Every finding on record at Evergreen Care Center

Based on interview and record review the facility failed to report an incident of bodily injury that required hospitalization for one of three sampled residents (Resident 1) when Resident 1 had an alleged fall on 5/13/26 and was sent to the hospital due to a head injury. This failure resulted in an inaccurate investigation and reporting to state agencies of events leading up to and resulting from Resident 1's fall with injury.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for blindness to the left eye, myocardial infarction(blood supply to the heart is blocked), heart failure, Peripheral Vascular disease (poor blood circulation in your legs and arms), difficulty in walking, need for assistance with personal care, absence of the right toes. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 4/21/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent interview and record review on 5/27/26 at 9:30 a.m. with the director of nurses (DON), Resident 1's electronic medical record (EMR) was reviewed. The EMR indicated Resident 1 had a reported fall on 5/13/26 that required hospital transfer for further evaluation after Resident 1 reported hitting his head when attempting to self-transfer from the commode to the bed. The DON stated the unwitnessed fall was not reported to state agencies because Resident 1 was alert with minor bleeding to the forehead. The DON stated the facility process was to report major injuries to the state agencies and even though Resident 1 was transferred to the acute care hospital with a head injury, it was considered a minor injury that the facility determined under their clinical judgment. During a review of Resident 1's document titled, Change in Condition Evaluation, dated 5/13/26, the document indicated, . Charge nurse immediately went to assess resident, resident was lying on the floor on his left side, resident was bleeding from left side head, provide pressure to left front of head bleeding stopped. [Resident 1] complains of headache pain 3out 10. [Resident 1] stated he was trying to transfer from bed to bedside commode and lost his balance and fell onto his left side of forehead. [Physician] notified via phone, [Physician] gave order to send [Resident 1] to acute hospital for further evaluation. The document indicated Resident 1 was found lying on the floor in his room with a head injury that required a hospital transfer. During an interview on 5/27/26 at 10:23 a.m. with Resident 2 in Resident 1's room, Resident 2 stated that on 5/13/26 Resident 1 was observed self-transferring from the commode to the bed. Resident 2 stated he observed Resident 1 losing his balance, hitting his head on the commode which caused his head to bounce off and hit the foot of the bed onto the floor. Resident 2 stated that Resident 1 was observed on different occasions to self-transfer without staff assistance. During an interview on 5/27/26 at 11:48 a.m. with the director of staff development (DSD), the DSD stated the facility process was to report falls with injury to the state agencies. The DSD stated the expectation was to report falls with injuries that required a hospital transfer for further evaluation. The DSD stated a head injury was a reason for a hospital transfer as it was considered a major injury. The DSD stated the process was to report the fall with injury to state agencies at the time of hospital transfer. During an interview on 5/27/26 at 12:15 p.m. with licensed vocational nurse (LVN) , LVN 1 stated the facility process for falls was to report to the state agencies when there was a fall with injury including a fall with a head injury that required a hospital transfer. LVN 1 stated that a head injury should have been reported to state agencies because the facility was unaware of the extent of the injuries. During a telephone interview on 5/28/26 at 10:00 a.m. with LVN 2, LVN 2 stated that on 5/13/26, Resident 1 had an unwitnessed fall in his room when Resident 1 was attempting to self-transfer. LVN 2 stated that Resident 1 had been noted to self-transfer to the commode in the past and was non-compliant with using his call light. LVN 2 stated Resident 1 required assistance with transferring to and from commode for supervision as he had a physician order for partial weight bearing to his foot. LVN 2 stated that Resident 1 was observed with a head injury on 5/13/26 that required a hospital transfer for further evaluation. LVN 2 stated the facility process was to report the incident to the administration staff who should have reported it to state agencies upon Resident 1's transfer to the hospital. During a telephone interview on 5/28/26 at 11:00 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated that on 5/13/26 Resident had an unwitnessed fall in his room that resulted in a head injury. CNA 1 stated Resident 1 was attempting to self-transfer from the commode to the bed as he was previously seen doing in the past without supervision. CNA 1 stated Resident 1 was non-compliant with the use of the call light and would self-transfer from the commode to the bed. CNA 1 stated Resident 1 required supervision assistance with transfers due to being a fall risk. CNA 1 stated Resident 1 was observed with bleeding to the forehead after the unwitnessed fall and was transferred to the acute hospital for further evaluation. During a review of the facility's policy and procedure (P&P) titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 2025, the P&P indicated, . It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. The facility will identify events, occurrences, patterns and trends that may constitute, Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will investigate all allegations and types of incidents. in accordance to facility procedure for reporting/response. The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The Administrator or designee will: Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified.

Based on interview and record review the facility failed to ensure a safe and orderly discharge from the facility for one of two sampled residents (Resident 1) when the facility discharged Resident 1 without needed medical equipment that included oxygen concentrator, wheelchair, and shower chair. This failure placed Resident 1 at risk for an unsafe discharge due to the inability to use medical equipment to prevent possible falls, injuries and respiratory distress.Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Diabetes Mellitus (DM- increased sugar in the blood), bacterial infections, End Stage Renal Disease (ESRD- Kidney failure), hypertension (high blood pressure), heart failure, Abnormalities of breathing. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/19/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 3/5/26 at 11:26 a.m. with registered nurse (RN) 1, RN 1 stated the facility process was for a resident discharge was to ensure residents had all medications, education and medical equipment needed for a safe discharge. RN 1 stated Resident 1 should not have been discharged without the physician ordered medical equipment and oxygen concentrator. RN 1 stated it was important to follow physician orders especially during a discharge in which medical equipment was needed to ensure the residents are safe when discharging from the facility. During a review of Resident 1's, Physician Discharge Orders, dated 2/19/26, the physician discharge orders indicated, . Discharge plans: [Resident 1] will be discharged . Home, post discharge needs services and medical equipment: home health nursing, wheelchair, home health physical therapy, home health occupational therapy, shower chair, oxygen. The physician order indicated Resident 1 required medical equipment prior to discharging from the facility. During an interview on 3/5/26 at 11:42 a.m. with the social services director the SSD stated Resident 1 was discharged on 2/19/2026 from the facility. The SSD stated Resident 1 had discharged with a physician order for home health, physical therapy, occupational therapy, shower chair, walker and oxygen concentrator. The SSD stated there was no medical equipment provided for Resident 1 upon discharge on [DATE] or prior. During a review of Resident 1's, Discharge Summary Instructions, dated 2/19/26, the discharge summary indicated, . date of discharge, 2/19/26, During the course of the stay, [Resident 1] received 24 hour skilled nursing care, including monitoring of medical conditions, medication administration, assistance with activities of daily living, and coordination of care with the interdisciplinary team. At the time of discharge on [DATE], [Resident 1's] condition was stable and appropriate arrangements were made for a safe transition home including follow up appointments and medication reconciliation period medical equipment was delivered at bedside [Resident 1's] stay at the skilled nursing facility addressed the identified medical and functional needs, and [Resident 1] was discharged with a plan designed to support continued care and safety in the next setting. [Resident 1] has order for use oxygen on 2 liters via nasal cannula as per needed, all oxygen supply hand over slash home health, explained how to use oxygen supply, well understood. During a review of Resident 1's, Order Summary, dated 12/5/25 the order summary indicated, . oxygen at 4 liters per minute via nasal cannula continuously monitor for removed by resident every shift related to other abnormalities of breathing. The order indicated Resident 1 required continuous oxygen use. During a telephone interview on 3/5/26 at 12:05 p.m. with family member (FM) 1, FM 1 stated Resident 1 was discharged from the facility on 2/19/226. FM 1 stated Resident 1 was discharged to a room he was renting with a friend. FM 1 stated resident 1 did not receive any medical equipment prior to being discharged from the facility. FM 1 stated they felt the discharge was unsafe due to the facility's failure to ensure Resident 1's place of residence was appropriate and safe for Resident 1 to discharge. During an interview on 3/5/26 at 1:13 p.m. with the SSD, The SSD stated Resident 1 was issued a notice of non-payment on 2/16/26. The SSD stated Resident 1 had informed the SSD on 2/17/26, that Resident 1 had found somewhere to live where he was going to be renting a room from a friend. The SSD stated Resident 1 required minimal assistance with transfers that required supervision from staff. SSD stated that on the day of discharge 2/19/26, home health was contacted and medical equipment order was sent to the home health agency to order the equipment needed for Resident 1. The SSD stated the home health agency had notified her that the oxygen concentrator would not be available for Resident 1 upon discharge. The SSD stated Resident 1's medical equipment and oxygen concentrator were not delivered to Resident 1's place of residence prior to Resident 1 being discharged from the facility. The SSD stated Resident 1's discharge from the facility was not safe. The SSD stated Resident 1 should have been educated on the need for medical equipment prior to discharging from the facility and should have been made aware of the potential consequences of not having ordered medical equipment. During an interview on 3/5/26 at 1:46 p.m. with the director of nurses (DON), the DON stated the facility process was to ensure all residents discharging from the facility received all medical equipment needed prior to discharging from the facility. The DON stated Resident 1's discharge from the facility was unsafe due to not having the medical equipment ordered by the physician. The DON stated the facility should have delayed Resident 1's discharge from the facility until medical equipment was available. During an interview on 3/5/26 at 2:15 p.m. with the administrator (ADM), the ADM stated the facility process was to discharge all residents with medical equipment needed prior to discharging from the facility. The ADM stated the facility process was to notify the administration staff when any medical equipment was denied or not available prior to residents discharging from the facility. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 2025, the P&P indicated, . It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team.

Based on interview and record review the facility failed to provide adequate supervision to ensure safety for one of four sampled residents (Resident 1), when Resident 1 had an order for a one to one staff member supervision due to a physical altercation and the facility did not have staff scheduled on 7/6/25 for the afternoon shift (PM- 2:45 p.m.-11:15 p.m.), 7/6/25 for the night shift (10:45 p.m.-7:00 p.m.) and no staff scheduled for one to one on 7/7/25 afternoon shift.This failure placed Resident 1 at risk for injury from further altercations that could have occurred in the facility.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Anxiety (excessive worry and fear), Blindness (both eyes), Glaucoma (eye condition that damages the nerves), hearing loss.During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/12/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 14 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During an interview on 7/8/25 at 2:21 p.m. with Resident 1, in Resident 1's room, Resident 1 recalled events that transpired in the facility. Resident 1 stated the bathroom was shared with the room next door as it had an entry door in both rooms. Resident 1 stated that on 7/1/25 he went to use the restroom, knocked on the door and since no one answered he proceeded to enter. Resident 1 stated he was pulling up his pants, when suddenly the restroom door leading into Resident 2's room opened. Resident 1 stated he then heard Resident 2 yelling profanity and slammed the restroom door. Resident 1 stated, Resident 2 was then heard yelling profanity and demanding that Resident 1 go to his room. Resident 1 stated he is blind and could not see what was happening and proceeded to tell Resident 2, to come toward him. Resident 1 stated, shortly after he felt punches on his body and began hitting back. Resident 1 stated he felt like he had hit Resident 2 once, but did not know where. Resident 1 stated he proceeded to pull up his pants once again when he suddenly felt two hands on his chest push him back causing him to fall and hit his head on the bathroom counter. Resident 1 stated that since the incident the facility had assigned a one to one staff member to him for safety but stated staff were not present every shift. Resident 1 stated there was no one to one staff assigned at times during the night. Resident 1 stated he would call out for staff prior to going to use the restroom multiple times throughout the night but no one was present to assist him.During a review of Resident 1's, Altercation Care Plan (CP), dated 7/1/25, the CP indicated, . Resident had an altercation with another resident. interventions: 1 to 1 close monitoring.During a review of Resident 1's, Order Summary report, dated 7/3/25, the Order Summary report indicated, . one to one monitoring.During a concurrent observation, interview and record review on 7/8/25 at 3:02 p.m. with the director of staff development (DSD), the facility schedule for staff dated 7/1/25-7/7/25 were reviewed on the DSD's computer documents. The staff schedules were not printed and indicated there was not a one on one staff member scheduled for 7/6/25 for the afternoon shift, 7/6/25 for the night shift and no staff scheduled for one to one on 7/7/25 afternoon shift. The DSD stated the schedules were not printed because they were kept on her computer. The review of the employee schedule on the computer, the one on one staff were not documented on the schedule. The DSD stated there were staff present in the facility for a one on one for the dates indicated but staff were not added to the schedule and staff had not signed in to the shift as working a one to one.During a concurrent interview and record review on 7/8/25 at 3:29 p.m. with licensed vocational nurse (LVN) 1, Resident 1's, Altercation Care Plan (CP), dated 7/1/25 and Order Summary report, dated 7/3/25. The CP indicated, . Resident had an altercation with another resident. interventions: 1 to 1 close monitoring. The Order Summary report indicated, . one to one monitoring. LVN 1 stated Resident was supposed to have a one-to-one staff member at all times. LVN 1 stated the purpose of the one-on-one staff member assigned to Resident 1 was to prevent further altercations and to ensure Resident 1's safety.During an interview on 7/8/25 at 3:35 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated Resident 1 was assigned a one to one staff member at all times. CNA 1 stated the role of the one to one was to remain with the resident at all times and when the staff member assigned needed to step away, another staff member would have to go and stay with Resident 1. CNA 1 stated it was important to follow the one to one order to keep Resident 1 safe and to prevent further altercations with Resident 2.During an interview on 7/8/25 at 3:57 p.m. with the director of nursing (DON), the DON stated Resident 1 had an order for a one-to-one staff member at all times until further notice. The DON stated there was no set schedule for the one to one, the staff was being scheduled on a daily basis through a group text message. The DON stated once a one to one staff member was found for the shifts, the DON would be notified.During a review of the facility's policy and procedure (P&P) titled, Accidents and Supervision, dated 2022, the P&P indicated, . The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes. Implementing interventions to reduce hazard(s) and risk(s). Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes. Communicating the interventions to all relevant staff, assigning responsibility. Ensuring that the interventions are put into action. Monitoring is the process of evaluating the effectiveness of care plan interventions. Ensuring that interventions are implemented correctly and consistently. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision, defined by type and frequency, based on the individual resident's assessed needs and identified hazards in the resident environment.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2025, the P&P indicated, . it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include. certain resident to resident altercations. the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to. Increased supervision of the alleged victim and residents, room or staffing changes, if necessary to protect the residents from the alleged perpetrator, protection from retaliation. revision of the residents care plan if the residents medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on interview and record review, the facility failed to assist residents in making transportation arrangements to and from their provider appointments for three of seven sampled residents (Residents 24, 29 and 40) when: 1. Residents 24 and Resident 40 missed their scheduled appointments due to the transportation arriving late and was not the preferred transportation company requested by Resident 24. This failure resulted in Resident 24 and Resident 40 having to re-schedule their appointments for later dates and caused anger and frustration to Resident 24 and Resident 40's Responsible Party (RP). 2. Resident 29 was not picked up from his appointment by the scheduled transportation company. On 5/21/25 Resident 29 left for a 1:00 p.m. appointment at 12:45 p.m. and did not return to the facility until 5:30 p.m. due to Resident 29 waiting four hours for another transportation company to pick him up. This failure had the potential to place Resident 29 at risk of being exposed to harm and resulted in Resident 29 waiting an extended period of time to be picked up from his appointment causing extreme anger and stress to Resident 29. Findings: 1. During a concurrent observation and interview on 6/10/25 at 12:23 p.m. with Resident 24, in Resident 24's room, Resident 24 was observed sitting in a wheelchair, dressed and speaking with her roommate. Resident 24 stated she had been at the facility for two years for a fractured back (broken bone in the spine) and broken femur (thigh bone) and knee. Resident 24 stated she has had trouble with her transportation to appointments. Resident 24 stated on two occasions she had missed her appointments when using (name of transport company, [Company A]) transport. Resident 24 stated she did not want to use that company anymore because she had to reschedule her appointments on two occasions. Resident 24 stated they had been late to pick her up on one of those occasions and the other time she asked about using another transport company, so they did not show up to pick her up and said she refused transportation. Resident 24 stated when she informed the Social Services Designee (SSD), she was told she needed to call and complain to her insurance about the transport company [Company A]. Resident 24 stated she used another transport company [Company B] for her dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) appointments and had no problems with them, and [Company B] was who she wanted to use for her transportation. During a review of Resident 24's admission Record (AR - a document with personal identifiable and medical information), dated 6/12/25, the AR indicated, Resident 24 was admitted to the facility from an acute care hospital on 9/6/23 with diagnoses of end stage renal disease (a condition where the kidneys can no longer function on their own) and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/10/25, the MDS section C indicated, Resident 24 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which suggested Resident 24 was cognitively intact. During a concurrent interview and record review on 6/12/25 at 10:31 a.m. with the SSD Resident 24's Progress Notes dated 4/16/25 through 5/30/29 for appointments were reviewed. The Progress Notes indicated, on 5/30/25 Resident 24's appointment at the hospital radiology (use of imaging technology) department was rescheduled. The SSD stated residents could requested preferred transportation company, but it was not guaranteed. The SSD stated Resident 24's complaints were for not having a specific company for her transportation. The SSD stated transportation issues had been brought up with the administrator. During an interview on 6/12/25 at 2:22 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated he had not gone with residents to their appointments but had heard of a bus not showing up to pick up residents. During an interview on 6/12/25 at 3:27 p.m. with the Director of Staff Development (DSD)/Infection preventionist (IP), the DSD/IP stated usually a CNA went with residents to appointments. The DSD/IP stated they have had some issues with the transportation company [Company A or B ]. The DSD/IP stated there was no good communication with [Company A], Company A would just leave without ringing the door bell in the front gate of the facility. During an observation on 6/10/25 at 10:29 a.m. in Resident 40's room, Resident 40 was observed asleep in bed, wearing a gown and ear plugs, Resident 40 did not answer questions asked. During a concurrent observation and interview on 6/10/25 at 11:53 a.m. with Resident 40 and Resident 40's family member (FM) in Resident 40's room, Resident 40 was observed in bed, dressed, wearing ear plugs and eating snacks. The FM stated Resident 40's transportation to appointments had been an issue. The FM stated one time the vehicle had a flat tire and Resident 40 missed his appointment. The FM stated Resident 40 was rescheduled and the SSD did not communicate to Resident 40 or his Responsible Party (RP) about him missing his appointment. During a review of Resident 40's AR, dated 6/12/25, the AR indicated, Resident 40 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), cerebral edema (swelling in the brain), speech disturbances, difficulty walking, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 40's MDS, dated 5/13/25, the MDS section C indicated, Resident 40 had a BIMS score of 10, which indicated Resident 40 was moderately impaired. During an interview on 6/11/25 at 9:05 a.m. with Resident 40's RP, the RP stated Resident 40 had been in the facility since December due to a stroke (cerebrovascular accident [CVA]-stroke, loss of blood flow to a part of the brain). The RP stated there was poor communication with the facility. The RP stated she had a lot of trouble with Resident 40's transportation to appointments and one appointment was for the neuroscience facility (study of the nervous system, including the brain and spinal cord). The RP stated transportation was often late for Resident 40's appointments. The RP stated she tried to go with Resident 40 to his appointments. The RP stated Resident 40's appointments had to be rescheduled when he was late because the transportation picked him up late and the facility did not tell her if Resident 40's appointment was rescheduled. The RP stated one appointment Resident 40 missed was in May and she was not notified. The RP stated she found out later that he missed his appointment and the facility rescheduled him. The RP stated one appointment in March that Resident 40 had rescheduled was for surgery on his skull, a skull replacement after his craniotomy (a surgical removal of part of the bone from the skull to expose the brain) that had been planned for one month. The RP stated she was notified by the physician at the hospital. The RP stated Resident 40 has had four to five issues with his transportation. The RP stated Resident 40 was to be transported in his wheelchair, but the transportation driver did not have the right equipment to fit the wheelchair in the vehicle, so they had to reschedule him. The RP stated the transportation driver came and pressed the button to enter facility, and no one at the facility knew Resident 40 had an appointment. The RP stated this happened last month. During a concurrent interview and record review on 6/12/25 at 10:31 a.m. with the SSD Resident 40's Progress Notes, dated 5/21/25 indicated , .(resident name) missed his appointment due to transportation issues. The SSD stated residents were schedule with a diagnosis code which the transportation company used to determine what type of vehicle to transport the resident in. The SSD stated Resident 40 used a special wheelchair that was large and allowed resident to recline. Resident 40 was picked up by transport in a small van which did not accommodate Resident 40 and was not able to transport Resident 40 to his appointment, which needed to be rescheduled. The SSD stated she notified the RP of Resident 40's rescheduled appointments, but did not document her conversations with Resident 40's RP. 2. During a concurrent observation and interview on 6/10/25 at 12:47 p.m. with Resident 29 in Resident 29's room, Resident 29 was observed dressed, sitting in a wheelchair, eating his meal. Resident 29 stated he had been at the facility for six months due to a fall injury to his leg and he could not walk. Resident 29 stated he had a transportation issue when the transport company did not pick him up after his provider appointment. Resident 29 stated he waited to be picked up from 1:00 p.m. until 5:30 or 6:30 p.m. Resident 29 stated the staff at the provider's office were getting ready to close and go home when they noticed he was still there and told him You're still here?. Resident 29 stated he had to call a taxi to get picked up and the facility did not tell him what happened. Resident 29 stated his sister usually took him to appointments but was unable to at that time. Resident 29 stated he felt terrible and was pissed he had to wait so long. Resident 29 stated he had not had any more appointments since then and hoped it did not happen again. During a review of Resident 29's AR, dated 6/12/25, the AR indicated, Resident 29 was admitted to the facility from an acute care hospital on 7/25/24 with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Hydrocephalus (a condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage), type 2 Diabetes Mellitus, congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and difficulty walking. During a review of Resident 29's MDS, dated 5/6/25, the MDS section C indicated, Resident 29 had a BIMS score of 14, which indicated Resident 29 was cognitively intact. During a review of Resident 29's Progress Notes, dated 5/21/25, the Progress Notes indicated, . Effective date: 5/21/25 12:43 (p.m.) .resident leave of absence (LOA) to scheduled appointment. Resident picked up by (name of independent transport company) and went to appointment alone . effective date: 5/21/25 17:30 (p.m.) . resident arrived to facility at 1730 . During an interview on 6/10/25 at 3:17 p.m. with the Administrator (ADM), the ADM stated he had not had any complaints on the transportation company the facility used. The ADM stated the facility called the residents to see if they were ready to be picked up after their appointments. During a concurrent interview and chart review on 6/12/25 at10:31 a.m. with the SSD, Resident 29's Progress Notes, dated 4/30/25, the Progress Notes indicated, . Effective date: 4/30/25 .(resident name) had an appointment on 5/21/25 at (@) 1:00 p.m. sister will assist with (w/) transportation . author: (SSD) . The SSD stated there were a few ambulatory residents who had a cell phone, and if they went alone and used the independent transportation company, the transportation company would send a link to the resident who needed to open the link to see when the transport would arrive. The SSD stated Resident 29 was normally accompanied by his sister and Resident 29 did not know how to use his phone to open the link. The SSD stated the provider's office called her regarding Resident 29 and informed her Resident 29 was still at their office after Resident 29 should have been picked up. The SSD stated she had to call a private company to pick up Resident 29, but he waited an additional hour. The SSD stated transportation issues had been brought up to the administrator. During an interview on 6/12/25 at 2:41 p.m. with LVN 2, LVN 2 stated he looked at the communication board in the computer to see which residents had appointments. LVN 2 stated he would add a note in LOA Via Transport in the system when the resident left and when the resident returned from the appointment. LVN 2 stated he did not log in the Resident Out on Pass Log. LVN 2 state if the resident was not back from their appointment at the estimated return time, he called the provider's office to verify if the resident was still there. LVN 2 stated if the resident was fully alert and went by themselves to the appointment, he called the cell phone of the resident. LVN 2 stated one resident was ready to return from his appointment in 15 min from his appt time, and they had to call the driver to turn around and pick up the resident, but the resident had to wait. During a concurrent interview and record review on 6/17/25 at 9:09 a.m. with the DON, the Resident Out On Pass Log (LOA), dated 3/30/25 to 5/30/25 was reviewed. The LOA indicated, Time out, Licensed Nurse Initials, Expected Return Time, Time Returned, and Licensed Nurse Initials were not filled in. The [NAME] stated the Charge Nurse was responsible for a resident's timely return. The DON stated an estimated time was given for resident appointments. The DON stated the nurses were responsible for making sure the AOL log was complete for resident's departure and return. The DON stated the LOA log was important to make sure the resident came back at the estimated time, and for the safety of the resident to make sure the resident returned unharmed. The DON stated nurses needed to perform an assessment of the resident when the resident left and when they returned, to be sure the resident was not harmed. The DON stated she did not recommend residents use the independent transportation company to go to appointments. The DON stated communication was not being sent to the SSD and residents had to wait longer to be picked up from their appointments. The DON stated the communication issues and wait times could not be continued. The DON stated if a resident had to wait extended periods of time to be picked up, it could have added more stress to the resident, even if the resident had a high BIMS score. The DON stated the SSD was responsible for resident's transportation to and from appointments, but overall, the DON was responsible for the residents. The DON stated her expectation was for the SSD to notify the resident's RP if the resident missed an appointment. The DON stated it was important for the RP to be notified so they were aware of what was going on with the resident and that proper care was given to the resident. The DON stated if the resident had missed appointments, it could have caused a delay of treatment to the resident. The DON stated the communication with the RP should have been documented in the resident's chart regarding any missed appointments. The DON stated if the communication was not documented, it did not happen. During an interview on 6/17/25 at 9:41 a.m. with the Administrator (ADM) and the Assistant Administrator (AA), the ADM stated his expectation was for transportation to be scheduled through the third-party transportation company. The ADM stated he had not received any complaints regarding using the third-party transportation company. The ADM stated nurses were to assess the resident to see if they could go by themselves to their appointment and if they were able to transfer themselves in and out of the car. The ADM stated if the resident was not self-transferable, a CNA should have gone with the resident for safety. The ADM stated residents were not usually assessed if they were able to use their cell phone for opening texted links from the transportation company. The AA stated they monitored the resident's return time depending on the approximate time given for the appointment and when the resident left the facility. The AA stated the LOA log was not filled out for appointments, but only if the resident was leaving with a family member. The AA stated the LOA log should have been filled in anytime the resident left the facility, even for appointments. The ADM stated the facility called residents to see if they were ready to be picked up after their estimated appointment time frame. The AA stated the nurse was made aware of when the resident came back. The AA stated she was aware of Resident 29 not being picked up timely and had been trying to get another transportation company to go pick up Resident 29. The ADM stated residents could have gotten anxious about not getting picked up from their appointment. The ADM stated the ADM and AA were responsible for resident safety when they left the facility. The ADM stated if a resident regularly went alone to an appointment, then they could have gone by themselves, but it was a risk for the resident's safety if the resident was waiting for a long period of time to be picked up. The ADM stated they were responsible for communication between both parties, the provider's office and the transportation company. The ADM stated usually nurses would have noticed a resident had not returned from their appointment during medication pass and the CNAs should have noticed when they did their rounds to see if the resident was taking a long time at an appointment. The ADM stated staff should have notified the nurse and called the office and resident, if they had a cell phone to see if they were okay. During an interview on 6/17/25 at 11:45 a.m. with the ADM, the ADM stated for department head training they have resource consultants and other building staff that could have come and trained new department heads. The ADM stated the SSD had the previous SSD train her before she left. The ADM stated as a new staff department head, the SSD will need to focus on priorities and have time to get their system down. The ADM stated he felt the SSD needed some more training. During a record review of the Social Services Professional Competency Evaluation (CE), dated 2/10/25, the CE indicated, . (SSD Name) . will need more support and continuing training . needs ongoing education . During a review of the facility's job description titled, SSD dated 2023, the job description indicated, .The Social Service Designee will assist residents in obtaining transportation to medical appointments, upon discharge . During a review of the facility's job description titled, Charge Nurse, undated, the job description indicated, .schedules follow up appointments for residents and transportation needs as indicated .reports any incidents or unusual occurrences to the supervisor, unit manager, assistant director or nursing or director of nursing and participates in the investigative process as needed . During a review of the facility's job description titled, Director of Nursing, undated, the job description indicated, .plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities .evaluates work performance of all nursing personnel .ensures delivery of compassionate quality care and nursing supervision .collaborates with members of the interdisciplinary team . to identify and resolve issues and improve the quality of services .communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns . During a review of the facility's job description titled, Administrator, undated, the job description indicated, .plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities .leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solution with facility leaders such as . customer satisfaction .evaluates work performance of department heads and maintains accountability across all departments .for expected performance outcomes in each respective department .ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff . During a review of the facility's policy and procedure (P&P) titled, Transporting a Resident dated 2025, indicated, .it is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary . facility will ensure that residents who require an escort to appointments, due to cognitive or physical limitations, have arrangements ahead of time . During a review of the facility's P&P titled, Competency Evaluation, dated 2025, indicated, .it is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job .the knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process .initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified .

Based on observation, interview and record review the facility failed to provide Trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1) when Resident 1 verbalized a history of being a survivor of trauma upon admission on 2/18/25 and the facility staff did not recognize the severity of the trauma and did not implement effective interventions to avoid triggers (specific stimuli or events that cause an intense emotional reaction or psychological response) that impacted Resident 1. This failure resulted in Resident 1 being exposed to triggers that caused her re-traumatization from past experiences with feelings of isolation, depression, lack of sleep and fear. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 3/11/25 at 12:46 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed crying as she recalled events that transpired in the facility. Resident 1 stated she had a history of trauma due to sexual and physical abuse experienced in the past. Resident 1 stated, due to the past traumas, she was afraid to be around men she did not recognize. Resident 1 stated she was placed in a room across the hall from a male resident room. Resident 1 stated due to being so close to a male room, she was unable to sleep and was constantly worrying that the male residents would enter her room at night to harm her. Resident 1 stated she used to enjoy sitting out in the halls and wheeling herself around the facility but had since isolated herself in her room to keep away from the male residents in the hallways. Resident 1 stated there were other triggers that had caused her to experience episodes of anxiety which included worrying about the care other residents in the facility, were receiving. Resident 1 stated there were multiple requests to the assistant administrator to move away from the male residents, but efforts were unsuccessful. Resident 1 recalled an instance when a male was seen entering her room, in which Resident 1 responded by yelling and screaming for the male to exit her room. Resident 1 stated it was later learned, the male, was the psychologist that the facility had arranged for her to see but had not notified her of the visit. Resident 1 stated she felt alone, isolated and cornered in her own mind as she would attempt to voice her concerns to the facility staff in which they would reply, you don't have to be here, you can leave. Resident 1 stated she had wanted to leave the facility due to feeling desperate for someone to listen to her concerns and mental state, but no one was available in the facility. During a review of Resident 1's MDS Section D- Mood, dated 2/23/25, the MDS indicated, . Feeling down, depressed, or hopeless, nearly every day, trouble falling asleep or staying asleep or sleeping too much, nearly every day, feeling bad about yourself or that you are a failure or have let yourself or your family down, nearly every day, trouble concentrating on things, such as reading the newspaper or watching television, nearly every day, Social Isolation, how often do you feel lonely or isolated from those around you? Enter code 1, Rarely . During a review of Resident 1's, Progress Note (PN)-Admission, dated 2/18/25, the PN indicated, . Resident does state she has anxiety from past abuse and aggressive behaviors observed from others do trigger her and cause to be hypervigilant (alert to potential dangers) and fearful, cause her to zone out at which calling her name will snap her out of it . During an interview 3/11/25 at 2:06 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she had cared for Resident 1 in the past. CNA 1 stated Resident 1 appeared to be angry and upset all the time and had once become angry with her for pulling the privacy curtain. CNA 1 stated Resident 1 would later apologize for the angry behaviors. CNA 1 stated Resident 1 liked things done a certain way and would stay in her room for activities. CNA 1 stated she was not aware of any trauma or triggers associated with Resident 1. CNA 1 stated she did not recall ever having education or in-services regarding trauma informed care. CNA 1 stated it was important to know Resident 1 had experienced some type of trauma to identify triggers that impacted her daily life. CNA 1 stated it was important to make a safe space for the residents when they were in the facility. CNA 1 stated it was important to establish a relationship with the residents and not dismiss resident attempts to share feelings or experiences. During a concurrent interview and record review on 3/11/25 at 2:23 p.m. with licensed vocational nurse (LVN) 1, Resident 1's Care Plan (CP), dated 2/18/25 was reviewed. The CP indicated the facility had not created a care plan for trauma informed care. LVN 1 stated there should have been a care plan to address the trauma in Resident 1's past and the associated triggers. LVN 1 stated it was important to have a care plan to be aware of Resident 1's needs to safely care for the resident. LVN 1 stated Resident 1's feelings of isolation and triggers could have been prevented by creating a plan of care that included moving Resident 1 to a room closer to the nurse's station and away from male residents. LVN 1 stated the facility process when identifying trauma was to review residents past history, notify the physician, communicate and monitor the resident. During an interview on 3/11/25 at 2:44 pm with LVN 2, LVN 2 stated the facility process for trauma informed care was to identify resident's past trauma to establish the plan of care. LVN 2 stated, when the care plan for trauma informed care was not created for Resident 1, the facility staff were not aware of Resident 1's traumatic history and environmental triggers that she was exposed to. LVN 2 stated the process included speaking with the resident, notifying the physician and creating a plan of care individualized to Resident 1's needs. During an interview on 3/11/25 at 3:25 p.m. with the social services director (SSD), the SSD stated Resident 1 had verbalized concerns with not receiving the assistance needed to address her mental and physical health in the facility. The SSD stated, Resident 1 had verbalized the history of past trauma, and a plan of care should have been established at that moment. The SSD stated there was no care plan to address Resident 1's past trauma and triggers. The SSD stated they should have a care plan implemented on admission to properly care for Resident 1. During an interview on 3/11/25 at 4:38 p.m. with the administrator (ADM), the ADM stated there was concerns for the lack of trauma informed care plan for Resident 1. The ADM stated Resident 1's trauma should have been identified and a plan of care should have been created to establish the proper care. During a telephone interview on 3/12/25 at 11:43 a.m. with clinical resource (CR), the CR stated the facility process was to identify resident traumas on admission and evaluate the resident for plan of care. The CR stated the purpose of identifying trauma on admission was to establish a plan of care to properly care for residents and prevent further trauma and triggers. The CR stated the expectation was for all staff to be trained in trauma informed care. The CR stated the expectation was for the admitting nurse and SSD to follow up with Resident 1's reported history of trauma and triggers upon admission. During a telephone interview on 3/13/25 at 1:39 p.m. with the director of staff development (DSD), the DSD stated there were no in-services or related trainings for trauma informed care provided for the facility staff. The DSD stated it was important for staff to have had trauma informed care training because the staff needed to be aware of all types of traumas in order to properly provide care to all residents affected. The DSD stated it was important for staff to be educated to identify triggers that could have been avoided for Resident 1. During a review of Resident 1's, Social Services-Trauma Informed Care Evaluation, dated 2/19/25, the evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . During a concurrent telephone interview and record review on 3/13/25 at 2:29 p.m. with the SSD, Resident 1's, Trauma Informed Care Evaluation, dated 2/19/25 was reviewed. The evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . The SSD stated the evaluation was completed upon admission to determine the level of trauma Resident 1 was presenting with in the facility. The SSD stated a high score on the evaluation indicated a high level of trauma presented. The SSD stated there was no care plan created to address Resident 1's trauma and triggers even after Resident 1 had indicated she had a history of trauma and scored high in the trauma evaluation. The SSD stated she could not recall why Resident 1's past trauma was not addressed in the interdisciplinary team (IDT-group usually consisting of physician, director of nurses, social services, resident/resident representative to collaborate in plan of care) meeting held on admission or why Resident 1's physician was not made aware at that time. The SSD stated it was important to document and follow up with any resident who reported a history of trauma. The SSD stated it was important to address Resident 1's trauma to avoid the triggers that were causing distress. The SSD stated it was important for all staff to receive the trauma informed care training in order to care for residents in the facility. During a review of Resident 1's, Independent Activity Monthly Record, dated 3/2025, the record indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . During a concurrent interview and record review on 3/14/25 at 11:22 a.m. with the activities director (AD), Resident 1's Independent Activity Monthly Record, dated 3/2025 was reviewed. The log indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . The AD stated Resident 1 stayed in her room most of the time even after activities are offered on a daily basis. The AD stated, Resident 1 would leave her room for a smoke break daily and would go back to her room to use her personal cellphone. The AD stated, Resident 1 would attempt to participate in some group activities but would become irritable (easily annoyed) and angry with other residents in the dining room, causing Resident 1 to go back to her room. During a review of Resident 1's, Care Plan (CP)-Activities, dated 2/24/25, the CP indicated, . [Resident 1] sets her own activity goal, she will attend group activities of choice, wheels around facility most of the day . During a review of Resident 1's, MDS Section F- Preferences for customary Routines and Activities, dated 2/23/25, the MDS indicated, . how important is it to you to do things with groups of people? Very important, how important is it to you to do your favorite activities? Very important, how important is it to you to listen to the music you like? Very important . During a record review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, dated 2023, the P&P indicated, . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . The facility will work to facilitate the principles of trauma informed care which include, Safety - Ensuring residents have a sense of emotional and physical safety. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident . Collaboration an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care . The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents' care plan . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization . Based on observation, interview and record review the facility failed to provide Trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1) when Resident 1 verbalized a history of being a survivor of trauma upon admission on 2/18/25 and the facility staff did not recognize the severity of the trauma and did not implement effective interventions to avoid triggers (specific stimuli or events that cause an intense emotional reaction or psychological response) that impacted Resident 1. This failure resulted in Resident 1 being exposed to triggers that caused her re-traumatization from past experiences with feelings of isolation, depression, lack of sleep and fear. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 3/11/25 at 12:46 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed crying as she recalled events that transpired in the facility. Resident 1 stated she had a history of trauma due to sexual and physical abuse experienced in the past. Resident 1 stated, due to the past traumas, she was afraid to be around men she did not recognize. Resident 1 stated she was placed in a room across the hall from a male resident room. Resident 1 stated due to being so close to a male room, she was unable to sleep and was constantly worrying that the male residents would enter her room at night to harm her. Resident 1 stated she used to enjoy sitting out in the halls and wheeling herself around the facility but had since isolated herself in her room to keep away from the male residents in the hallways. Resident 1 stated there were other triggers that had caused her to experience episodes of anxiety which included worrying about the care other residents in the facility, were receiving. Resident 1 stated there were multiple requests to the assistant administrator to move away from the male residents, but efforts were unsuccessful. Resident 1 recalled an instance when a male was seen entering her room, in which Resident 1 responded by yelling and screaming for the male to exit her room. Resident 1 stated it was later learned, the male, was the psychologist that the facility had arranged for her to see but had not notified her of the visit. Resident 1 stated she felt alone, isolated and cornered in her own mind as she would attempt to voice her concerns to the facility staff in which they would reply, you don't have to be here, you can leave. Resident 1 stated she had wanted to leave the facility due to feeling desperate for someone to listen to her concerns and mental state, but no one was available in the facility. During a review of Resident 1's MDS Section D- Mood, dated 2/23/25, the MDS indicated, . Feeling down, depressed, or hopeless, nearly every day, trouble falling asleep or staying asleep or sleeping too much, nearly every day, feeling bad about yourself or that you are a failure or have let yourself or your family down, nearly every day, trouble concentrating on things, such as reading the newspaper or watching television, nearly every day, Social Isolation, how often do you feel lonely or isolated from those around you? Enter code 1, Rarely . During a review of Resident 1's, Progress Note (PN)-Admission, dated 2/18/25, the PN indicated, . Resident does state she has anxiety from past abuse and aggressive behaviors observed from others do trigger her and cause to be hypervigilant (alert to potential dangers) and fearful, cause her to zone out at which calling her name will snap her out of it . During an interview 3/11/25 at 2:06 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she had cared for Resident 1 in the past. CNA 1 stated Resident 1 appeared to be angry and upset all the time and had once become angry with her for pulling the privacy curtain. CNA 1 stated Resident 1 would later apologize for the angry behaviors. CNA 1 stated Resident 1 liked things done a certain way and would stay in her room for activities. CNA 1 stated she was not aware of any trauma or triggers associated with Resident 1. CNA 1 stated she did not recall ever having education or in-services regarding trauma informed care. CNA 1 stated it was important to know Resident 1 had experienced some type of trauma to identify triggers that impacted her daily life. CNA 1 stated it was important to make a safe space for the residents when they were in the facility. CNA 1 stated it was important to establish a relationship with the residents and not dismiss resident attempts to share feelings or experiences. During a concurrent interview and record review on 3/11/25 at 2:23 p.m. with licensed vocational nurse (LVN) 1, Resident 1's Care Plan (CP), dated 2/18/25 was reviewed. The CP indicated the facility had not created a care plan for trauma informed care. LVN 1 stated there should have been a care plan to address the trauma in Resident 1's past and the associated triggers. LVN 1 stated it was important to have a care plan to be aware of Resident 1's needs to safely care for the resident. LVN 1 stated Resident 1's feelings of isolation and triggers could have been prevented by creating a plan of care that included moving Resident 1 to a room closer to the nurse's station and away from male residents. LVN 1 stated the facility process when identifying trauma was to review residents past history, notify the physician, communicate and monitor the resident. During an interview on 3/11/25 at 2:44 pm with LVN 2, LVN 2 stated the facility process for trauma informed care was to identify resident's past trauma to establish the plan of care. LVN 2 stated, when the care plan for trauma informed care was not created for Resident 1, the facility staff were not aware of Resident 1's traumatic history and environmental triggers that she was exposed to. LVN 2 stated the process included speaking with the resident, notifying the physician and creating a plan of care individualized to Resident 1's needs. During an interview on 3/11/25 at 3:25 p.m. with the social services director (SSD), the SSD stated Resident 1 had verbalized concerns with not receiving the assistance needed to address her mental and physical health in the facility. The SSD stated, Resident 1 had verbalized the history of past trauma, and a plan of care should have been established at that moment. The SSD stated there was no care plan to address Resident 1's past trauma and triggers. The SSD stated they should have a care plan implemented on admission to properly care for Resident 1. During an interview on 3/11/25 at 4:38 p.m. with the administrator (ADM), the ADM stated there was concerns for the lack of trauma informed care plan for Resident 1. The ADM stated Resident 1's trauma should have been identified and a plan of care should have been created to establish the proper care. During a telephone interview on 3/12/25 at 11:43 a.m. with clinical resource (CR), the CR stated the facility process was to identify resident traumas on admission and evaluate the resident for plan of care. The CR stated the purpose of identifying trauma on admission was to establish a plan of care to properly care for residents and prevent further trauma and triggers. The CR stated the expectation was for all staff to be trained in trauma informed care. The CR stated the expectation was for the admitting nurse and SSD to follow up with Resident 1's reported history of trauma and triggers upon admission. During a telephone interview on 3/13/25 at 1:39 p.m. with the director of staff development (DSD), the DSD stated there were no in-services or related trainings for trauma informed care provided for the facility staff. The DSD stated it was important for staff to have had trauma informed care training because the staff needed to be aware of all types of traumas in order to properly provide care to all residents affected. The DSD stated it was important for staff to be educated to identify triggers that could have been avoided for Resident 1. During a review of Resident 1's, Social Services-Trauma Informed Care Evaluation, dated 2/19/25, the evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . During a concurrent telephone interview and record review on 3/13/25 at 2:29 p.m. with the SSD, Resident 1's, Trauma Informed Care Evaluation, dated 2/19/25 was reviewed. The evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . The SSD stated the evaluation was completed upon admission to determine the level of trauma Resident 1 was presenting with in the facility. The SSD stated a high score on the evaluation indicated a high level of trauma presented. The SSD stated there was no care plan created to address Resident 1's trauma and triggers even after Resident 1 had indicated she had a history of trauma and scored high in the trauma evaluation. The SSD stated she could not recall why Resident 1's past trauma was not addressed in the interdisciplinary team (IDT-group usually consisting of physician, director of nurses, social services, resident/resident representative to collaborate in plan of care) meeting held on admission or why Resident 1's physician was not made aware at that time. The SSD stated it was important to document and follow up with any resident who reported a history of trauma. The SSD stated it was important to address Resident 1's trauma to avoid the triggers that were causing distress. The SSD stated it was important for all staff to receive the trauma informed care training in order to care for residents in the facility. During a review of Resident 1's, Independent Activity Monthly Record, dated 3/2025, the record indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . During a concurrent interview and record review on 3/14/25 at 11:22 a.m. with the activities director (AD), Resident 1's Independent Activity Monthly Record, dated 3/2025 was reviewed. The log indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . The AD stated Resident 1 stayed in her room most of the time even after activities are offered on a daily basis. The AD stated, Resident 1 would leave her room for a smoke break daily and would go back to her room to use her personal cellphone. The AD stated, Resident 1 would attempt to participate in some group activities but would become irritable (easily annoyed) and angry with other residents in the dining room, causing Resident 1 to go back to her room. During a review of Resident 1's, Care Plan (CP)-Activities, dated 2/24/25, the CP indicated, . [Resident 1] sets her own activity goal, she will attend group activities of choice, wheels around facility most of the day . During a review of Resident 1's, MDS Section F- Preferences for customary Routines and Activities, dated 2/23/25, the MDS indicated, . how important is it to you to do things with groups of people? Very important, how important is it to you to do your favorite activities? Very important, how important is it to you to listen to the music you like? Very important . During a record review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, dated 2023, the P&P indicated, . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . The facility will work to facilitate the principles of trauma informed care which include, Safety - Ensuring residents have a sense of emotional and physical safety. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident . Collaboration an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care . The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents' care plan . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization .

Based on interview and record review the facility failed to designate and employ a full time Director of Nursing (DON) for the facility from 12/2024 to 3/2025. This failure had the potential for all residents to result in inadequate residents ' care planning and supervision of the nursing department which placed all residents ' health and safety at risk. Findings: During an interview on 3/11/25 at 4:38 p.m. with the Administrator (ADM) and Assistant Administrator (AADM), the ADM and AADM stated there was no DON assigned to the facility since 12/2024. The ADM and AADM stated there was a DON that was supposed to start working full time in the facility, but due to unforeseen circumstances, the DON did not begin employment with the facility. The ADM and AADM stated the facility nursing consultant had been completing some DON duties 1-2 times per week but was not full time. ADM and AADM stated the facility should have had a DON from 12/2024 to 3/2025. The ADM stated there were Registered Nurses assigned as supervisor for the day, but were not completing any DON duties. During a telephone interview on 3/13/25 at 11:43 a.m. with the clinical resource (CR), the CR stated there was no DON employed for the facility. The CR stated she was assigned to assist the facility as needed during the week and would complete DON duties 1-3 days a week. The CR stated she was not the interim DON and did not work full time hours in the facility. During a record review of the facility ' s policy and procedure (P&P) titled, Nursing Services-Registered Nurse (RN), dated 2025, the P&P indicated, . It is the intent of the facility to comply with Registered Nurse staffing requirements . The facility will designate a Registered Nurse to serve as the Director of Nursing on a full-time basis . During a review of the facility ' s job description titled, Director of Nursing, dated 2023, the job description indicated, . position purpose, planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents . Based on interview and record review the facility failed to designate and employ a full time Director of Nursing (DON) for the facility from 12/2024 to 3/2025. This failure had the potential for all residents to result in inadequate residents' care planning and supervision of the nursing department which placed all residents' health and safety at risk. Findings: During an interview on 3/11/25 at 4:38 p.m. with the Administrator (ADM) and Assistant Administrator (AADM), the ADM and AADM stated there was no DON assigned to the facility since 12/2024. The ADM and AADM stated there was a DON that was supposed to start working full time in the facility, but due to unforeseen circumstances, the DON did not begin employment with the facility. The ADM and AADM stated the facility nursing consultant had been completing some DON duties 1-2 times per week but was not full time. ADM and AADM stated the facility should have had a DON from 12/2024 to 3/2025. The ADM stated there were Registered Nurses assigned as supervisor for the day, but were not completing any DON duties. During a telephone interview on 3/13/25 at 11:43 a.m. with the clinical resource (CR), the CR stated there was no DON employed for the facility. The CR stated she was assigned to assist the facility as needed during the week and would complete DON duties 1-3 days a week. The CR stated she was not the interim DON and did not work full time hours in the facility. During a record review of the facility's policy and procedure (P&P) titled, Nursing Services-Registered Nurse (RN) , dated 2025, the P&P indicated, . It is the intent of the facility to comply with Registered Nurse staffing requirements . The facility will designate a Registered Nurse to serve as the Director of Nursing on a full-time basis . During a review of the facility's job description titled, Director of Nursing , dated 2023, the job description indicated, . position purpose, planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents .

Based on observation, interview and record review, the facility failed to protect and promote the rights of residents' privacy for two of nine sampled residents (Resident 1 and Resident 2) when the facility did not provide a private area for Resident 1 and Resident 2 to discuss their personal health information. This failure had the potential to result in health information for Resident 1 and Resident 2, to have been overheard by other unrelated staff and residents in the facility resulting in lack of confidentiality and privacy. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), and alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS -screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 3//11/25 at 12:46 p.m. with Resident 1, Resident 1 stated there was a concern regarding the lack of privacy provided within the facility during personal conversations and medical visits. Resident 1 stated during conversations with the social services director (SSD), she was not able to discuss private health information due to Resident 1's roommate being in the room, staff going in and out of the room and the SSD not having an office with enough space to accommodate any resident. Resident 1 stated there were instances when she heard conversations related to other residents in the facility about their personal medical information. During an interview on 3/11/25 at 1:31 p.m. with Resident 2, Resident 2 stated she felt there was no privacy provided in the facility for private conversations unless roommates were removed from the room. Resident 2 stated she would meet with facility physicians in her room but felt her privacy curtain was not enough to keep her health information private from staff and other residents. Resident 2 stated the SSD did not have a private area to meet and accommodate for the privacy of residents. During a review of Resident 2's AR, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for Morbid Obesity (excessive weight), Anxiety, and other stimulant abuse. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 15 out of 15 which indicated Resident 2 was cognitively intact. During a concurrent observation and interview on 3/11/25 at 3:25 p.m. with the SSD, in the SSD's office. The office was observed located in the hallway between two resident rooms and across the hall from two other resident rooms. The SSD office appeared to contain a desk with drawers and desk chair. When the SSD opened the door of her office, there was no room for surveyor and SSD to conduct an interview privately with the door closed. The SSD advised to move interview to the facility conference room located outside in the back of the facility. The SSD stated there was a concern that private medical and mental health information was discussed in an area without privacy. The SSD stated the office space provided was too small to accommodate a resident with enough privacy to discuss private information. The SSD stated she had voiced concerns regarding the lack of privacy and was directed to conduct private health conversations with residents in their assigned rooms. The SSD stated there was no privacy for residents in their rooms when there were other roommates or staff present during the room visits. During an interview on 3/11/24 at 4:38 p.m. with the Administrator (ADM) and assistant administrator (AADM), the ADM and AADM stated all residents in the facility had a right to privacy and if the room that was provided to the SSD was not big enough or was a concern, the facility could provide the SSD with another office to accommodate the SSD and residents to ensure their privacy. During a record review of the facility's policy and procedure (P&P) titled, Confidentiality of Personal and Medical Records, dated 2024, the P&P indicated, . This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record . Employees should discuss confidential information about residents only during the course of business with other employees or contracted professionals, on a need to know basis. Information regarding one resident should not be shared with other residents or visitors . Employees should not discuss resident information in public or semi-public areas . During a record review of the facility's P&P titled, Resident Rights, dated 2025, the P&P indicated, . The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overhead. This includes the right to retain and use a cellular phone at the resident's own expense . The resident has the right to have reasonable access to, and privacy of, their use of electronic communication such as email and video communications and for internet research . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident . The resident has a right to secure and confidential personal and medical records . Based on observation, interview and record review, the facility failed to protect and promote the rights of residents' privacy for two of nine sampled residents (Resident 1 and Resident 2) when the facility did not provide a private area for Resident 1 and Resident 2 to discuss their personal health information. This failure had the potential to result in health information for Resident 1 and Resident 2, to have been overheard by other unrelated staff and residents in the facility resulting in lack of confidentiality and privacy. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), and alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS -screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 3//11/25 at 12:46 p.m. with Resident 1, Resident 1 stated there was a concern regarding the lack of privacy provided within the facility during personal conversations and medical visits. Resident 1 stated during conversations with the social services director (SSD), she was not able to discuss private health information due to Resident 1's roommate being in the room, staff going in and out of the room and the SSD not having an office with enough space to accommodate any resident. Resident 1 stated there were instances when she heard conversations related to other residents in the facility about their personal medical information. During an interview on 3/11/25 at 1:31 p.m. with Resident 2, Resident 2 stated she felt there was no privacy provided in the facility for private conversations unless roommates were removed from the room. Resident 2 stated she would meet with facility physicians in her room but felt her privacy curtain was not enough to keep her health information private from staff and other residents. Resident 2 stated the SSD did not have a private area to meet and accommodate for the privacy of residents. During a review of Resident 2's AR, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for Morbid Obesity (excessive weight), Anxiety, and other stimulant abuse. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 15 out of 15 which indicated Resident 2 was cognitively intact. During a concurrent observation and interview on 3/11/25 at 3:25 p.m. with the SSD, in the SSD's office. The office was observed located in the hallway between two resident rooms and across the hall from two other resident rooms. The SSD office appeared to contain a desk with drawers and desk chair. When the SSD opened the door of her office, there was no room for surveyor and SSD to conduct an interview privately with the door closed. The SSD advised to move interview to the facility conference room located outside in the back of the facility. The SSD stated there was a concern that private medical and mental health information was discussed in an area without privacy. The SSD stated the office space provided was too small to accommodate a resident with enough privacy to discuss private information. The SSD stated she had voiced concerns regarding the lack of privacy and was directed to conduct private health conversations with residents in their assigned rooms. The SSD stated there was no privacy for residents in their rooms when there were other roommates or staff present during the room visits. During an interview on 3/11/24 at 4:38 p.m. with the Administrator (ADM) and assistant administrator (AADM), the ADM and AADM stated all residents in the facility had a right to privacy and if the room that was provided to the SSD was not big enough or was a concern, the facility could provide the SSD with another office to accommodate the SSD and residents to ensure their privacy. During a record review of the facility's policy and procedure (P&P) titled, Confidentiality of Personal and Medical Records, dated 2024, the P&P indicated, . This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record . Employees should discuss confidential information about residents only during the course of business with other employees or contracted professionals, on a need to know basis. Information regarding one resident should not be shared with other residents or visitors . Employees should not discuss resident information in public or semi-public areas . During a record review of the facility's P&P titled, Resident Rights, dated 2025, the P&P indicated, . The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overhead. This includes the right to retain and use a cellular phone at the resident's own expense . The resident has the right to have reasonable access to, and privacy of, their use of electronic communication such as email and video communications and for internet research . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident . The resident has a right to secure and confidential personal and medical records .

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for Trauma informed Care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1), when the facility's admitting nurse and social services director (SSD) identified Resident 1's history of trauma upon admission and did not create a care plan to recognize trauma and triggers that impacted Resident 1's care. This failure resulted in Resident 1 experiencing triggers that caused her to relive past traumas during her care in the facility. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8- 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview 3/11/25 at 2:06 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she had cared for Resident 1 in the past. CNA 1 stated Resident 1 liked things done a certain way during her care times. CNA 1 stated she was not aware of any trauma or triggers associated with Resident 1. CNA 1 stated it was important to know Resident 1 had experienced some type of trauma to identify triggers that impacted her daily life and provide the care needed. CNA 1 stated it was important to make a safe space for the residents when they were in the facility. CNA 1 stated it was important to establish a relationship with the residents and not dismiss resident attempts to share feelings or experiences. During a concurrent interview and record review on 3/11/25 at 2:23 p.m. with licensed vocational nurse (LVN) 2, Resident 1's Care Plan (CP), dated 2/18/25 was reviewed. The CP indicated the facility had not created a care plan for trauma informed care. LVN 1 stated there should have been a care plan to address the trauma in Resident 1's past and the associated triggers. LVN 1 stated it was important to have a care plan to be aware of Resident 1's needs to safely provide care. During an interview on 3/11/25 at 2:44 pm with LVN 2, LVN 2 stated the facility process for trauma informed care was to identify resident's past trauma to establish the plan of care. LVN 2 stated, when the care plan for trauma informed care was not created for Resident 1, the facility staff were not aware of Resident 1's traumatic history and environmental triggers that she was exposed to. LVN 2 stated the process included speaking with the resident, notifying the physician and creating a plan of care individualized to Resident 1's needs. During an interview on 3/11/25 at 3:25 p.m. with the SSD, the SSD stated, Resident 1 had verbalized the history of past trauma, and a plan of care should have been established at that moment upon admission. The SSD stated there was no care plan to address Resident 1's past trauma and triggers. The SSD stated there should have a care plan implemented on admission to properly care for Resident 1. During an interview on 3/11/25 at 4:38 p.m. with the administrator (ADM), the ADM stated there was concern for the lack of trauma informed care plan for Resident 1. The ADM stated Resident 1's trauma should have been identified and a plan of care should have been created to establish the proper care. During a telephone interview on 3/12/25 at 11:43 a.m. with clinical resource (CR), the CR stated the facility process was to identify resident traumas on admission and evaluate the resident for plan of care. The CR indicated the purpose of identifying trauma on admission was to establish a plan of care to properly care for residents and prevent further trauma and triggers. The CR stated the expectation was for the admitting nurse and SSD to follow up with Resident 1's reported history of trauma and triggers upon admission and create an individualized care plan. During a telephone interview on 3/13/25 at 11:27 a.m. with the MDS/LVN, the MDS/LVN stated the facility process was to create a baseline care plan upon admission and during resident's stay in the facility when changes occur. The MDS/LVN stated the expectation was to identify resident trauma and triggers, create a care plan, and notify physician to properly create a plan of care. During a telephone interview on 3/13/25 at 1:39 p.m. with the director of staff development (DSD), the DSD stated it was the expectation that a baseline care plan be created to address Resident 1's history of trauma. The DSD stated it was important for all staff to be aware of possible triggers and interventions to address Resident 1's trauma and to avoid re-traumatization. During a concurrent telephone interview and record review on 3/13/25 at 2:29 p.m. with the SSD, Resident 1's, Trauma Informed Care Evaluation, dated 7/2024 was reviewed. The evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . The SSD stated there was no care plan created to address Resident 1's trauma and triggers even after Resident 1 had indicated she had a history of trauma and scored high in the trauma evaluation. During a record review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 2022, the P&P indicated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives . Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident . The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . During a record review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, dated 2023, the P&P indicated, . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . The facility will work to facilitate the principles of trauma informed care which include, Safety - Ensuring residents have a sense of emotional and physical safety. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident . Collaboration an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care . The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization . Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for Trauma informed Care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1), when the facility's admitting nurse and social services director (SSD) identified Resident 1's history of trauma upon admission and did not create a care plan to recognize trauma and triggers that impacted Resident 1's care. This failure resulted in Resident 1 experiencing triggers that caused her to relive past traumas during her care in the facility. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8- 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview 3/11/25 at 2:06 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she had cared for Resident 1 in the past. CNA 1 stated Resident 1 liked things done a certain way during her care times. CNA 1 stated she was not aware of any trauma or triggers associated with Resident 1. CNA 1 stated it was important to know Resident 1 had experienced some type of trauma to identify triggers that impacted her daily life and provide the care needed. CNA 1 stated it was important to make a safe space for the residents when they were in the facility. CNA 1 stated it was important to establish a relationship with the residents and not dismiss resident attempts to share feelings or experiences. During a concurrent interview and record review on 3/11/25 at 2:23 p.m. with licensed vocational nurse (LVN) 2, Resident 1's Care Plan (CP), dated 2/18/25 was reviewed. The CP indicated the facility had not created a care plan for trauma informed care. LVN 1 stated there should have been a care plan to address the trauma in Resident 1's past and the associated triggers. LVN 1 stated it was important to have a care plan to be aware of Resident 1's needs to safely provide care. During an interview on 3/11/25 at 2:44 pm with LVN 2, LVN 2 stated the facility process for trauma informed care was to identify resident's past trauma to establish the plan of care. LVN 2 stated, when the care plan for trauma informed care was not created for Resident 1, the facility staff were not aware of Resident 1's traumatic history and environmental triggers that she was exposed to. LVN 2 stated the process included speaking with the resident, notifying the physician and creating a plan of care individualized to Resident 1's needs. During an interview on 3/11/25 at 3:25 p.m. with the SSD, the SSD stated, Resident 1 had verbalized the history of past trauma, and a plan of care should have been established at that moment upon admission. The SSD stated there was no care plan to address Resident 1's past trauma and triggers. The SSD stated there should have a care plan implemented on admission to properly care for Resident 1. During an interview on 3/11/25 at 4:38 p.m. with the administrator (ADM), the ADM stated there was concern for the lack of trauma informed care plan for Resident 1. The ADM stated Resident 1's trauma should have been identified and a plan of care should have been created to establish the proper care. During a telephone interview on 3/12/25 at 11:43 a.m. with clinical resource (CR), the CR stated the facility process was to identify resident traumas on admission and evaluate the resident for plan of care. The CR indicated the purpose of identifying trauma on admission was to establish a plan of care to properly care for residents and prevent further trauma and triggers. The CR stated the expectation was for the admitting nurse and SSD to follow up with Resident 1's reported history of trauma and triggers upon admission and create an individualized care plan. During a telephone interview on 3/13/25 at 11:27 a.m. with the MDS/LVN, the MDS/LVN stated the facility process was to create a baseline care plan upon admission and during resident's stay in the facility when changes occur. The MDS/LVN stated the expectation was to identify resident trauma and triggers, create a care plan, and notify physician to properly create a plan of care. During a telephone interview on 3/13/25 at 1:39 p.m. with the director of staff development (DSD), the DSD stated it was the expectation that a baseline care plan be created to address Resident 1's history of trauma. The DSD stated it was important for all staff to be aware of possible triggers and interventions to address Resident 1's trauma and to avoid re-traumatization. During a concurrent telephone interview and record review on 3/13/25 at 2:29 p.m. with the SSD, Resident 1's, Trauma Informed Care Evaluation, dated 7/2024 was reviewed. The evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . The SSD stated there was no care plan created to address Resident 1's trauma and triggers even after Resident 1 had indicated she had a history of trauma and scored high in the trauma evaluation. During a record review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 2022, the P&P indicated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives . Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident . The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . During a record review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, dated 2023, the P&P indicated, . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . The facility will work to facilitate the principles of trauma informed care which include, Safety - Ensuring residents have a sense of emotional and physical safety. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident . Collaboration an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care . The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization .

Based on interview and record review, the facility failed to ensure resident rights were exercised for two of four sampled residents (Resident 1 and Resident 2), when Resident 1 and Resident 2 were denied the opportunity to reheat their food brought in by family past 7:00 p.m. This failure resulted in Resident 1 and Resident 2's rights not having access to reheat their food past 7:00 p.m. causing anger by not recognizing Resident 1 and Resident 2's individuality and autonomy. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), Bipolar disorder (mood swings including sadness and anger). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 1/15/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 2/26/25 at 11:08 a.m. with Resident 1, Resident 1 stated there was no microwave in the facility to assist in reheating his food. Resident 1 stated the facility staff would use the microwave located in the staff breakroom to heat up residents' foods, but the microwave had since stopped functioning . Resident 1 stated the facility staff informed him they were not supposed to assist him with reheating his food. Resident 1 stated he felt angry when he could not reheat his food while in the facility. During a review of Resident 2's AR, the AR indicated, Resident 2 was admitted to the facility on [DATE] diagnosis for type 2 diabetes mellitus (disease that causes high blood sugar), anemia (low iron in the blood). During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 14 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 2 was cognitively intact. During an interview on 2/26/25 at 11:12 a.m. with Resident 2, Resident 2 stated the facility staff had informed him the microwave that was previously used to reheat resident food was not working . Resident 2 stated he was informed by facility staff that they were no longer allowed to assist in reheating resident foods. Resident 2 stated he felt angry because he did not have the ability to reheat the food himself and the facility was not accommodating his request to reheat his food after dinner. Resident 2 stated he was offered facility snacks at night instead of being allowed to consume his own food due to the lack of resources available to reheat his food. During a review of Resident 1's, Dietary Note, dated 2/26/25, the note indicated, . certified dietary manager (CDM) and assistant administrator were in hall and [Resident 1] had asked how he could heat up his food. Assistant administrator stated that the facility had to remove his personal microwave from his room for safety reasons. CDM explained that foods prepared outside the kitchen could not be re-heated in the kitchen . During an interview on 2/26/25 at 11:34 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated the facility microwave used to reheat residents' food, was broken. CNA 1 stated the facility process was to not reheat residents' food and instead the food would be taken to the kitchen and request for the dietary staff to reheat residents' food. During an interview on 2/26/25 at 12:00 p.m. with the assistant administrator (AADM) the AADM stated the facility did not have a microwave for resident use. The AADM stated the facility process was for the staff to take resident food to the kitchen for reheating. The AADM stated the kitchen staff were in the facility only until 7:00 p.m. and there was no dietary staff present after that time. The AADM stated, she was not comfortable with the facility staff reheating resident food as the staff were not trained on proper reheating of food. The AADM stated residents did not have access to reheating food after 7:00 p.m. During a telephone interview on 3/5/25 at 3:15 p.m. with CNA 2, CNA 2 stated the facility process was for the staff to not reheat any food for residents. CNA 2 stated the facility staff was supposed to take food to the kitchen to be reheated by the dietary staff. CNA 2 stated the facility staff was told not to reheat residents' food and instead give residents the snacks that were provided from the kitchen. CNA 2 stated there was no microwave available to reheat residents' foods. During a telephone interview on 3/7/25 at 11:46 a.m. with the administrator (ADM), the ADM stated the facility did not have a microwave for resident use after 8:00 p.m. The ADM stated the facility process was for the dietary staff to reheat resident food while they were working in the facility. The ADM stated the residents had the opportunity to ask facility staff to reheat their food before 8 p.m. The ADM stated the dietary staff should have been the only staff reheating resident food as the CNAs were not properly trained to reheat resident food. The ADM stated residents did not have the option to reheat food between the hours of 8:00 p.m. and 4:00 a.m. as there was no dietary staff available to assist resident needs. During a record review of the facility's policy and procedure (P&P) titled, Foods brought by Family/Visitors, dated 2001, the P&P indicated, . Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. family members and visitors are asked to inform nursing staff when foods are brought for a resident . safe food handling practices are explained to family/visitors in a language and format they understand. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food . During a record review of the facility's P&P titled, Resident Rights, dated 2025, the P&P indicated, . The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice . The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on interview and record review the facility failed to ensure residents were free from free from abuse for one of three sampled residents (Resident 1), when certified nursing assistant (CNA)1 was observed hitting Resident 1 with a closed fist. This failure resulted in Resident 1 being physically harmed on the right thigh causing unnecessary mental trauma and physical pain to the area. Findings: During a record review of Resident 1 ' s Nurses Note, dated 11/1/24, the nurses note indicated, . CNA 1 and CNA 2 continued to change Resident 1, Resident 1 ' s aggression increased, Resident 1 began kicking, hitting, and scratching CNA 1. Resident 1 made contact multiple times while swinging at CNA 1, including Kicking CNA 1 in the side of the face and scratching her hand. CNA 1 finished changing Resident 1 and left the room. Resident 1 stated to director of nursing (DON) and assistant administrator, that CNA 1 hit her with a closed fist 2 times on her right upper thigh before CNA 1 left the room . During a review of Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis for hemiplegia (severe or complete loss on one side of the body), epilepsy (brain disorder with sudden alteration of behavior due to change in the brain) morbid obesity, muscle weakness, Major Depressive disorder (condition that causes a persistent feeling of sadness and loss of interest in activities) . During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 9/6/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 14 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 11/13/24 at 11:21 a.m. with Resident 1, Resident 1 recalled incident that occurred on 11/1/24 and stated CNA 1 had hit her twice on the right hip with a closed fist. Resident 1 stated CNA 1 and CNA 2 had entered her room to provide personal hygiene care assistance, Resident 1 stated she was upset about something that had happened during care but could not recall what led to the incident. Resident 1 stated she kicked CNA 1 so that CNA 1 could leave the room. Resident 1 stated CNA 2 was present in the room and assisting with care when the incident occurred. Resident 1 stated CNA 2 told CNA 1 to stop providing care when CNA 1 hit Resident 1 with a closed fist. Resident 1 stated she felt pain at the time of incident, but the pain had subsided and no other physical injuries were noted. During an interview on 11/13/24 at 11:31 a.m. with CNA 3, CNA 3 stated Resident 1 was not verbally or physically aggressive toward staff. CNA 3 stated Resident 1 ' s behavior on the day of incident on 11/1/24, was not normal behavior for Resident 1. CNA 3 stated it was not appropriate when CNA 1 hit Resident 1 when Resident 1 was exhibiting aggressive behaviors. CNA 3 stated it was the facility process to attempt to redirect the resident who was experiencing behaviors and if unsuccessful, step away from the situation and allow resident to calm down and offer care at a later time. CNA 3 stated when CNA 1 hit Resident 1, it was considered abuse. During an interview on 11/13/24 at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the facility process was for staff to recognize when a resident was exhibiting behaviors such as aggression to allow the resident to calm down before attempting to provide care. LVN 1 stated the incident that occurred on 11/1/24 was considered abuse when CNA 1 hit Resident 1 during care. During a concurrent interview and record review with the Director of Staff Development (DSD), the facility ' s in service titled, Freedom and abuse and Neglect, dated 5/3/24, the in service indicated CNA 1 was in serviced on understanding resident rights, explanation of the types of abuse and what constitutes abuse. The DSD stated the abuse training was completed at least 3-4 times a year and as needed to ensure staff was trained on identifying abuse. During an interview on 11/13/24 at 12:56 p.m. with the administrator (ADM), the ADM stated the facility expectation was for staff to assess the situation and exit the room as needed. The ADM stated it was the facility expectation for staff to back away call for assistance if the residents weree exhibiting behaviors and allow residents the space they are requesting. The ADM stated CNA 1 had been terminated from the facility and last day of employment was 11/1/24. During a telephone interview on 11/14/24 at 12:34 p.m. with CNA 2, CNA 2 stated on 11/1/24, CNA 1 was observed, hitting Resident 1 multiple times on the right thigh using a closed fist. CNA 2 stated that on 11/1/24, CNA 1 requested the assistance of CNA 2 to provide care for Resident 1. CNA 2 stated Resident 1 was exhibiting behaviors toward CNA 1 which included attempts to remove CNA 1 from providing care. CNA 2 stated that Resident 1 was angry and was resisting care from CNA 1. CNA 2 stated that Resident 1 hit CNA 1 and attempted to keep hitting her until CNA 1 restrained Resident 1 ' s arm. CNA 2 stated that CNA 1 was then observed hitting Resident 1 with a closed fists on Resident 1 ' s right side of leg. CNA 2 stated that the incident was reported right away because it was abuse when CNA 1 hit Resident 1. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2024, the P&P indicated, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse . During a review f the facility ' s P&P titled, Resident Rights, dated 2024, the P&P indicated, . The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. One of three kitchen personnel, [NAME] (CK) 2 did not use a surface sanitizer with the correct concentration when wiping the food preparation table. 2. One of three kitchen personnel, CK 1 did not take the temperature reading of food items after the items were heated in the microwave before serving it to one of 47 residents. 3. Plates, Plate holders, lids, and cooking pans were not air dried and were stacked and stored wet in the kitchen. These failures had the potential to expose 46 of 47 residents who received food from the kitchen to pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and cause foodborne illness (illness caused by ingestion of contaminated food or beverages) to residents who ate the food. Findings: 1. During a concurrent observation and interview on 5/14/24 at 8:52 a.m. in the kitchen, the Cook/Dietary Aide (CK) 2 was observed wiping the food preparation table that had been inadvertently sprayed with water from the dishwasher with a cloth that was in a red sanitizer bucket. CK 2 was requested to test the sanitizer solution to verify it had the appropriate sanitizer concentration. CK 2 dipped a test strip in the sanitizer solution, and it was observed to register zero parts-per-million (ppm- describes the concentration of sanitizer in water) of sanitizer concentration. CK 2 changed the sanitizer solution and retested the solution with a new test strip. The test strip was observed to register between 100-200 ppm. CK 2 stated the range for the sanitizer solution should be between 50ppm and 100ppm. During an interview on 5/15/24 at 11:20 a.m. with the Registered Dietician (RD), the RD stated her expectation was for the sanitizer solution to be at the correct concentration. The RD stated a solution reading of zero ppm was not acceptable. The RD stated there was a possibility that bacteria could grow and get residents sick. During an interview on 5/17/24 at 10:56 a.m. with CK 1, CK 1 stated if the sanitizer solution was not within adequate ppm range, then food would be prepped on dirty surfaces and germs would go to the items or food placed on it. CK 1 stated it was the cooks' job to be sure the food prep area was sanitized, and food was prepped correctly. During an interview on 5/17/24 at 11:16 a.m. with the Dietary Services Manager (DSM), the DSM stated the sanitation solution should be changed every two hours and have the correct concentration of ppm. The DSM stated residents could get sick if food was prepped on dirty surfaces. During a review of the facility document titled, Job Description (JD) . Dietary Aide , dated 2023, the JD indicated, .Ensures that food procedures are followed in accordance with established policies . cleaning of the kitchen per established protocols . assists in daily cleaning duties as assigned to include worktables . in accordance to established policies and procedures . During a review of the facility document titled, Job Description-Dietary Cook, dated 2023, the JD indicated, .Ensures that food procedures are followed in accordance with established policies . assists/directs daily cleaning duties in accordance to established policies and procedures . ensures the department, necessary equipment and supplies are clean and maintained in a safe manner . During a review of the facility document titled, Job Description-Dietary Manager(JD), dated 2023, the JD indicated, .Maintains a clean and sanitary environment . During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2001, the P&P indicated, . All equipment, food contact surfaces and utensils shall be . sanitized using hot water and/or chemical sanitizing solutions . sanitizing of environmental surfaces must be performed with one of the following solutions . 50-100 ppm chlorine solution . 150-200 ppm quaternary ammonium compound (QAC) . During a review of professional reference (PR) titled, FDA Food Code, section 4-602.11 Equipment Food-Contact Surfaces and Utensils, dated 2022, the PR indicated, . Equipment food-contact surfaces and utensils shall be cleaned . at any time during the operation when contamination may have occurred . 2. During an observation on 5/14/24 at 12:07 p.m. in the kitchen, CK 1 was observed putting frozen breaded vegetable patties in the microwave to heat. CK 1 was then observed plating the microwave heated patties and sending it out with the meal trays without taking the temperature of the patties. During a concurrent interview and record review on 5/17/24 at 10:56 a.m. with CK 1, the Service Line Checklist (Checklist), dated 5/14/24 was reviewed. The Checklist indicated, . item names and temperatures for all hot and cold foods should be taken prior to service and recorded in the boxes below . CK 1 stated the alternate frozen food item was a vegetarian patty. CK 1 stated the vegetarian patties were not temped or entered in the log on 5/14/24. CK 1 stated the vegetarian patties should have been heated to 165 degrees Fahrenheit. During an interview on 5/17/24 at 11:16 a.m. with the DSM, the DSM stated staff should be temping alternate food items. The DSM stated it was a safety and a quality issue for the resident. The DSM stated residents could get sick. During a review of the facility's P&P titled, Record of Food Temperatures, dated 2024, indicated, .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled . food temperatures will be checked on all items prepared in the dietary department . During a review of professional reference titled, FDA Food Code, section 3-403.11 Reheating for Hot Holding, dated 2022, indicated, . (C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57oC (135oF) when being reheated for hot holding . 3. During a concurrent observation and interview on 5/14/24 at 8:52 a.m. with CK 1 in the kitchen, CK 1 was observed placing wet plate holders and lids inverted on top of each other on the counter and wet plates stacked on top of each other on the plate warmer. CK 1 stated the plates were air dried for one minute and were still a little wet when placed on the warmer. CK 1 stated it was okay to stack plates on the warmer when not completely dry. The plate holders, and lids were observed stacked and left wet on the warmer. During a concurrent observation and interview on 5/14/24 at 9:14 a.m. with the DSM, heating pans were observed stacked and stored under the food preparation table with drops of water inside them. The DMS stated pots and pans should not be stacked wet. The DMS stated plates were air dried for a bit then placed on the warmer to continue drying. The DMS stated the lids and plate holders were air dried for a bit then stacked on top of each other upside down to continue drying. The DMS stated this practice was okay since the plate holders and lids were upside down and the water would drip down off the plate holders and lids until dry. During an interview on 5/15/24 at 11:20 a.m. with the RD, the RD stated, the policy for storing dishware was that dishware was to be completely dry before storing. The RD stated if dishware was stored wet, there was the possibility that bacteria could grow and residents could get sick. The RD stated her expectation was that the dishware was dry before being stored. During an interview on 5/17/24 at 11:16 a.m. with the DSM, the DSM stated, water from the inverted plate holders and lids dripped down onto the counter. The DMS stated there was no other dry area the plate holders and lids could moved to. The DMS stated the plate holders and lids were stored in a wet area. During a review of professional reference titled, FDA Federal Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, dated 2022, indicated, . Cleaned EQUIPMENT and UTENSILS . shall be stored . in a clean, dry location .where they are not exposed to splash, dust, or other contamination . During a review of professional reference retrieved from, https://www.anfponline.org/docs/default-source/legacy-docs/docs/ce-articles/fpc032019.pdf titled, Sanitation Pitfalls in the healthcare Kitchen, dated March-April 2019, the professional reference indicated, .wet-nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. FDA guidelines mandate that all wares should be air dried .

Based on observation, interview and record review, the facility failed to ensure residents were provided with dignity and respect for two of eight sampled residents (Resident 146 and Resident 243) when: 1. Licensed Vocational Nurse (LVN) 3 checked vital signs (V/S-measurements of blood pressure, pulse rate and temperature) and administered medication to Resident 146 in hallway B and did not provide privacy. 2. LVN 3 checked V/S and administered medication to Resident 243 in Residents' room and did not provide privacy. These failures resulted in Resident 146 and Resident 243 not being treated with respect and dignity while their vital signs were taken and while taking their medications. Findings: 1. During a concurrent observation and interview on 5/15/24 at 8:51 a.m. in B hallway, Resident 146 was sitting up in his wheelchair. LVN 3 checked Resident 146's V/S and prepared Resident 146's medications. LVN 3 administered Resident 146's medications in the hallway with other residents and staff walking by. During a review of Resident 146's clinical record titled, Admission Record (AR-document with resident demographic and medical diagnosis information), dated 5/16/24, AR indicated Resident 146 was admitted to the facility on [DATE], with diagnosis which included cerebral infarction (damage of issues in the brain due to a loss of oxygen), hemiplegia (paralysis- unable to move or control the muscles in the affected body part) and hemiparesis (weakness or the inability to move on one side of the body) and muscle weakness. During a review of Resident 146's Minimum Data Set (MDS - an assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 146's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 146 had no cognitive deficit. During an interview on 5/15/24 at 3:45 p.m. with LVN 3, LVN 3 stated she should not have checked Resident 146's V/S and administered his medications in the hallway. LVN 3 stated the practice was to not administer medications or check V/S in the hallway because of privacy issue. LVN 3 stated she should have asked Resident 146 to go in his room and check his V/S and administered his medications. During an interview on 5/17/24 at 10:30 a.m. with the Director of Nursing (DON), the DON stated LVN 3 should have asked Resident 146 to go in his room then checked his V/S and administered Resident 146's medications. The DON stated it was a resident rights to privacy, there were other residents, staff and visitors walking by and could see what was going on. The DON stated resident's privacy was very important. 2. During a concurrent observation and interview on 5/15/24 at 9:10 a.m. in Resident 243's room, Resident 243 was laying in bed with head of bed elevated, Resident 243's upper body and legs were exposed and privacy curtain was not drawn to provide privacy. LVN 3 checked Resident 243's V/S without providing privacy. LVN 3 prepared Resident 243's medications and administered his medications while Resident 243 was laying in bed and did not provide privacy with other residents and staff walking by. During a review of Resident 243's clinical record titled, Admission Record (AR), dated 5/16/24, AR indicated Resident 243 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, epilepsy (seizures-a sudden, uncontrolled burst of electrical activity in the brain) depression (a low mood or loss of pleasure or interest in activities for long periods of time) and muscle weakness. During a review of Resident 243's MDS assessment dated [DATE], indicated Resident 243's BIMS assessment score was 15 out of 15 indicating Resident 243 had no cognitive deficit. During an interview on 5/15/24 at 3:45 p.m. with LVN 3, LVN 3 stated she did not provide privacy to Resident 243 when she checked V/S and administered his medications. LVN 3 stated privacy curtain was open and Resident 243 was exposed to other residents, staff and visitors walking by the hallway. LVN stated she should have closed the privacy curtain providing privacy to Resident 243 while his V/S were taken and when taking his medications. LVN 3 stated the practice was to provide privacy when administering medications and when checking V/S. During an interview on 5/17/24 at 10:35 a.m. with the DON, the DON stated LVN 3 should have provided privacy to Resident 243 by closing the privacy curtain when she checked the V/S and administered resident's medications. The DON sated there were other residents, staff and visitors walking by in the hallway and could see residents taking their medications. The DON stated residents' privacy was very important, it was one of their rights as a resident in the facility. During a review of facility's Policy and Procedure (P&P) titled, Resident Rights/Resident Exercise Right, dated 10/2022, the P&P indicated, . Be treated with respect and dignity . right to personal privacy and confidentiality . During a review of facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 1/21, the P&P indicated, . Provide for privacy as appropriate .

Based on observation, interview, and record review, the facility failed to ensure dialysis (procedure to remove wastes and excess fluids from the body) communication forms were completed for two of four sampled residents (Resident 142 and Resident 25) when Residents 25 and 142 did not have documentation of completed post-dialysis assessments of access sites (site used for dialysis) on multiple dates. These failures placed Resident 142 and 25 at risk for delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through blood vessels)access sites. Findings: During a concurrent observation and interview on 5/13/24 at 7:40 a.m. in Resident 142's room, Resident 142 was observed sitting up in bed, eating breakfast. Resident stated she had hip surgery due to a fracture (break in bone) sustained from a fall at home. Resident stated she had been in the facility for a month and working with therapy to get stronger so she can go back home. During a record review of Resident 142's, Admission Record (AR-document with resident demographic and medical diagnosis information), dated 5/16/24, the AR indicated, Resident 142 was admitted on [DATE], with a diagnosis that include End-Stage kidney disease (final permanent stage of kidney disease when kidneys no longer function, needing dialysis) and fracture of right femur (long bone). During an interview on 5/15/24 at 1:30 p.m. with certified nursing assistant (CNA) 3, CNA stated Resident 142 was alert and oriented. CNA 3 stated Resident 142 went to dialysis three times a week, every Tuesday, Thursday and Saturday. CNA 3 stated she made sure Resident 142 ate breakfast before she was picked up for dialysis. During a record review of Resident 25's, AR dated 5/17/24, the AR indicated, Resident 25 was admitted on [DATE], with diagnosis which included End-Stage Renal Disease. During a record review on 5/16/24, at 10:28 a.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated the charged nurse was responsible in making sure dialysis communication forms were filled up and given to residents when they leave for dialysis. LVN 1 stated when resident returns from dialysis the charged nurse checked the dialysis communication form to make sure dialysis nurse filled up their part and assessed resident and fill the post treatment box of the dialysis communication form. LVN 1 stated dialysis communication forms were important to ensure the facility were not missing any new orders and updates of resident status while in dialysis center. During a concurrent interview and record review on 5/16/24 at 2:02 p.m. with LVN 2, Resident 25's dialysis communication form was reviewed. LVN 2 stated Resident 25 went to dialysis every Tuesday, Thursday and Saturday. LVN 2 stated there was only one dialysis communication form dated 5/14/24 in the binder for the month of May 2024. LVN 2 stated there should have been a dialysis communication forms for the following dates: 5/2/24, 5/4/24, 5/7/24, 5/9/24 and 5/11/24. LVN 2 stated all dialysis communication form should be completed as soon as resident returned from dialysis and filed in the dialysis binder. LVN 2 stated medical records audits the binders and followed up with dialysis centers for incomplete dialysis communication forms. During a concurrent interview and record review on 5/16/24 at 2:30 p.m. with Medical Records staff (MR), she stated she was responsible in auditing the dialysis forms. MR stated she checked the resident dialysis binder to make sure the dialysis communication forms were completed for all the dialysis residents. MR reviewed Resident 124's dialysis communication form and stated Resident 14's dialysis communication forms dated 5/11/24 and 5/14/24 are incomplete and should have been completed. MR reviewed Resident 25's dialysis communication forms and stated there was only one dialysis communication form dated 5/14/24 for the month of May 2024. During an interview on 5/17/24 at 10:40 a.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurse and medical records to make sure dialysis communications forms were completed and filed in the dialysis binder. DON stated licensed nurses are responsible in making sure to complete dialysis communication form for each resident who goes to dialysis and follow up with the dialysis center for incomplete dialysis communication forms assessment. DON stated the MR should have been auditing the dialysis binder on a regular basis to make sure all dialysis communication forms were completed and filed in the dialysis binder. During a review of the facility's policy and procedure (P&P) titled, Hemodialysis dated 10/2022, the P&P indicated, .The facility will assure that each resident receives care and services for the provision of hemodialysis . The licensed nurse will communicate to the dialysis facility . such as dialysis communication form . Timely medication administration . Physician/treatment orders . weights . intake and output measurements . Dialysis treatment provided and resident's response . recommendations for follow up observations and monitoring .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of five sampled residents (Resident 142) when Resident 142 was administered heparin (anticoagulant-blood thinner) medication as prophylaxis (prevention) for venous thromboembolism (condition that occurs when a blood clot forms in a vein) and the facility did not initiate a care plan. This failure had the potential for Resident 142 to experience a thromboembolism. Findings: During a concurrent observation, and interview on 5/13/24, at 7:40 a.m. in Resident 142's room, Resident 142 was lying down in his bed. Resident 147 stated she had been in the facility for a month. Resident 147 stated she had a hip surgery due to a fall at home and sustained a hip fracture (broken bone). Resident 147 stated she was working with therapy to walk again and go home. During a review of Resident 142's Admission Record (AR-document with resident demographic and medical diagnosis information), dated 5/16/24, AR indicated Resident 142 was admitted in the facility on 4/17/24 with diagnoses which included fracture of right femur (long bone), end stage renal disease (kidney failure-kidney no longer work to meet body's needs) and muscle weakness. During a review of Resident 142's clinical record titled Order Summary Report (OSR) undated, indicated, .Order date 4/25/24 . Heparin Sodium (Porcine) Solution 5000 UNIT/ML [milliliter-unit of measurement] Inject 5000 unit subcutaneously (under the skin) every 12 hours for Prophylaxis of venous thromboembolism. for three (3) weeks . During a concurrent interview and record review on 5/16/24 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 142's OSR was reviewed. LVN 2 stated Resident 142's heparin was prescribed on 4/25/24. LVN 2 stated she did not find a care plan for Resident 142's heparin use. LVN 2 stated there should have been a care plan developed and it was the Minimum Data Set Nurse (MDSN) responsibility to initiate a care plan. LVN 2 stated care plan was very important because it directed the nursing staff how the care was provided to residents. During a concurrent interview and record review on 5/16/24, at 3:50 p.m. with the Minimum Data Set Nurse (MDSN), Resident 142's care plan was reviewed. The MDSN stated she did not find a care plan for Resident 142's use of anticoagulant medication. The MDSN stated she was responsible in making sure there was a care plan in place. The MDSN stated there should have been a care plan to monitor for side effects of the anticoagulant medication. The MDSN stated there should have been a care plan in place but there was not. During a concurrent interview and record review on 5/17/24 at 10:16 a.m. with the Director of Nursing (DON), the DON stated Resident 142 had an order for anticoagulant medication to be given for three weeks. The DON stated she could not find a care plan for the use of anticoagulant medication. The DON stated there should have been a care plan initiated to monitor Resident 142 for any side effects of the medication. The DON stated, . Care plan is the driving force of the care of residents . During a review of facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 3/22, the P&P indicated, . The comprehensive, person-centered care plan is developed within seven (7) days . and no more than 21 days after admission . includes measurable objectives and timeframe; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to provide quality of care and treatment in accordance with professional standards of practice for one of four sampled residents (Resident 18) when fasting blood sugar levels (FBS- A test to determine how much sugar is in blood after an overnight fast) was not performed per physician's orders. This failure resulted in Resident 18's blood sugar level not being monitored which could lead to hypoglycemia (a condition where there isn't enough sugar in the blood) or hyperglycemia (a condition where there is too much sugar in the blood). Findings: During a concurrent observation and interview on 5/13/24 at 2:59 p.m. with Resident 18 in his room, Resident was sitting upright in bed eating. Resident 18's both legs were amputated (cut off). Resident 18 stated, his legs were amputated two years ago due to diabetes mellitus (DM-a condition in which the sugar is high in the blood). Resident 18 stated his blood sugar levels were not checked. During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) Section C, dated 3/7/24 was reviewed. The MDS Section C indicated Resident 18 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 18 was cognitively intact. During a concurrent interview and record review on 5/15/24 at 3:41 p.m. with the Director of Nursing (DON), Resident 18's Admissions Record (AR-document with resident demographic and medical diagnosis information), the AR was reviewed. The DON validated, Resident 18's AR indicated, Resident 18 had DM. During a review of Resident 18's AR, dated 5/16/24, the AR indicated, Resident 18 had a diagnosis of Type 2 Diabetes Mellitus .(DM) During a record review of Resident 18's Order Summary Report (OSR) dated 3/6/24, the OSR indicated, .FBS (Fasting Blood Sugar) one time a day related to TYPE 2 DIABETES MELLITUS . Start Date: 3/7/24 0600 End Date: Indefinite . During a concurrent interview and record review on 5/15/24 at 4:04 p.m. with the Director of Nursing (DON), Resident 18's Medication Administration Record (MAR) dated March 2024 was reviewed. The DON stated, the MAR indicated there was an order from the MD (Medical Doctor) to check blood sugar levels everyday at 6:00 a.m. The DON stated, there were no records of Resident 18's blood sugar levels being checked since the order was placed on 3/6/24. The DON stated, It's a mistake [nurses should have been checking blood sugars as ordered]. The DON stated, Nurses should have been following orders. The DON stated, not knowing the accurate levels of blood sugars had the potential to result in hypoglycemia or hyperglycemia. The DON stated, it was important to follow the orders to check blood sugar levels daily at 6 a.m. to have accurate measurements of resident's blood sugar levels. The DON stated, having accurate measurements were important so the MD would be aware of any potential hypoglycemic (low blood sugar levels ) or hyperglycemic (high blood sugar levels) conditions and to receive appropriate treatments. During a phone interview on 5/16/24 at 8:08 a.m. with Licensed Vocational (LVN) 4, LVN 4 stated, she was the night shift LVN for Resident 18. LVN 4 stated, I never knew that Resident 18 had DM or have an order to check Resident 18's blood sugars. LVN 4 stated, today [5/16/24] was the first time she had checked the blood sugar levels for Resident 18, it was never checked in the past. LVN 4 stated, it was important to know the resident's diagnosis and orders so quality of care could be provided. LVN 4 stated, the resident had wounds on his back and with his diagnosis of DM could potentially extend the healing time of those wounds if Resident 18's blood sugar was not controlled properly [expected healing time]. LVN 4 stated, by following the orders that were in place to check the blood sugar levels, would provide an accurate measurement of blood sugar levels. During a concurrent interview and record review on 5/16/24 at 8:41 a.m. with the Minimum Data Set Nurse (MDSN), Resident 18's OSR dated March 2024 was reviewed. The MDSN stated, the Orders indicated blood sugar levels to be checked daily at 6 a.m. The MDSN stated, I didn't know it [blood sugar checks prompts] wasn't popping up in the MAR. The MDSN stated, because the blood sugar was not being checked, there was potential for hypoglycemia and hyperglycemia to occur. During an interview on 5/16/24 at 9:17 a.m. with the Medical Records Staff (MR), the MR stated, she and the DON review orders monthly. The MR stated, the orders should have been reviewed more carefully. During an interview on 5/16/24 at 9:20 a.m. with the DON, the DON stated, nurses should review the MD orders daily to know what type of care residents need. The DON stated, failing to check MD orders could lead to potential mistakes and harm. During a review of the facility's policy and procedure (P&P) titled, Diabetes-Clinical Protocol dated 2001, the P&P indicted, .The physician will order .monitoring and reporting information related blood sugar management . During a review of Nursing 2024 The Peer-Reviewed Journal of Clinical Excellence (N2024), Who has the authority to give RNs an order?, dated 10/17/2018, the N2024 indicated, .you [nurses] have a legal duty to carry out a physician's .orders.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medication to meet the need for one of eight sampled residents (Resident 20) when Resident 20's Lactulose (brand name-laxative medication taken to treat constipation) was not available for administration for one day (5/15/24). This failure had the potential for Resident 20 to develop constipation which could lead to more serious health condition like stool impaction (the result of severe constipation, unable to regularly pass stool or feces and it backs up inside the large intestine (colon). Findings: During a concurrent medication pass observation and interview on 5/15/24 at 8:22 a.m. at A- hallway, Licensed Vocational Nurse (LVN) 3, was preparing Resident 20's medications. LVN 3 did not administer Resident 20's lactulose medication. LVN 3 stated the medication was not available to give to Resident 20. During a review of Resident 20's Admission Record (AR-document with resident demographic and medical diagnosis information), dated 5/16/24, the AR indicated, Resident 20 was admitted in the facility on 1/28/19 with diagnoses which included constipation and muscle weakness. During a review of Resident 20's Order Summary Report (OSR) dated 5/16/24, the OSR indicated, .Lactulose Oral Solution 20GM[gram-unit of measurement]/30ML[milliliter-unit of measurement] (Lactulose) 30 ml by mouth one time a day for constipation . Order Date 01/19/2024 . During an interview on 5/15/24 at 3:31 p.m. with LVN 3, LVN 3 stated Resident 20's lactulose was routine medication and should have been available to administer to Resident 20. LVN 3 stated the outgoing nurse did not mention Resident 20's lactulose medication was not available and if pharmacy was notified of medication not being available. LVN 3 stated she notified the Director of Nursing (DON) and the DON called the Medical Doctor (MD) to inform of medication not available to administer to Resident 20. LVN 3 stated DON called pharmacy to deliver medication. During an interview on 5/17/24 at 10:30 a.m. with the DON, DON stated licensed nurses were responsible in making sure they were ordering residents' medications from the pharmacy and available for administration. The DON stated the licensed nurse who administered the last dose should have followed up with the pharmacy. The DON stated Resident 20's missed medication was for her constipation and if not given as ordered it could lead to more serious health conditions. During a review of facility's policy and procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy Provider Ordering and Receiving Non-Controlled Medications, dated 01/22, the P&P indicated, . All medications shall be reordered in advanced by writing the medication name and prescription number . Timely delivery . is required so that medication administration is not delayed .

Based on observation, interview and record review, the facility failed to ensure the appropriate food texture was provided for one of six sampled residents (Resident 11) when Resident 11 did not received large portions finger foods as ordered. This failure placed Resident 11 at risk for weight loss due to not being able to utilize utensils. Findings: During a concurrent observation, interview and record review on 5/13/24 at 12:13 p.m. with Certified Nursing Assistant (CNA) 1 in the dining room, Resident 11 was observed eating lunch. In Resident 11's plate, there were two whole pieces of chicken breast, steamed rice, cut up broccoli and fruit cobbler in a dessert bowl. Review of meal tray ticket indicated, .Large Portions FINGER FOODS . CNA 1 stated she served the tray to Resident 11 and did not know Resident 11's diet was regular finger foods. CNA 1 stated she did not check the food in the tray when she served the food to Resident 11 because the licensed nurse already checked the tray and did not find any mistake. CNA 1 stated CNAs were supposed to check foods, comparing the food with the meal tray ticket prior to serving to residents. CNA 1 stated she should have checked the food when she served it to Resident 11 but she did not. Resident 11 did not answer questions but instead just looked at surveyor. During a record review of Resident 11's Admission Record (AR-document with resident demographic and medical diagnosis information), dated 5/16/24, the AR indicated, Resident 11 was readmitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis) and hemiparesis (one-sided weakness), dysphagia (difficulty swallowing). During a review of Resident 11's Order Summary Report (OSR) dated 5/16/24, the OSR indicated, . Regular diet Finger Food Texture .Order Date 3/22/24 . During an interview on 5/13/24 at 12:30 p.m. with Rehabilitative Nurse Assistant (RNA) in the dining room, RNA stated licensed nurses were supposed to check the food consistency making sure it was correct and CNAs picks up the tray and served to residents. RNA stated finger foods were foods that can be picked up using the fingers and not using any utensils. RNA stated she did not think Resident 11's food was considered finger foods. During a concurrent interview and record review on 5/13/24, at 12:37 p.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed the meal ticket of Resident 11 and observed the foods placed in front of Resident 11 and she stated the foods was not finger foods. MDSN stated finger foods were foods that can be picked up without using utensils. MDSN stated Resident 11's diet was changed to finger food on 3/22/24 because he did not have a good grip on the utensils to bring the food to his mouth. MDSN stated Resident 11 could lose more weight when not served the correct diet consistency. During an interview on 5/14/24, at 10:43 a.m. with Registered Dietitian (RD), RD stated she went in the facility once a week and available on phone as needed. RD stated Resident 11 was switched to finger food because he did not like the chopped up food and did not want staff cutting up his food. RD stated not following Resident 11's diet consistency could lead to weight loss because of his inability to feed self so he was eating less food. During an interview on 5/17/24, at 10:15 a.m. with the Director of Nursing (DON), DON stated dietary and nursing staff should be making sure residents were receiving the correct diet ordered. DON stated there was no reasons for Resident 11's diet not to be corrected before it reached resident. DON stated the checking started in the kitchen then the licensed nurse checked and compared the meal tray ticket and the CNAs when they bring the food in front of Resident 11. During an interview on 5/17/24 at 11:29 a.m. with the Dietary Services Manager (DSM), the DSM stated all residents' diet should be followed. The DSM stated the practice was; cook read the diet slip and put food in the plate, the licensed nurse checked and compared the diet consistency with the diet tray slip and the CNAs checked the food consistency when they placed the food in front of residents. The DSM stated Resident 11's diet order was large portion finger foods. The DSM stated Resident 11 did not received the correct diet consistency for lunch on 5/13/24. Review of facility's policy and procedure (P&P) titled, Food and Nutrition Services, dated 10/17, the P&P indicated, . The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs . A resident-centered diet and nutritional plan will be based on this assessment . Food and nutrition services staff will inspect food trays to ensure the correct meal is provided to each resident .

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for one of five sampled residents (Resident 34) when brown-colored, fecal stains and remnants (remaining, small amount) was found on the toilet and toilet seat in Resident 34's bathroom. This failure had the potential of cross-contamination from one resident to another. Findings: During an interview on 5/13/24 at 7:52 a.m. with Resident 34 in his room, Resident 34 stated his bathroom was dirty with feces and urine. Resident 34 stated, when other residents use the bathrooms; there were remnants of feces and urine. Resident 34 stated, he did not feel comfortable in using the bathroom due to the issues with cleanliness. During an observation on 5/13/24 at 8:07 a.m. in Resident 34's room, fecal matter was observed smeared on the toilet seat and toilet bowl in Resident 34's bathroom. During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) Section C, dated 02/25/24 was reviewed. The MDS Section C indicated Resident 34 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 34 was cognitively intact. During a concurrent observation and interview on 5/13/24 at 8:10 a.m. with the Director of Nursing (DON) in Resident 34's bathroom, the DON stated, the stains and remnants on the toilet seat and bowl were fecal matter and toilet needed to be cleaned. The DON stated the dirty toilet was an infection control issue. During a concurrent observation and interview on 5/13/24 at 8:14 a.m. with the Infection Preventionist (IP-are professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections) Nurse in Resident 34's bathroom, the IP validated the brown stain on the toilet and toilet seat were fecal stains and should be cleaned. The IP stated the unclean toilet was an infection control issue. The IP stated, diseases such as CDIFF (clostridium difficile- a bacteria that causes an infection of the colon), Hepatitis C (a virus that causes inflammation of the liver), and other pathogens (disease causing microorganisms [microscopic animals]) could be transmitted to other residents from the fecal matter. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program dated 2024, the P&P indicated, .This facility has established and maintains infection prevention and control .designed to provide a .sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility . During a review of the facility's P&P titled, Safe and Homelike Environment, dated 2023, the P&P indicated, .the facility will provide a safe, clean, and comfortable .environment .Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the resident's .bathrooms .Sanitary includes .preventing the spread of disease causing organisms by keeping resident equipment clean .includes, but not limited to, equipment used in the completion of the activities of daily living . During a review of the facility's P&P titled, Routine Cleaning and Disinfection, dated 2023, the P&P indicated, .it is the policy of this facility to ensure .routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections .Cleaning refers to the removal of visible soil from objects and surfaces .Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces .to include .toilet seats .

Based on observation and interview during the survey period of 5/13/24 to 5/17/24, the facility failed to provide and maintain minimum square footage for each resident in 12 of 19 rooms (Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19). Findings: During an observation of the facility on 5/13/24 to 5/17/24, the following rooms did not provide the minimum square footage as required by the regulation: Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19. The residents had reasonable amount of privacy. Closets and storage spaces were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Room # Square Feet # Residents 7 203.7 3 8 210.2 3 9 213.3 3 10 209.1 3 11 203.2 3 12 209.5 3 13 154.0 2 14 152.4 2 15 159.2 2 16 158.2 2 17 154.9 2 19 154.7 2 Recommend waiver continue in effect. _______________________________ Health Facility Evaluator Nurse / Date Request continuance of waiver. ________________________ Administrator Signature / Date

Based on observation, interview and record review, the facility failed to implement care plan intervention for one of seven sampled residents (Resident 1), when the facility did not provide continuous monitoring as indicated in Residnt1 ' s care plan and Resident 1 eloped (left the health care facility unsupervised and undetected) from the facility on 9/23/23. This failure resulted in Resident 1 leaving the facility unsupervised and had a potential for accident which could lead to serious injury. Findings: During a review of Resident 1 ' s Admission Record (AR-a document with personal identifiable and medical information), dated 11/2/23, the AR indicated, Resident 1 was admitted in the facility on 4/25/23, with diagnosis which included dementia (loss of cognitive functioning- thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities ), depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities), anxiety (a feeling of fear, dread, and uneasiness) and muscle weakness. During an interview on 11/2/23 at 3:38 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated if a resident has a sitter, then the sitter must be with the resident the entire time. During an interview on 11/2/23 at 4:16 p.m. with Licensed Vocational Nurse Infection Control (LVN/IC), LVN/IC stated, Resident 1 was initially on every 15-minute observation due to Resident 1 ' s history of wandering but was changed to 1:1 (continuous observation provided by healthcare worker) due to history of elopements. LVN/IC stated CNAs are not supposed leave the resident they are watching if the resident was on a 1:1. LVN/IC stated there should not be a lapse in monitoring. LVN/IC stated it ' s important that they keep constant supervision so resident cannot get away. LVN/IC stated Resident 1 had history of wandering and had noticed trying to leave the facility. During an interview on 11/2/23 at 5:20 p.m. with Administrator (ADM), the ADM stated, Resident 1 was on 1:1 at the time of the elopement on 9/23/23. ADM stated if CNAs are assigned to watch a resident on 1:1, they (CNAs) cannot leave the resident unattended. The ADM stated this was important, so the resident would not elope. ADM stated when a resident is on 1:1 it meant the staff knew exactly what the resident was doing or where they were. ADM stated it was important to constantly watch Resident 1, You don ' t want the resident to elope. During an interview on 11/2/23 at 5:25 p.m. with the DON, the DON stated, Resident 1 was able to elope because at the time of the incident, even though the Resident 1 was on 1:1, a code blue (patient requiring resuscitation or needs immediate medical attention) happened and a lot of the staff helped with the code blue. DON stated the CNA who was monitoring resident 1 left Resident 1 unsupervised, and he was able to leave the facility unsupervised. The DON stated the CNA should have stayed with Resident 1. DON stated the expectations were not to leave the resident alone at any time when Resident is on 1:1. During a phone interview on 1/3/24 at 1:33 p.m. with the DON, the DON stated, the resident will always have somebody with him since he was on 1:1. During a concurrent record review and interview on 1/3/23 at 1345 p.m., with DON, facility ' s 1:1 CNA/STAFF watch or Q15 Monitor Sheet (MS), dated 9/23/23 was reviewed. There were missing documentation of the resident ' s whereabouts starting from 7am to 10 a.m. The DON stated, There was a code blue, and everyone went to help, he (resident) was already awake during the code blue. During a concurrent record review and interview on 1/3/23 at 1400 p.m. of the resident ' s Care Plans (CP) undated, the CP indicated, .is high risk for elopement r/t to cognitive status .Resident will be on 1:1 continues and while awake. Resident has a sitter schedule every day. The DON stated, the 1:1 intervention was added on 9/25/23 by the MDS/DSD for the undated CP. The DON stated, the CP was initiated on 4/27/23, the date does not show when printed. During a review of the facility ' s policy and procedure (P&P) titled, Elopement and Wandering Residents, dated 2023, the PP indicated, .Policy: this facility ensures that resident who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Staff are to be vigilant in responding to alarms in a timely manner .adequate supervision will be provided to help prevent accidents or elopements . During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents dated 7/2017, the P&P indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently .Systems Approach to Safety .2. Resident supervision is a core component of the systems approach to safety The type and frequency of resident supervision is determined by the individual resident ' s assessed needs .Resident Risks and Environmental Hazards .e. unsafe wandering .

Based on observation, interview and record review, the facility failed to ensure each resident was free from sexual abuse for one of three sampled residents (Resident 15) when on two separate occasions (3/25/19 and 4/3/19) Resident 38 without permission grabbed Resident 15's breasts in the hallway of the facility. For Resident 15, the facility failed to protect her from sexual abuse from Resident 38 on 4/3/19, ten days after a previous incident of sexual abuse occurred on 3/25/19 with Resident 38. This failure had the potential to impact the physical and mental well-being of Resident 15 by increasing her anxiety and depression from potential feelings of disrespect and violation of her personal body space. Findings: During an observation in the dining room, on 4/5/19, at 12:39 p.m., Resident 15 was sitting in a reclining wheelchair and being assisted by a Certified Nursing Assistant (CNA) with her lunch meal. The CNA was speaking in Spanish to Resident 15. Resident 15 did not engage in conversation with the CNA. During an observation in Resident 38's room, on 4/5/19, at 12:46 p.m., Resident 38 was sitting in bed with the head of the bed elevated up. CNA 2 interpreted for Resident 38 in the Spanish language. Resident 38 stated what his name was. Resident 38 stated he did not know who Resident 15 was. Resident 38 did not know what happened on 4/3/19. During an interview with CNA 3, on 4/5/19, at 12:53 p.m., she stated on 4/3/19 at about 11:20 a.m., she was walking to B Hall when she saw Resident 38 grab Resident 15's breasts from behind. CNA 3 stated Resident 15 was directly outside her room in the hallway at the time of the incident. CNA 3 stated Resident 38 was in his wheelchair behind Resident 15 when he reached around and grabbed her breasts. CNA 3 stated Resident 38 let go of Resident 15 when he saw CNA 3. CNA 3 stated she separated the residents immediately and reported the incident to the charge nurse. CNA 3 stated Resident 38 told her, I didn't do nothing after the incident occurred. CNA 3 stated on the day of the incident on 4/3/19, Resident 15's room was located right next door to Resident 38. CNA 3 stated the incident on 4/3/19 was the second time Resident 38 grabbed Resident 15's breasts. CNA 3 stated she was not at work in the facility on the day the first incident occurred and did not know the details of the first incident. CNA 3 stated Resident 38 had behaviors of making sexual comments to staff since his admission to the facility. CNA 3 stated Resident 38 had not made sexual comments to residents in the facility. CNA 3 stated Resident 38 would respond to verbal cueing to stop making sexual comments to staff. CNA 3 stated she had not witnessed any other incidents with Resident 38 and other residents in the facility. CNA 3 stated Resident 15 was not able to understand commands and would mumble words in Spanish. CNA 3 stated Resident 15 sometimes would yell out of nowhere random words in Spanish. CNA 3 stated Resident 15 needed total assistance with activities of daily living (ADLs). CNA 3 stated Resident 15 was not able to move herself in her wheelchair. CNA 3 stated the interventions made after the 4/3/19 incident was to keep an eye on Resident 38 at all times by keeping him involved in activities. CNA 3 stated the interventions implemented for Resident 15 consisted of keeping her at the nurses' station and taking her to activity programs when Resident 38 was not in the activities room. During a review of the clinical record for Resident 15, the Nurses Notes dated 4/3/19 at 2:15 p.m., indicated, . CNA stated that she witnessed the act [grabbing Resident 15's breasts] while transferring [mechanical lift] from one side of the facility to the other. Once the CNA saw the male resident during the act the male resident lowered his hands and broke eye contact. When the CNA asked the male resident what he was doing, he responded with 'nothing' and male resident wheeled himself away. The CNA separated the residents and the CNA told the charge nurse of the incident .Put both residents on Q [every] 15 [minute] checks . During an interview with CNA 4, on 4/5/19, at 1:34 p.m., she stated Resident 15 was moved to a different room on 4/4/19 [further away from Resident 38's room]. CNA 4 stated she was told by another CNA about the incident on 4/3/19. CNA 4 stated she was told by the licensed nurses to keep Resident 38 away from Resident 15. CNA 4 stated Resident 38 had behaviors of making sexual comments to staff. CNA 4 stated she had not seen Resident 38 make sexual comments towards residents. CNA 4 stated Resident 38 was able to propel himself in his wheelchair and understood his actions. CNA 4 stated Resident 15 was not able to understand actions of others. CNA 4 stated Resident 15 would scream or make cat noises or hiss. CNA 4 stated when staff would check on Resident 15, she would look up and stay quiet. CNA 4 stated the interventions implemented after 4/3/19 was for staff to do checks every 15 minutes on Resident 38 and to have Resident 15 in an area where staff could see her. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 4/5/19, at 2:37 p.m., she stated this was the second time Resident 38 grabbed Resident 15's breasts. LVN 2 stated Resident 38 was placed on every 15-minute monitoring since the first incident on 3/25/19. LVN 2 stated every 15-minute monitoring was completed by the CNAs. LVN 2 stated the CNAs documented the time and place of the resident in 15 minute intervals. LVN 2 reviewed the care plan for Resident 38 and stated the interventions after the incident on 3/25/19 were to keep the resident separated, alert charting of the resident's status for 72 hours [nurses would document every shift on the status], every 15-minute monitoring of Resident 38, and to redirect residents to other areas or interests. LVN 2 stated Resident 15 was kept at the nurses' station and Resident 38 was kept in activities. During an observation in Resident 15's room, on 4/5/19, at 3:02 p.m., Resident 15 was lying in bed. Resident 15 was mumbling sounds and did not respond to questions. During an interview with the Social Services Director (SSD), on 4/5/19, at 3:08 p.m., he stated the Interdisciplinary Team (IDT, a group of professionals including the Director of Nurses (DON), SSD, Director of Staff Development, Minimum Data Set Coordinator (MDSC) (MDS-an assessment of cognitive and functional abilities), and physician to review a resident's plan of care) determined the best solution was to keep the residents apart from each other after the incident on 4/3/19. The SSD stated when Resident 38 was interviewed regarding the incidents, Resident 38 denied anything happening between Resident 15 and himself. The SSD stated Resident 38 was alert and oriented and was able to understand others. The SSD stated the incident between Resident 15 and Resident 38 had happened twice. The SSD stated staff need to be vigilant all the time to prevent another incident from occurring. During a concurrent interview and record review with the DON, on 4/5/19, at 3:46 p.m., she stated the incident between Resident 15 and Resident 38 occurred on 4/3/19 at 11:20 a.m. The DON stated the inappropriate touching of a resident was a new behavior for Resident 38. The DON stated Resident 38's new behavior of touching other residents was going to be a problem since this was the second time this occurred. During a concurrent interview and record review with the MDSC, on 4/5/19, at 4:08 p.m., she reviewed Resident 15's care plans and stated the new intervention for Resident 15 was to provide a room change. The MDSC stated the room change did not happen until 4/4/19, one day after the incident occurred on 4/3/19. The MDSC stated the room Resident 15 was moved to was in a hallway that did not lead to anywhere in the facility where Resident 38 would have to pass through. The MDSC stated the second incident could have been prevented if Resident 15 was moved after the first incident on 3/25/19. During a review of the clinical record for Resident 15, the Admission Record dated 4/5/19, indicated Resident 15 had diagnoses of aphasia (inability to comprehend language caused by a stroke), dementia (long term and gradual decrease in the ability to think and comprehend), and anxiety (exaggerated feeling of worry and fear). During a review of the clinical record for Resident 15, the MDS assessment under section B dated 3/11/19, indicated, Resident 15 rarely understood verbal content. Under section C, Resident 15 was assessed to be severely impaired with cognitive skills for making daily decisions. During a review of the clinical record for Resident 38, the Admission Record dated 4/5/19, indicated Resident 38 had diagnoses of anxiety and depression (feeling of sadness, loss, or anger). During a review of the clinical record of Resident 38, the MDS assessment under section B dated 1/21/19, indicated Resident 38 understood verbal content. Under section C, Resident 38 was assessed with moderate cognitive impairment. The facility policy and procedure titled, Abuse and Neglect- Clinical Protocol dated 3/18, indicated . 3. Sexual Abuse is defined .as non-consensual sexual contact of any type with a resident. Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with physician support, will address situations of suspected or identified abuse .

Based on observation, interview and record review, the facility failed to ensure each resident was free from sexual abuse for one of three sampled residents (Resident 15) when on two separate occasions (3/25/19 and 4/3/19) Resident 38 without permission grabbed Resident 15's breasts in the hallway of the facility. For Resident 15, the facility failed to protect her from sexual abuse from Resident 38 on 4/3/19, ten days after a previous incident of sexual abuse occurred on 3/25/19 with Resident 38. This failure had the potential to impact the physical and mental well-being of Resident 15 by increasing her anxiety and depression from potential feelings of disrespect and violation of her personal body space. Findings: During an observation in the dining room, on 4/5/19, at 12:39 p.m., Resident 15 was sitting in a reclining wheelchair and being assisted by a Certified Nursing Assistant (CNA) with her lunch meal. The CNA was speaking in Spanish to Resident 15. Resident 15 did not engage in conversation with the CNA. During an observation in Resident 38's room, on 4/5/19, at 12:46 p.m., Resident 38 was sitting in bed with the head of the bed elevated up. CNA 2 interpreted for Resident 38 in the Spanish language. Resident 38 stated what his name was. Resident 38 stated he did not know who Resident 15 was. Resident 38 did not know what happened on 4/3/19. During an interview with CNA 3, on 4/5/19, at 12:53 p.m., she stated on 4/3/19 at about 11:20 a.m., she was walking to B Hall when she saw Resident 38 grab Resident 15's breasts from behind. CNA 3 stated Resident 15 was directly outside her room in the hallway at the time of the incident. CNA 3 stated Resident 38 was in his wheelchair behind Resident 15 when he reached around and grabbed her breasts. CNA 3 stated Resident 38 let go of Resident 15 when he saw CNA 3. CNA 3 stated she separated the residents immediately and reported the incident to the charge nurse. CNA 3 stated Resident 38 told her, I didn't do nothing after the incident occurred. CNA 3 stated on the day of the incident on 4/3/19, Resident 15's room was located right next door to Resident 38. CNA 3 stated the incident on 4/3/19 was the second time Resident 38 grabbed Resident 15's breasts. CNA 3 stated she was not at work in the facility on the day the first incident occurred and did not know the details of the first incident. CNA 3 stated Resident 38 had behaviors of making sexual comments to staff since his admission to the facility. CNA 3 stated Resident 38 had not made sexual comments to residents in the facility. CNA 3 stated Resident 38 would respond to verbal cueing to stop making sexual comments to staff. CNA 3 stated she had not witnessed any other incidents with Resident 38 and other residents in the facility. CNA 3 stated Resident 15 was not able to understand commands and would mumble words in Spanish. CNA 3 stated Resident 15 sometimes would yell out of nowhere random words in Spanish. CNA 3 stated Resident 15 needed total assistance with activities of daily living (ADLs). CNA 3 stated Resident 15 was not able to move herself in her wheelchair. CNA 3 stated the interventions made after the 4/3/19 incident was to keep an eye on Resident 38 at all times by keeping him involved in activities. CNA 3 stated the interventions implemented for Resident 15 consisted of keeping her at the nurses' station and taking her to activity programs when Resident 38 was not in the activities room. During a review of the clinical record for Resident 15, the Nurses Notes dated 4/3/19 at 2:15 p.m., indicated, . CNA stated that she witnessed the act [grabbing Resident 15's breasts] while transferring [mechanical lift] from one side of the facility to the other. Once the CNA saw the male resident during the act the male resident lowered his hands and broke eye contact. When the CNA asked the male resident what he was doing, he responded with 'nothing' and male resident wheeled himself away. The CNA separated the residents and the CNA told the charge nurse of the incident .Put both residents on Q [every] 15 [minute] checks . During an interview with CNA 4, on 4/5/19, at 1:34 p.m., she stated Resident 15 was moved to a different room on 4/4/19 [further away from Resident 38's room]. CNA 4 stated she was told by another CNA about the incident on 4/3/19. CNA 4 stated she was told by the licensed nurses to keep Resident 38 away from Resident 15. CNA 4 stated Resident 38 had behaviors of making sexual comments to staff. CNA 4 stated she had not seen Resident 38 make sexual comments towards residents. CNA 4 stated Resident 38 was able to propel himself in his wheelchair and understood his actions. CNA 4 stated Resident 15 was not able to understand actions of others. CNA 4 stated Resident 15 would scream or make cat noises or hiss. CNA 4 stated when staff would check on Resident 15, she would look up and stay quiet. CNA 4 stated the interventions implemented after 4/3/19 was for staff to do checks every 15 minutes on Resident 38 and to have Resident 15 in an area where staff could see her. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 4/5/19, at 2:37 p.m., she stated this was the second time Resident 38 grabbed Resident 15's breasts. LVN 2 stated Resident 38 was placed on every 15-minute monitoring since the first incident on 3/25/19. LVN 2 stated every 15-minute monitoring was completed by the CNAs. LVN 2 stated the CNAs documented the time and place of the resident in 15 minute intervals. LVN 2 reviewed the care plan for Resident 38 and stated the interventions after the incident on 3/25/19 were to keep the resident separated, alert charting of the resident's status for 72 hours [nurses would document every shift on the status], every 15-minute monitoring of Resident 38, and to redirect residents to other areas or interests. LVN 2 stated Resident 15 was kept at the nurses' station and Resident 38 was kept in activities. During an observation in Resident 15's room, on 4/5/19, at 3:02 p.m., Resident 15 was lying in bed. Resident 15 was mumbling sounds and did not respond to questions. During an interview with the Social Services Director (SSD), on 4/5/19, at 3:08 p.m., he stated the Interdisciplinary Team (IDT, a group of professionals including the Director of Nurses (DON), SSD, Director of Staff Development, Minimum Data Set Coordinator (MDSC) (MDS-an assessment of cognitive and functional abilities), and physician to review a resident's plan of care) determined the best solution was to keep the residents apart from each other after the incident on 4/3/19. The SSD stated when Resident 38 was interviewed regarding the incidents, Resident 38 denied anything happening between Resident 15 and himself. The SSD stated Resident 38 was alert and oriented and was able to understand others. The SSD stated the incident between Resident 15 and Resident 38 had happened twice. The SSD stated staff need to be vigilant all the time to prevent another incident from occurring. During a concurrent interview and record review with the DON, on 4/5/19, at 3:46 p.m., she stated the incident between Resident 15 and Resident 38 occurred on 4/3/19 at 11:20 a.m. The DON stated the inappropriate touching of a resident was a new behavior for Resident 38. The DON stated Resident 38's new behavior of touching other residents was going to be a problem since this was the second time this occurred. During a concurrent interview and record review with the MDSC, on 4/5/19, at 4:08 p.m., she reviewed Resident 15's care plans and stated the new intervention for Resident 15 was to provide a room change. The MDSC stated the room change did not happen until 4/4/19, one day after the incident occurred on 4/3/19. The MDSC stated the room Resident 15 was moved to was in a hallway that did not lead to anywhere in the facility where Resident 38 would have to pass through. The MDSC stated the second incident could have been prevented if Resident 15 was moved after the first incident on 3/25/19. During a review of the clinical record for Resident 15, the admission Record dated 4/5/19, indicated Resident 15 had diagnoses of aphasia (inability to comprehend language caused by a stroke), dementia (long term and gradual decrease in the ability to think and comprehend), and anxiety (exaggerated feeling of worry and fear). During a review of the clinical record for Resident 15, the MDS assessment under section B dated 3/11/19, indicated, Resident 15 rarely understood verbal content. Under section C, Resident 15 was assessed to be severely impaired with cognitive skills for making daily decisions. During a review of the clinical record for Resident 38, the admission Record dated 4/5/19, indicated Resident 38 had diagnoses of anxiety and depression (feeling of sadness, loss, or anger). During a review of the clinical record of Resident 38, the MDS assessment under section B dated 1/21/19, indicated Resident 38 understood verbal content. Under section C, Resident 38 was assessed with moderate cognitive impairment. The facility policy and procedure titled, Abuse and Neglect- Clinical Protocol dated 3/18, indicated . 3. Sexual Abuse is defined .as non-consensual sexual contact of any type with a resident. Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with physician support, will address situations of suspected or identified abuse .