, which was against the wall. The Assistant Director of Nurses (ADON) emptied the urine collection bag into two (2) urinals and attempted to empty the blue plastic cover into a urinal and spilled an undeterminable amount onto the floor. Due to spillage the total amount of urine in the collection bag and the cover could not be determined. SA observed three (3) standard plastic 1000 milliliter (ml) urinals were filled.On 10/21/25 at 12:49 PM observation and interview revealed CNA #7 carried a two (2) foot tall stack of clean linen down the hallway clutched to her body/uniform. CNA #7 stated, I forgot my bag, my bad. CNA #7 confirmed she was aware that it was important to cover linens during transport to carts/resident rooms to prevent the spread of infection.On 10/21/25 at 1:00 PM interview with the Assistant Director of Nurses (ADON), who was the facility Infection Preventionist (IP), revealed she confirmed that it was important to cover linens during transport to carts/resident rooms to prevent the spread of infection. She confirmed that the nurses, she and the Director of Nurses (DON) supervised the care of residents and provision of care by the CNAs. She confirmed that nursing staff should monitor residents with indwelling urinary catheters and associated urine collection systems and the collection bags should be emptied as needed and not allowed to become full or overflowing.On 10/21/25 at 2:00 PM an interview with the Administrator revealed she expected nurses and the ADON and DON to supervise the CNAs and care of residents, and that she expected the CNA.s to transport clean linens covered with disposable trash can liners supplied by the facility. The Administrator confirmed that she expected nursing staff to monitor residents with indwelling catheters and associated urine collection systems and meet the needs of those residents, including emptying the collection bags as needed.Record review of the admission Record for Resident #4 revealed the facility admitted the resident on 9/12/25 and the resident had diagnoses of benign prostatic hyperplasia, need for assistance with personal care, urinary tract infection, retention of urine, and heart disease.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/19/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS review revealed the facility assessed the resident as having an indwelling catheter.

Based on observation, record review, policy review and interviews, the facility failed to provide incontinent supplies and services for one (1) resident with indwelling urinary catheter (Resident #4) and for three (3) incontinent residents out of six (6) sampled incontinent residents, Residents #1, #2 and #3. Findings include:Policy review of the facility policy titled Proper Techniques for Urinary Catheter Maintenance, undated, revealed the policy revealed, .Do not rest the bag on the floor .Empty the collecting bag regularly, as a standard of practice at least every shift The policy did not address necessity of physician's order for indwelling catheters. Record review of the Incontinence Care Statement dated 10/27/25 signed by the facility Administrator revealed the facility provides incontinence care and follows the audit tool; the document did not address incontinence supplies. Record review of the Peri Care Audit Tool, undated revealed, If Foley catheter present .maintains drainage. Resident #1, #2 and #3 Incontinence suppliesOn 10/20/25 at 9:10 AM the facility Ombudsman confirmed that she had received multiple complaints from Resident #1 and his Resident Representative and from other residents during October 2025 regarding the lack of incontinent supplies and postponed care due to residents having to wait for direct care providers having to wait for supplies to be provided for resident care. She stated that the Administrator had reported to her that there had been incidents of delayed delivery of supplies and supplies delivered to other facilities and not arriving at the facility. On 10/20/25 at 11:08 AM during telephone interview the Resident Representative (RR) for Resident #1 revealed she had filed complaint with the State Agency (SA) due to events of October 2025 during which Resident #1 had telephoned or messaged her and reported that the staff had told him there were no more incontinence briefs in the facility. She said he was concerned and told her that he didn't want to have a bowel movement or request a change because the facility was out of briefs. She said she had instructed him to request assistance as needed with incontinence care. She stated that she had reported her concern to the facility's corporate hotline for concerns/complaints and had been told that there were problems with supply deliveries being late or sent to the wrong facility. She stated she had also reported this to SA on 10/02/25 after calling the facility and being told by staff that the facility was out of incontinence briefs. She could not provide the name of staff due to confidentiality concerns (she promised them she would not divulge their name).On 10/20/25 at 1:25 PM during an interview with Resident #1 in his room revealed he said he had learned from Certified Nursing Assistants (CNA) (he was unable to provide the names of staff) on multiple occasions including Sunday, 10/19/25, that the facility was out of incontinence briefs. He stated that earlier in the month he had spoken with the Administrator and had been provided with a package of briefs initially placed on his nightstand and then moved to his closet and then removed from his room. Resident #1 stated that he had spoken with another member of management at the facility who had confirmed that they were out of diapers; he did not wish to provide the name of the staff member and said, I don't want to get her in trouble. He said that he could not understand how the facility ran out of briefs with full knowledge that there were residents like him that required briefs for care. He said that on Sunday, 10/19/25 his care was postponed for at least an hour, and he was told that it was because there were no incontinence briefs available in the facility. Resident #1 stated that he was unable to transfer onto toilet or commode because he was not able to bear weight on his feet per physician's orders. He said he was also unable to use bedpans.On 10/20/25 at 2:25 PM during an interview CNA #3 confirmed that there had been shortage of incontinent care supplies for Resident #1 and other incontinent residents. On 10/20/25 at 2:40 PM interview with CNA #2 revealed there had been times during October 2025 when she did not have access to incontinence supplies for certain sized residents. She said that management staff would go to local vendors and buy some, and that resident care was postponed waiting for the supplies to arrive at the facility. On 10/20/25 at 2:52 PM a confidential interview with a direct care staff member who requested to remain anonymous, who SA confirmed was on duty on the 7:00 AM through 3:00 PM shift on 10/19/25, revealed there were no incontinent briefs available for resident care at approximately 8:00 AM through approximately 9:30 AM which resulted in lack of care or postponement of care for incontinent residents, including Resident #2 and Resident #3. The staff member stated that direct care staff had to wait for a member of the facility management staff to come to the facility with a key and unlock the supply closet for them to have access to incontinence briefs for the care of incontinent residents. The staff member stated that being low on supplies had caused issues for most of the month of October 2025. The staff member stated that low supply levels of incontinence supplies had been reported by themselves and other staff to the Assistant Director of Nurses (ADON) and the Administrator, and that even though there were times that the facility would purchase incontinence briefs from local vendors, the problem persisted. The staff member stated that there was not a problem with supplies at the time of survey (10/20/25) because a supply truck had delivered supplies at approximately 8:00 AM. She stated that she didn't offer information to residents that there were no incontinence briefs available, but she did not lie to them if they asked.On 10/20/25 at 3:05 PM an interview with CNA #1 revealed she stated that the facility was not usually out of incontinence briefs but had run out of certain sizes. She stated that C.N.A.s were instructed to let the Director of Nurses, Assistant Director of Nurses or Administrator know if supplies were low.On 10/20/25 at 3:33 PM observation and interview with Resident #2 revealed she was waiting for requested incontinence care. She said she had returned from the therapy gym at approximately 1:00 PM and had not received any care since returning to her room. She stated she had notified CNA#4 at approximately 3:00 PM that she needed assistance with incontinence care. She said that she frequently had to wait for care, including incontinent care. She stated that on 10/19/25 she had to wait until approximately 10:00 AM and had been told by staff (she was unable to recall staff name) that the postponement of care was due to lack of supplies, specifically that there weren't any incontinent briefs available. She stated that she had been told the same thing two or three times during the month of October 2025, but she was unable to recall dates other than Sunday, 10/19/25, and that there had been other times when she said, I had to wear another size because the facility was out of her size incontinence briefs. She reported that on the night of Saturday, 10/18/25 (she was unsure of the time), her CNA had brought in one (1) brief and told her that it was the last one available and on the morning of 10/19/25 she had been told that she would have to wait for care until supplies were available. She confirmed that her roommate was told the same thing.On 10/20/25 at 3:45 PM interview with Resident #3 revealed she reported that she was frustrated by being told on Sunday, 10/19/25 that she had to wait for care until staff could obtain incontinence briefs needed for her care. She stated that she received no care on 10/19/25 until approximately 10:00 AM. On 10/20/25 at 3:55 PM observation and interview with CNA #4 revealed she confirmed that she was assigned to the care of Resident #2 and Resident #3 and had not made rounds or provided any care for either Resident #2 or Resident #3 at 3:55 PM because she had to straighten the cart and make someone's bed. She confirmed that Resident #2 had requested incontinence care at approximately 3:00 PM. She was unable to say how quickly incontinent care should be provided upon receipt of request for brief change due to incontinence but confirmed that the facility instructed CNAs to provide requested care in a timely manner, including incontinence care. On 10/20/25 at 4:07 PM during an interview, the Administrator stated that on 10/16/25 the facility had purchased incontinent supplies from local vendors and that the nurses had a key to the rooms where the supplies were stored. She said she was not sure if the nurses understood that they had keys to the rooms, but that the nurses should have known that. She confirmed that she had been made aware of the issue of staff telling residents that the facility was low on or out of incontinence supplies, and that the facility had provided instructions for all direct care workers to notify the DON, ADON, or Administrator if there were any issues with supplies. She stated she was not aware that the facility had ever run out of incontinent briefs. The Administrator reported that incontinent briefs were purchased on 10/16/25 at approximately 5:30 PM from a local vendor to ensure the facility was stocked for the weekend. She said she considered an acceptable wait time for staff to gather equipment and return to a resident's room to provide requested incontinence care would be five to ten (5-10) minutes, possibly fifteen (15) minutes if there were some serious situation that required attention; she stated that she considered fifty-five (55) minutes too long for a resident to have to wait for requested incontinent care.On 10/21/25 at 1:03 PM during an interview, CNA #5 stated that there was a constant shortage of incontinence briefs for resident care. She said she was on duty at the facility for the dayshift (7:00 AM to 3:00 PM) 10/19/25 and that she had texted the facility's Human Resource Coordinator (HRC) shortly prior to 8:00 AM and notified her that the CNAs needed incontinence briefs. She stated that incontinence care for incontinent residents was postponed for at least one and a half (1 1/2) hours on the morning of 10/19/25 while direct care staff waited for the HRC to arrive with the key to unlock the storage room; she stated, Everyone had to wait to get changed. She said she didn't know who else had a key to the storage room and she didn't know if nurses had a key to the storage room. She said that the nurses were the immediate supervisors for the CNAs and supervised resident care. On 10/21/25 at 1:20 PM during interview the facility HRC confirmed she received a text from CNA #5 on 10/19/25 at 7:43 AM that stated, Need some briefs. She stated that she arrived at the facility between 9:00 AM and 9:30 AM with the key to the storage room and unlocked the room and CNA #5 and other CNAs came and got incontinence briefs out of the closet. She stated that she was not sure if the nurses had a key to the storage room. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 8/22/25 with an Original admission Date of 1/02/24 and the resident had diagnoses of diabetes end stage renal disease and dependence on renal dialysis.Record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with Assessment Reference Date (ARD) 10/14/25 revealed the resident had a Brief interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS review revealed the facility assessed the resident could not walk, dependent on the use of wheelchair for mobility and required substantial/maximal assistance for toileting hygiene. The MDS review revealed the facility assessed the resident had occasional urinary incontinence and frequent bowel incontinence. The MDS review revealed the resident received dialysis. Record review of the Admissions Record for Resident #2 revealed the facility admitted the resident on 4/01/25 and the resident had diagnoses of diabetes, neuropathy, and acute kidney failure.Record review of the Quarterly MDS with ARD 10/09/25 for Resident #2 revealed the resident had a BIMS score of 15, which indicated no cognitive impairment. The MDS review revealed the facility assessed Resident #2 unable to walk 10 feet and dependent on wheelchair for mobility and required substantial/maximal assistance for toileting hygiene; toilet transfer was not attempted, and the resident did not perform this activity. The MDS review revealed the facility assessed the resident was always incontinent of bowel and bladder. Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 7/14/25 and the resident had diagnoses of chronic obstructive pulmonary disease, muscle weakness, lack of coordination, unsteadiness on feet, need for assistance with personal care, and cerebral infarction. Record review of the Nursing Home Part A PPS Discharge MDS with ARD 9/22/25 for resident #3 revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment. The MDS review revealed the facility assessed the resident as dependent on staff for toileting hygiene and walking 10 feet with toilet transfer not attempted due to medical condition or safety concerns with continuous oxygen therapy. Resident #4On 10/21/25 at 12:25 PM observation and interview with Resident #4 revealed the resident's room smelled strongly of urine and there was a six (6) square foot area of the floor under and next to the resident's bed that was covered in urine which was dripping from a blue plastic urine bag cover. The resident said that the prior night shift nor the 10/21/25 day shift staff had emptied his urine collection bag. On 10/21/25 at 12:39 PM interview in the room of Resident revealed the Maintenance Supervisor stated that the room smelled like urine. On 10/21/25 at 12:40 PM observation and interview with the Administrator in Resident #4's room revealed she confirmed that Resident #4's room smelled like urine and that there was approximately seven (7) square feet of the floor beneath and beside the resident's bed that was covered with urine. On 10/21/25 at 12:45 PM observation revealed the uncovered catheter urine collection bag was lying on the floor next to the Resident #4's bed along with the blue plastic urine collection bag cover, both were full to overflowing with urine. There was urine covering an eight square foot area of the floor beneath and next to the resident's bed, which was against the wall. The ADON and Wound Care Nurse emptied the urine collection bag into two (2) urinals and attempted to empty the blue plastic cover into a urinal and spilled an undeterminable amount onto the floor. Due to spillage the total amount of urine in the collection bag and the cover was not able to be determined. SA observed three (3) standard plastic 1000 milliliter (ml) urinals were filled from the collection bag and cover. On 10/21/25 at 1:03 PM CNA #5 stated that she had not noticed that resident #4's urine collection bag was full or overflowing or that there was urine under and beside his bed when she was in his room prior to 12:30 PM on 10/21/25. She confirmed that she had been in Resident #4's room and removed his lunch tray and clocked out for lunch; she stated that she did not smell urine in Resident #4's room because, I can't really smell. On 10/21/25 at 1:30 PM an interview with LPN #1 revealed she stated that she had not provided catheter care or checked to ensure catheter care was provided for Resident #4 on 10/21/25. She stated that the nurses were responsible for supervision of resident care. She stated that she had glanced at the indwelling catheter urine collection bag in it's blue cover and had not noted anything unusual or any problem with the drainage collection system between 12:00 PM and 12:30 PM. She stated that on 10/19/25 the HRC had reported to the facility and the storage room where incontinent briefs were stored and opened the room with a key at approximately 9:30 AM. On 10/21/25 at 3:25 PM during interview the Corporate Nurse Consultant confirmed that there was no physician's order for indwelling catheter for Resident #4 and that if a resident had an indwelling catheter, they should have a corresponding order. Record review of the admission Record for Resident #4 revealed the facility admitted the resident on 9/12/25 and the resident had diagnoses of benign prostatic hyperplasia, need for assistance with personal care, urinary tract infection, and retention of urine.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/19/25 revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment. The MDS review revealed the facility assessed the resident as having an indwelling catheter.Record review of the order Summary Report for Resident #4 revealed no physician's order for indwelling catheter.

Based on observations, policy review, and interviews the facility failed to ensure the right of the residents to reside and receive services in the facility with reasonable accommodation of resident needs to achieve independent functioning, dignity and well-being that reflect the resident's needs, specifically to call system within reach for two (2) of six (6) sampled residents, Resident #1 and Resident #4. Findings included: Policy review of the facility policy titled, Nurse Call System Effective Date 9/01/14, revealed the policy revealed, 2. Each cord needs to be visible and reachable by the resident to which it operates for . Resident #1On 10/20/25 at 1:25 PM during observation and interview with Resident #1 in his room revealed the call light for Resident #1 was attached to the transfer bar on the right side of the resident's bed by a clamp and not within the reach of the resident seated in his wheelchair on the left side of the bed. Resident #1 stated that he was not able to reach the call light.Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/25 revealed a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. Resident #4On 10/21/25 at 12:25 PM observation and interview with Resident #4 revealed the resident was resting in his bed, which was against the wall facing the door with head of bed elevated and his call light was coiled and lying on the floor behind the head of the resident's bed. Resident #4 confirmed that he was not able to reach his call light. Record review of Resident #1's MDS with an ARD of 9/19/25 revealed a BIMS score of 6, indicating severely impaired cognition.On 10/21/25 at 12:40 PM observation and interview with the Administrator in the rooms of Resident #1 and Resident #4 revealed that she confirmed that Resident #1's call light was not within his reach as he was seated in his wheelchair on the left side of the bed and the call light was attached to his bed's right transfer bar. The Administrator confirmed that Resident #4 could not reach his call light coiled and lying on the floor behind the head of his bed.On 10/21/25 at 1:03 PM during an interview, Certified Nursing Assistant (CNA) #5 stated that she was assigned to the care of Resident #1 and Resident #4. She stated that she had not touched the call light of Resident #1 all day and confirmed that the call light was not in reach of the resident as he was seated in his wheelchair on the left side of the bed and the call light was attached to his bed's right transfer bar. She confirmed that making sure each resident's call light was within their reach was important to ensure the residents could call for assistance as needed. She said that Resident #4 could not reach his call light coiled up and lying on the floor behind the head of his bed. She said she had not noticed that the resident's call light had been out of their reach. On 10/21/25 at 1:30 PM an interview with Licensed Practical Nurse (LPN) #1 revealed she stated that she had been in the rooms of Resident #1 and Resident #4 and had not noticed that their call lights were out of reach. She confirmed it was important for residents to have their call bells in reach to summon assistance as needed.

Based on observation, interview, record review, and facility policy review, the facility failed to protect residents right to be free from verbal, mental, and physical abuse for two (2) of four (4) sampled residents (Resident #2 and Resident #3). Specifically, Certified Nurse Aide (CNA) #1 verbally and physically abused Resident #2 during incontinence care on 5/21/25 by striking the resident's legs, scolding him, and failing to provide care in a safe, supportive, and respectful manner, resulting in the resident experiencing fear, shame, emotional distress, and feelings of helplessness. Additionally, CNA #1 verbally and mentally abused Resident #3 on 5/21/25 by scolding and berating the resident for incontinence, causing the resident to feel humiliated, ashamed, and fearful that the behavior would recur. Findings Included: Record review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed, .Purpose: To prohibit and prevent abuse, neglect .Definitions: Abuse: The willful infliction of .intimidation .with resulting physical harm, pain or mental anguish. A record review of the Investigation Template, dated 5/21/25, revealed the facility described the allegation that Resident #2 reported that a CNA had hit him on the leg with both hands because he was wearing a condom catheter. The Investigation Summary indicated that Interviews with all residents with BIMS (Brief Interview for Mental Status) greater than eleven. A review of the Summary of Interview revealed Resident #2 stated he was hit last night on his legs. Another Summary of Interview revealed Resident #3 indicated The CNA .that was assigned to him on 11pm-7pm was pissed off with him because he had urinated in the bed and she had to change him. Resident #2 Record review of the admission Record revealed the facility admitted Resident #2 on 5/09/25 with current diagnoses including Urinary Tract Infection. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. Further review revealed Resident #2 had no behavioral issues, was always incontinent of bowel and bladder, and was dependent for toileting hygiene and required substantial/maximal assistance to roll left and right on bed. Record review of the Social Services Progress Note for Resident #2, dated 5/21/25 at 14:49 (2:49 PM) revealed the Social Services and Admissions Liaison (SSD) documented that she visited the resident to ask about the incident that happen over night with the CNA. I let him know that we would handle the situation asap (as soon as possible). That we would make sure nothing like this ever happened again to him or anyone else. On 6/02/25 at 11:45 AM, an interview with Resident #2 with the assistance of his communication device revealed the resident stated that during the early hours of 5/21/25 Certified Nurses' Aide (CNA) #1 entered his room and discovered that his condom catheter had come off and his incontinence brief was wet, and he thought she acted like she got mad. He reported that when she started to turn him during incontinence care he had muscle spasms in his legs and the CNA struck him twice on his legs and told him to stop tensing up. He said he had involuntary muscle spasms and took medication for them. He said that he had not tried to communicate with the CNA after she struck him because he was scared. He said this incident upset him because he was dependent and could not defend himself. He said he immediately wanted to go home because nobody treated him like that at home, and he was afraid because the incident could occur again. He said that he was unable to go back to sleep and cried due to feeling afraid and humiliated. He confirmed the incident caused him to feel shame, fear and demeaned. He said he only agreed to remain at the facility after being assured that CNA would not be allowed back into his room and confirming that his wife could stay with him at night until he could complete his therapy and return home as scheduled. On 6/02/25 at 12:10 PM, an interview with the Resident Representative (RR) for Resident #2 revealed she had been notified of the resident's allegation of abuse on 5/21/25. She stated that when she arrived, he was very upset and demanded to go home immediately. She stated that her immediate reaction was to take him home, but that he was doing very well with his therapy and the two of them agreed for him to stay with her spending nights in his room with him. On 6/02/25 at 2:25 PM an interview with CNA #2 revealed she reported she had worked 7-3 shift on 5/21/25 and at approximately 7:30 PM she entered the room of Resident #2, and he was resting in bed with tears on his face and crying. She said she asked him what was wrong, and he used his communication device to tell her that he had been hit. She said she asked him who hit him, and he typed in the name of CNA #1. She stated that the resident told her he had been scared and crying and wanted to go home because no one hit him at home. She said she had immediately reported the allegation of abuse to the former Assistant Director of Nursing Services (ADNS). Resident #3 Record review of the admission Record revealed the facility admitted Resident #3 on 3/27/25 with current diagnoses including Benign Neoplasm of Cerebral Meninges. Record review of the admission MDS with an ARD of 4/03/25 revealed Resident #3 had a BIMS score of 8, which indicated his cognition was moderately impaired. Further review revealed he had no behaviors, was always incontinent of bowel and bladder, and required substantial/maximal assistance for toileting hygiene and moderate assistance to roll left and right on bed. On 6/02/25 at 3:50 PM during interview with Resident #3 in his room, he revealed that during the early morning hours of 5/21/25, CNA #1 had entered his room and scolded him for wetting his bed. He said that made him feel ashamed and said, I can't help wetting the bed; if I could, I wouldn't do it. It made me feel like getting up and getting out of here and I would have if I could. The resident said the incident made him feel shame and humiliated for wetting the bed and he was afraid because CNA #1 intimidated him while scolding him and that he was afraid the incident may recur. On 6/03/25 at 2:54 PM, during a telephone interview the former ADNS, she stated that she was the nurse assigned to the care of Resident #1 on 5/21/25 and was made aware of an allegation of abuse by Resident #2 around 7:30 AM by CNA #2. She said she immediately assessed and interviewed Resident #2 who was actively crying and told her that CNA #1 had hit his legs during the earlier hours of 5/21/25 when he wet his brief and then had muscle spasms in his legs during incontinence care and berated him to stop tensing up. She reported she had also assessed the resident, and his condom catheter was off, but in his brief. She said she had spoken with CNA #1 at approximately 6:45 AM on 5/21/25 and the CNA had asked her if the resident had any more condom catheters. She stated that the resident was traumatized and that on 5/21/25 the resident's wife had started spending the night with the resident in his room. She said that she was unaware of any other complaint ever made by Resident #2. She stated that as part of the investigation into Resident #2's allegation, she interviewed and assessed Resident #3 who reported that CNA #1 had scolded him because he had wet his bed. On 6/04/25 at 9:30 AM, during a telephone interview the District Ombudsman revealed she had received a report from the RR for Resident #2 that the resident had been struck by CNA #1 who spoke to him in a demeaning manner that made him feel degraded. She said the facility staff reported that CNA #1 had confirmed tapping the resident's leg. The Ombudsman said that there was no report given to her that Resident #3 had also reported verbal or mental abuse by CNA #1 during the same shift. On 6/04/25 at 10:35 AM, an interview with the Social Services and Admissions Liaison (SSD) revealed she was made aware of the allegation of abuse by Resident #2 on the morning of 5/21/25, a little after 8:00 AM and visited him on 5/21/25 to make sure he wasn't too upset and see if I needed to try to make him feel better and reiterate to him that the incident wouldn't happen again. She stated that she recalled somebody said something about Resident #3 saying CNA #1 got upset with him because he wet his bed but she did not visit the resident. On 6/04/25 at 11:11 AM, an interview with the Director of Nursing Services (DNS) revealed she was made aware of the allegation of abuse reported by Resident #2 by the Administrator at home on the morning of 5/21/25 via telephone call. She stated that she called CNA #1 and notified her that she was suspended pending investigation. She stated she had completed a couple of coaching sessions with CNA #1 in November 2024 related to resident care and Resident Rights and the CNA's assignment was changed to another group for the resident's comfort. She stated she became aware of the allegation of abuse by Resident #3 when she read the final draft of the investigation prior to sending it to the State Agency (SA) on 5/24/25. She stated that she was not aware of any follow-up investigation, interventions, or counseling provided as a result of the allegation by Resident #3. She said she felt CNA #1 had adequate information and training to provide appropriate care for Resident #2 and Resident #3. On 6/04/25 at 11:25 AM, during a telephone interview with CNA #1, she said she had 'patted' Resident #2 on his leg to get him to relax during incontinence care on the morning of 5/21/25. She stated it was possible she was frustrated. She said Resident #2 had never acted like that before, never tensed up before. It's harder on me. She explained that she had entered the room to empty the resident's catheter drainage bag, but it was empty, and she checked his brief, and it was wet. She noted his condom catheter had come off and she had to provide incontinent care and change his brief. She said she had told him that she was going to have to change his brief and when she started to turn him, his legs were tensed up and she was unable to turn him. She said she patted his leg and told him to relax and was then able to turn him onto his side and completed incontinence care. She said nobody ever told her that Resident #2 had muscle spasms. She said that Resident #2 used a communication device that was always on his over the bed table but that the device was not in his reach and he did not have it, and she did not give it to him. She said, When I talk to him, I try to understand him without using the tablet. I didn't use or give him the tablet. She said the resident didn't say anything to her. She reported that when she made final rounds, she entered Resident #3's room and was frustrated with him because he had peed out the bed. I think it was intentional. CNA #1 said she had fussed at Resident #3 and said, I shouldn't have, but I did. I told him he needed to stop urinating in bed. I had to change the bed and his clothes and give him a bed bath three (3) times during the shift. She said Resident #3 didn't respond. She said the DNS had called her at home and she had to meet with the DNS and the Administrator and was written up regarding the allegation by Resident #2 but was not asked any questions regarding Resident #3. She confirmed that she had complaints made against her and received coaching from the DNS in November 2024 and said, Usually I get changed to another hall. On 6/04/25 at 1:50 PM an interview with the Administrator revealed she was made aware of the allegation of abuse by Resident #2 on the morning of 5/21/25 by the ADNS. She said actions taken to protect the residents during the investigation included placing CNA #1 on suspension. She confirmed that the facility investigation determined the allegation of abuse was unfounded because there were no witnesses and no apparent injury such as bruise or abrasion. She acknowledged that Resident #2 had new behaviors of crying and had not made any allegations before or since the allegation of abuse voiced on 5/22/25 and she was aware that Resident #2's wife began to stay with him overnight in his room. She stated CNA #1 was brought back with training to educate regarding abuse and neglect prevention and resident rights and reassignment to a different group of residents.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure care was provided in a manner that protected the dignity and privacy of residents for three (3) of four (4) sampled residents (Resident #1, Resident #2, and Resident #4). Specifically, the facility failed to maintain privacy during incontinence care for Resident #1 when staff provided care with the window curtain open, exposing the resident's perineal area; failed to provide a catheter bag cover for Resident #2 to maintain dignity; and failed to assist Resident #4 with meals in a respectful manner by standing over the resident while providing feeding assistance, rather than sitting at the resident's side. Findings Include: A review of the facility's policy, Resident Rights and Quality of Life, dated 3/13/20 revealed, .It is the policy of .that all residents and patients have the right to a dignified existence . A record review of the facility's Peri (Perineal) Care Audit Tool, undated, revealed Action including Staff must .provide privacy (door, window, room divider curtain . Resident #1 Record review of the admission Record revealed the facility admitted Resident #1 on 4/05/24 and she had current diagnoses including Alzheimer's Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/25 revealed for Resident #1's Cognitive Skills for Daily Decision Making was Severely Impaired. On 6/03/25 at 10:45 AM observation revealed Certified Nursing Assistant (CNA) #3 and CNA #5 provided incontinent care for Resident #1 in her bed in her room next to the bed with the bed elevated and the double window curtain open; the window on the right was open approximately two (2) inches. The view from the window was the facility front yard and front porch and portico and the front parking lot and sidewalk. After positioning the resident and her clothing, CNA #5 exposed Resident #2's perineal area and after cleaning the front of the resident's perineal area turned the resident toward the window and cleaned the resident's back perineal area. Resident #2 Record review of the admission Record revealed the facility admitted Resident #2 on 5/09/25 with current diagnoses including Urinary Tract Infection. Record review of the admission MDS with an ARD of 5/16/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. On 6/02/25 at 3:44 PM, an observation revealed Resident #2's catheter drainage system collection bag was uncovered, containing clear yellow fluid. Resident #4 On 6/03/25 at 11:10 AM observation revealed CNA #5 standing at the bedside of Resident #4 assisting the resident to eat a midday meal (lunch). Record review of the admission Record revealed the facility admitted Resident #4 on 6/02/25 with current diagnoses including Senile Degeneration of Brain. Record review of the medical record for Resident #4 revealed the baseline care plan and MDS had not been completed for the resident at the time of survey. On 6/03/25 at 1:34 PM, an interview with CNA #5 revealed she was assigned to the care of Resident #1 and Resident #2 on 6/02/25 and 6/03/25. She said she was aware that Resident #2 did not have a catheter bag cover in place and that it was supposed to be covered but said she was not aware why. She stated that she stood to assist Resident #4 to eat lunch because there was no chair in the room and that she was not aware that she was supposed to be seated at the residents' side to assist with eating meals. She stated that she had not noticed that Resident #1's window curtain was open when she exposed the resident and provided incontinence care at 10:45 AM. On 6/04/25 at 11:11 AM an interview with the Director of Nursing Services (DNS) revealed that catheter bags should be covered to ensure the dignity of residents with catheter drainage systems. She stated that during incontinence care staff should provide privacy by closing the room door, privacy curtain and window curtains to maintain the dignity of the resident. She stated that when feeding a resident that required assistance with eating staff should be seated at the side of the resident with the purpose of maintaining the dignity of the resident.

Based on policy review, record review and interviews the facility failed to conduct a thorough investigation of an allegation of verbal and mental abuse for one (1) of two (2) sampled residents that reported an allegation of abuse, Resident #3. Findings included: Policy review of the facility titled Abuse, Neglect, Misappropriation, Exploitation Policy with Effective Date January 2019 revealed .Investigation If actual violation or alleged violation occurs the resident will immediately be assessed and removed from any potential harm (as applicable). The Administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of abuse .Investigations will be prompt, comprehensive and responsive to the situation .The investigation will include .Notification of the physician and resident or resident representative .Interviews of all involved persons .Follow-up resolution .All material and documentation of the pertinent data to the investigation is collected, maintained and safeguarded by the center . A record review of the Investigation Template, dated 5/21/25, revealed the facility described the allegation that Resident #2 reported that a CNA had hit him on the leg with both hands because he was wearing a condom catheter. The Investigation Summary indicated that interviews were conducted with all residents with BIMS (Brief Interview for Mental Status) greater than eleven. A review of the Summary of Interview revealed Resident #2 stated he was hit last night on his legs. Another Summary of Interview revealed Resident #3 indicated The CNA .that was assigned to him on 11pm-7pm was pissed off with him because he had urinated in the bed and she had to change him. During an interview on 6/02/25 at 3:50 PM, Resident #3 revealed that during the early morning hours of 5/21/25, CNA #1 had entered his room and scolded him for wetting his bed. He said that made him feel ashamed and said, I can't help wetting the bed; if I could, I wouldn't do it. It made me feel like getting up and getting out of here and I would have if I could. The resident said the incident made him feel shame and he was afraid because the CNA #1 scolded him and that he was afraid the incident may recur. He confirmed he had reported the incident to the Assistant Director of Nursing Services (ADNS) on 5/21/25 and did not remember anybody else coming to ask him about it. During a telephone interview on 6/03/25 at 2:54 PM, the former ADNS stated that she was involved in an investigation into an allegation of abuse for a different resident on 5/21/25 and interviewed and assessed Resident #3. She stated that during the interview Resident #3 reported verbal and mental abuse by CNA #1 on the morning of 5/21/25. She said that Resident #3 reported that CNA #1 had scolded him for wetting his bed. She said she reported the allegation to the Administrator on 5/21/25. During an interview on 6/04/25 at 10:35 AM, the Social Services and Admissions Liaison (SSD) said regarding the allegation of verbal and mental abuse by Resident #3 she recalled somebody said something about Resident #3 saying the CNA got upset because he wet his bed but she was not requested or instructed to visit the resident and had not visited, interviewed or assessed Resident #3 following the allegation. During an interview on 6/04/25 at 11:11 AM, the Director of Nursing Services (DNS) revealed that she became aware of the allegation of abuse by Resident #3 when she read the final draft of the investigation prior to sending to SA on 5/24/25. She stated that she was not aware of any follow-up with Resident #3's allegation or any investigation into the allegation. During a telephone interview on 6/04/25 at 11:25 AM, CNA #1 said that when she made final rounds on the morning of 5/21/25 she entered the room of Resident #3 and was frustrated with him because he had peed out the bed. I think it was intentional. She said she had fussed at Resident #3 and said, I shouldn't have but I did. I told him he needed to stop urinating in the bed. I had to change the bed and his clothes and give him a bed bath three (3) times during the shift. She said the DNS called her and she had been suspended pending an investigation into a separate allegation and had to meet with the DNS and the Administrator and was written up regarding the allegation by a different resident but was not asked any questions regarding Resident #3. During an interview on 6/04/25 at 1:50 PM, the Administrator revealed that she was notified of the allegation by Resident #3 on 5/21/25 by the ADNS (former) and stated He told (ADNS) that the CNA was pissed off at him because he wet the bed; she confirmed that Resident #3 was incontinent of bowel and bladder and required incontinence care by staff. She stated that the allegation was not investigated, and no psychosocial assessment, treatment or counseling were offered to or provided for Resident #3. The Administrator said she did not know why the resident reported that the CNA was pissed off or how he got that impression. She said she was unaware of how the interaction between CNA #1 and Resident #3 made him feel. She stated she had not asked CNA #1 about the allegation reported by Resident #3 during the investigation into the allegation of abuse reported by Resident #2. Record review of the admission Record revealed the facility admitted Resident #3 on 3/27/25 with current diagnoses including Benign Neoplasm of Cerebral Meninges. Record review of the admission MDS with an ARD of 4/03/25 revealed Resident #3 had a BIMS score of 8, which indicated his cognition was moderately impaired. Further review revealed he had no behaviors, was always incontinent of bowel and bladder, and required substantial/maximal assistance for toileting hygiene and moderate assistance to roll left and right on bed.

Based on observation, interview, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for one (1) of four (4) sampled residents reviewed for care plan implementation, Resident #1. Findings included: A review of the facility's policy titled Care Plans, 09/2020, revealed, .Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines . A record review of the Care Plan Report revealed Resident #1 had a Focus of At risk for falls . with Interventions including Resident to be taken to the dining room for meals, initiated on 4/28/25. On 6/2/25 at 12:00 PM, during an observation, Resident #1 was observed seated in her wheelchair in the hallway next to the door of her room, across from the nurses station, assisted by staff while eating lunch. On 6/3/25 at 12:00 PM, during an observation, Resident #1 was observed seated in her wheelchair in the hallway next to the door of her room, across from the nurses station, assisted by Certified Nurse Aide (CNA) #3 while eating lunch. On 6/3/25 at 2:05 PM, during an interview with CNA #7, she stated that she observed Resident #1 eating all meals either in her room or in the hallway outside her room. She stated that was where the resident usually ate all her meals. She confirmed she was unaware of the care plan intervention for Resident #1 to eat meals in the dining room. She stated that evening meals (suppers) were served in the dining room with staff present to assist residents as needed. On 6/4/25 at 11:11 AM, during an interview with the Director of Nursing Services (DNS), she stated that care plan development and implementation were very important to ensure proper and appropriate care for each resident. She stated she expected staff to follow through with interventions listed in each resident's care plan. She confirmed that the care plan intervention for Resident #1 to eat in the dining room was developed as a fall prevention measure. On 6/4/25 at 1:50 PM, during an interview with the Administrator, she stated that care plan development and implementation were very important to ensure residents receive proper care. She stated she expected staff to follow through with care plan interventions. She further stated that failure to develop or implement care plans could result in residents not receiving needed care, leading to potential negative outcomes. Record review of the admission Record revealed the facility admitted Resident #1 on 4/05/24 and she had current diagnoses including Alzheimer's Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/25 revealed for Resident #1's Cognitive Skills for Daily Decision Making was Severely Impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to follow hand hygiene practices consistent with accepted standards of practice during incontinence care for one (1) of four (4) sampled residents reviewed for incontinence care, Resident #1. Findings included: A review of the facility's Peri (Perineal) Care Audit Tool, undated, revealed Action including, .7. STOP! Removes gloves, washes/sanitizes hands and re-gloves. 8. Applies clean brief, dresses resident . On 6/4/25 at 10:45 AM, during an observation, Certified Nurse Aide (CNA) #3 and CNA #5 provided incontinence care for Resident #1. After completing the care, the CNAs did not perform hand hygiene or change gloves before applying a clean brief and adjusting the resident's clothing. On 6/4/25 at 11:11 AM, during an interview with the Director of Nursing Services (DNS), she stated that during incontinence care, staff were supposed to stop after cleaning a resident with a wet and/or soiled brief, change gloves, and perform hand hygiene by washing hands or using hand sanitizer prior to donning clean gloves. She stated gloves should be changed as often as necessary but at least one time between handling wet/soiled briefs and applying clean briefs and adjusting the resident's clothing. On 6/4/25 at 1:34 PM, during an interview with CNA #5, she confirmed that at 10:45 AM, when she provided care for Resident #1, she did not change her gloves or perform hand hygiene. She stated she understood that improper incontinence care could contribute to the development of urinary tract infections (UTIs). On 6/4/25 at 1:50 PM, during an interview with the Administrator, she confirmed that she expected staff to provide care in accordance with current infection control standards as outlined in the facility's policies and procedures and as instructed during in-service and training. A record review of Resident #1's admission Record revealed the facility admitted the resident on 4/5/24 with current diagnoses including Alzheimer's Disease. A record review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/25 revealed the resident's Cognitive Skills for Daily Decision Making were severely impaired.

Based on observation, staff and resident interviews and record review the facility failed to ensure that a resident's CPAP (Continuous Positive Airway Pressure) mask was properly stored when not in use, for one (1) of fourteen (14) sampled residents. (Resident # 48) Findings Include: During an observation and interview with Resident #48 on 06/17/24 at 11:10 AM, he stated that he had been told by staff that they were not responsible for assisting with his CPAP mask. The resident's CPAP mask was observed uncovered and lying on the dresser near the foot of the resident's bed. On 06/17/24 at 4:28 PM, during an observation and interview, License Practical Nurse (LPN) #3 stated that the CPAP mask should be in a bag. She explained that this is to prevent the resident from contracting respiratory infections. She emphasized that nurses must ensure that the mask is sealed in a zip-lock bag when not in use, to prevent contamination of the mask. In an interview with the Director of Nursing (DON) on 6/20/24 at 3:12 PM, she explained that it is common nursing knowledge that CPAP masks should be stored in a manner to prevent contamination when not in use. Moreover, it is the responsibility of the nursing staff to ensure that there are no breaches in infection control regarding care of the resident's mask. She further claimed that failing to store the CPAP mask properly could result in the resident contracting a respiratory illness. A record review of the Order Summary Report, for Resident #48, with active orders as of 6/18/24, revealed an order dated 5/31/24, Apply C-Pap at bedtime related to OBSTRUCTIVE SLEEP APNEA . A record review of the Admission Record, for Resident #48 revealed the resident was admitted on [DATE] by the facility. His diagnoses included Quadriplegia, Chronic Obstructive Pulmonary Disease with acute lower respiratory infection and Obstructive sleep apnea. A review of Resident #48's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/3/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. 48669

Based on observations, resident and staff interviews and record reviews, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two (2) medication errors observed out of 27 opportunities for errors, resulting in a medication error rate of 7.4%. Residents #25 and #32 Findings Include: Review of the facility's policy for Medication Administration, titled, , Administration of Nasal Spray Preparations, dated 04/22 revealed, Medications are administered as prescribed . Personnel authorized to administer medication do so only after they have familiarized themselves with the medications . Review of the facility's policy for Medication Administration, titled, Administration of Metered dose Inhalers, reviewed/updated 04/22, revealed, Medications are administered as prescribed . Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Procedure: . 10. Rinse mouth when required per manufacturer's recommendations or according to standards of practice . A review of manufacturer's guidelines on Important Safety Information for Symbicort revealed, .Symbicort may cause serious side effects, including: . Fungal infection in your mouth and throat (thrush). Rinse your mouth with water without swallowing after using Symbicort to help reduce your chance of getting thrush . Resident #25 On 06/19/24 at 8:45 AM, an observation of Licensed Practical Nurse (LPN) #2 administering Flonase nasal spray to Resident # 25, revealed the nurse administered one (1) spray of Flonase in each nostril. A record review of the Order Summary Report, with active orders as of 06/19/24 revealed an order dated 4/1/24 Flonase Allergy Relief Nasal Suspension, 2 sprays in each nostril one (1) time a day for sneezing. On 06/19/24 at 8:50 AM in an interview with LPN #2 confirmed she administered Resident #25 one spray of Flonase in each nostril. LPN #2 confirmed she did not follow the physician orders. The nurse explained she should have read the order before administering the medication, as the medications is not effective if the correct dose is not administered. Record review of the Admission Record revealed the facility admitted Resident #25 on 07/16/18. Current diagnoses included Allergic Rhinitis. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/13/24, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #32 An observation on 06/19/24 at 7:30 AM, during medication administration to Resident #32 revealed License Practical Nurse (LPN) #1, administered two (2) puffs of Symbicort inhaler. LPN #1 left Resident #32's room without instructing the resident to rinse her mouth with water. Record review of the Order Summary Report with active orders as of 6/19/2024, revealed an order dated 11/21/23 Symbicort Inhalation Aerosol .2 puff inhale orally two times a day related to ACUTE BRONCHITIS, UNSPECIFIED .rinse and spit with water following inhalation. During an interview on 06/19/24 at 8:30 AM, LPN #1 confirmed that while administering the Symbicort Inhaler to Resident #32, she failed to offer Resident #32 water to rinse and spit to prevent the resident from getting thrush in her mouth. LPN #1 reviewed the physician orders and guidelines for the use of the medication and confirmed the resident should have rinsed her mouth with water after the administration of the Symbicort inhaler, to reduce the chance of getting thrush. During an interview on 06/19/24 at 9:00 AM with Resident #32, she revealed she had never been asked to rinse her mouth after receiving her inhaler. During an interview on 06/19/24 at 1:45 PM, the Director of Nursing (DON), she explained that she expected the nurses to follow the guidelines for medication administration and confirmed the reason for instructing residents to rinse their mouth after the administration of a steroid inhaler is to prevent possible complications. The DON also said she expects the nurse to follow the physician's orders when administering nose drops. The nurse should have administered two (2) sprays of Flonase per nostril. During an interview on 6/19/24 at 2:00 PM, with Nurse Practitioner (NP) #1 she explained she expected the nurse to follow the physician's orders. LPN #1 should have asked the resident to rinse her mouth and spit the water out to prevent oral complications. During an interview on 06/20/24 at 3:17 PM, with NP #2, she explained she expected the staff to follow the physician's orders and to administer the Flonase according to what is ordered, which in this case, the nurse should have administered two (2) sprays per nostril, per physician's order. A record review of the Admission Record revealed the facility admitted Resident #32 on 06/01/23. The resident had diagnoses that included Type 2 Diabetes with diabetic chronic kidney disease and Wheezing. Record review of the Annual MDS with an ARD of 05/30/2024, revealed Resident #32 had a BIMS score of 15, which indicated the resident was cognitively intact.

Based on observation, staff and resident interviews, record review, facility policy review, and manufacturer's guidelines review, the facility failed to ensure a resident rinsed her mouth after the administration of a steroid Metered-Dose Inhaler to prevent possible mouth and throat irritation for one (1) of one (1) resident observed for administration of a Metered-Dose Inhaler. (Resident #32) Findings include: Review of the facility's policy for Medication Administration, titled, Administration of Metered dose Inhalers, reviewed/updated 04/22, revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Procedure: . 10. Rinse mouth when required per manufacturer's recommendations or according to standards of practice . A review of manufacturer's guidelines on Important Safety Information for Symbicort revealed, . Symbicort may cause serious side effects, including .Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Symbicort to help reduce your chance of getting thrush . On 06/19/24 at 7:30 AM, during an observation of medication administration with Licensed Practical Nurse (LPN) #1, she administered two (2) puffs of a Symbicort inhaler and exited the room without instructing the resident to rinse her mouth. Record review of the Order Summary Report with active orders as of 6/19/2024, revealed an order dated 11/21/23 Symbicort Inhalation Aerosol .2 puff inhale orally two times a day related to ACUTE BRONCHITIS, UNSPECIFIED .rinse and spit with water following inhalation. On 06/19/24 at 8:30 AM, during an interview with LPN #1, she confirmed that on 06/19/24, while administering the Symbicort Inhaler to Resident #32, she did not offer the resident water to rinse her mouth. LPN #1 reviewed the guidelines for the use of the medication and confirmed the resident should have rinsed her mouth after the administration of the Symbicort inhaler to prevent thrush and other complications. On 06/19/24 at 9:00 AM, during an interview with Resident #32 revealed she has never been asked to rinse her mouth after receiving her inhaler. On 06/19/24 at 1:45 PM, during an interview with the Director of Nursing (DON), she explained she expected the nurses to follow the guidelines for medication administration and confirmed the reason for instructing residents to rinse after the administration of a steroid inhaler is to prevent possible complications. On 6/19/24 at 2:00 PM, during an interview with the Nurse Practitioner (NP) explained she expected the nurse to follow the physician's orders. LPN #1 should have asked the resident to rinse her mouth and spit the water out to prevent possible oral complications. A record review of the Admission Record revealed the facility admitted Resident #32 on 06/01/23. The resident had diagnoses that included Type 2 Diabetes with diabetic chronic kidney disease and Wheezing. A record review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/30/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on record reviews, staff interviews, and facility policy review, the facility failed to correctly code a discharge from the facility on the Discharge Minimum Data Set Assessment (MDS) for one (1) of 14 sampled residents reviewed for assessment accuracy. Resident #49 Findings Include: Record review of the facility's policy titled, MDS and Care Plans, with the latest effective date, August 2019, revealed, Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. Record review of the facility's, Progress Notes, revealed Resident #49 was discharged to home, with a local Home Health Agency on 4/2/2024. Record Review of the Discharge MDS, with an Assessment Reference Date (ARD) of 04/02/24, revealed in Section A that Resident #49 was discharged to an acute hospital. Review of the facility's, Admission Record for Resident #49 revealed an admitted [DATE], which included diagnoses of Fracture of Left Patella, Unspecified Dementia, and Major Depression. During an interview with the Director of Nursing (DON) on 06/19/24 at 2:30 PM, she confirmed the facility failed to code the discharge MDS correctly. The DON also explained it was her expectation that the MDS Coordinator would code the MDS correctly. During an interview with the Registered Nurse (RN#1) on 6/19/24 at 3:00 PM, she confirmed she failed to accurately code Resident #49's Discharge MDS, dated [DATE]. The MDS Nurse said she hit the wrong button. The nurse said she normally looks at the orders or the progress notes to determine the resident's discharge status. She stated she was busy doing a lot of MDS's and might have mixed the resident up with another resident. During an interview with the Administrator on 6/19/24 at 3:30 PM, she stated that she expects the MDS to be coded accurately and sent in a timely manner.

Based on interviews, record review, and facility policy review, the facility failed to ensure the Physician and Resident Representative (RR) were notified when a resident refused to take medications for one (1) of seven (7) sampled residents. (Resident #3) Findings include: Review of the facility's policy, Notifications of Patient/Resident Change, dated 11/1/16, revealed, The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient/resident's legal representative or an interested family member when there is: . (C) A need to alter treatment significantly . Record review of the Order Summary Report with active orders as of 12/1/23 revealed an order dated 12/30/22 for Albuterol Sulfate HFA (Hydrofluoroalkane) Aerosol Solution 108 mcg (micrograms) 2 puffs inhale orally two times a day related to Chronic Obstructive Pulmonary Disease (COPD). Record review of Resident #3's Electronic Medication Administration Record (EMAR) revealed Resident #3 refused Albuterol Sulfate HFA Aerosol Solution 108 mcg (micrograms) 2 puffs inhale orally twice daily on 12/1/23, 12/2/23 and 12/3/23. On 03/20/24 at 4:53 PM, in an interview the Director of Nurses (DON) stated when a resident refuses medication, the nurses should document the refusal and notify the provider. She stated they are supposed to notify the physician each time a resident refuses to take their medications. On 03/21/24 at 9:27 AM, in a telephone interview with the daughter of Resident #3, she revealed she was told by a Registered Nurse (RN) #2 that the resident often refused his medication. The daughter stated that the facility never contacted the RR, which was her mother that Resident #3 was refusing to take his medications. On 03/21/24 at 10:15 AM, in a telephone interview RN #1 stated she mostly works weekends. She stated if a resident refuses medication, she usually contacts the physician and RR. However, she revealed she could not recall if she contacted them regarding Resident #3 refusing his medications. She stated the policy is to notify the Physician and RR after 2 days of resident refusing medications. She revealed she did recall that Resident #3 usually refused nebulizer treatments on the weekends. On 03/21/24 at 12:08 PM, in a telephone interview with RN #2, she stated when Resident #3 refused his medications, she would chart it and contact Hospice. She stated she cannot recall if she contacted his physician. She stated she was told to contact Hospice and the RR. However, she added that she cannot remember what she charted, but she usually writes a short note referencing the refusal. On 03/21/24 at 12:15 PM, in an interview with Hospice/RN #3, she stated the Hospice Nurse visits the facility twice weekly to see her residents on hospice. She stated RN #4 was the Hospice Nurse. RN #3 added that the facility can contact Hospice 24 hours a day, 7 days a week when a resident refuses their medication. On 03/21/24 at 12:38 PM, in an interview with RN #4, the Hospice Nurse for Resident #3, she stated the staff would update her on the resident on her visits to the facility. She revealed she cannot remember if she was contacted, but she always makes a note in the chart whenever they inform her of resident falls or refusal to take medications. She commented if there is no note in the chart, then she was not informed. On 03/21/24 at 2:23 PM, in an interview with the Physician, he stated the facility nurses are supposed to contact him if a resident refuses to take their medication. He stated that way, he can come up with a plan to treat residents. Record review of Resident #3's Progress Notes dated 12/1/23, 12/2/23 and 12/3/23 revealed Resident #3 refused Albuterol Aerosol treatments.There was no documentation the RR or the physician had been notified of the refusals. A record review of the Admission Record for Resident #3 revealed the facility admitted the resident on 12/29/22, with diagnoses that included Alzheimer's Disease and Chronic Obstructive Pulmonary Disease. A record review of the Minimum Data Set (MDS) for Resident #3, with an Assessment Reference Date (ARD) of 12/7/23, revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating Resident #3 had severe cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that each resident was treated with respect as evidenced by staff using foul language in the presence of residents for one (1) of four (4) residents reviewed. Resident #1. Findings include: Record review of the facility policy Resident Rights and Quality of Life, dated May 1, 2012, revealed, Policy Statement: It is the policy of Advocat that all residents have the right to a dignified existence . On 8/29/23 at 9:00 AM, during a telephone interview with the facility ombudsman, he confirmed he had received notification of inappropriate speech with foul language by Certified Nursing Assistant (CNA) #1, during care of Resident #1. On 8/29/23 at 9:40 AM, during an interview with the Administrator, she revealed CNA #1 was using poor customer service and was cursing and used foul language in the presence of residents. She stated that CNA #1 had received disciplinary action prior to 7/20/23 and that CNA #1's employment at the facility had been terminated on 7/24/23. The Administrator further explained that on 7/20/23 CNA #1 was heard using foul language while propelling Resident #1 in the hallway near the nursing station but that she was not speaking to any resident. She stated it was like she was complaining out loud. She noted that following the report of the incident, Resident #1 was interviewed and assessed for physical or psychosocial harm and did not recall the incident. Record review of the Progressive Discipline Form, for CNA #1, dated 6/4/21 revealed .First Warning.Failure to treat a patient or resident with dignity and respect . Inappropriate behavior/failure to adhere to (facility) Service Standards . Record review of the Progressive Discipline Form for CNA #1,dated 7/24/23, revealed a termination date of 7/24/23. The violation identified as the reason for the termination was listed as .Use of profane, abusive, or threatening language or unnecessary shouting .Failure to treat a patient or resident with dignity and respect. The form revealed that a therapist had reported an incident in which she had observed CNA #1 coming out of a resident's room with the resident and stating, I didn't take anyone's 'expletive' money. I don't need your 'expletive' money. I am so tired of this 'expletive' place. Record review of the (Company Name) Personnel Change/Termination Form dated 7/24/23 revealed .Reason for Termination Misconduct . On 8/29/23 at 10:05 AM, during an interview with the Occupational Therapist (OT) that reported the incident, she revealed that on 7/20/23 at approximately 2:30 PM, she witnessed CNA #1 propelling Resident #1 in the hallway past the nursing station and heard the CNA state I didn't take anybody's 'expletive' money. I don't need your 'expletive' money. I'm so tired of this 'expletive' place! The OT stated she had reported the incident to the Director of Nursing (DON). On 8/29/23 at 3:19 PM, an interview with the Resident Representative (RR) for Resident #1 revealed she had not noted any change in the behavior of Resident #1 since 7/20/23. On 8/31/23 at 9:00 AM, an observation and interview with Resident #1 revealed she was alert, able to communicate verbally and was oriented to self. She was unable to recall previous days or events. On 8/31/23 at 12:01 PM, an interview with the Social Worker revealed she reported that on 7/20/23 she observed CNA #1 rapidly propelling Resident #1 down the hallway but revealed she had been unable to hear anything that had been said. The Social Worker stated that she had observed Resident #1 since the incident and had not noted any change in behavior. On 8/31/23 at 6:14 PM, in a telephone interview with CNA #1, she revealed she did not understand why her employment at the facility was terminated. She stated she voiced her opinion and had spoken her mind, however, she denied that she cursed the resident or was abusive toward any resident in any way. She did not deny use of foul language in the hallway of the facility. She stated, I am known for speaking my mind. Record review of the Admission Record for Resident #1 revealed that the resident was admitted by the facility on 4/27/23 and had diagnoses that included Dementia and Atherosclerotic Heart Disease. Record review of the Quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 8/04/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had mild cognitive impairment.