Every finding on record at Georgiana Health and Rehabilitation, LLC

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure that each resident was free from abuse for 4 (Residents #42, #61, #68, and #82) of 7 residents reviewed for abuse and failed to ensure that each resident was free from neglect for 1 (Resident #79) of 5 residents reviewed for neglect.Findings included: A facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, effective 05/01/2023, revealed, All of our resident/guest(s) have the right to be free from abuse, neglect, exploitation and misappropriation of resident/guest property. The policy indicated the definition of neglect as, Neglect is a failure of the facility or its employees or service providers to provide goods and services necessary, to attain or maintain physical, mental, and psychosocial well-being to avoid physical harm, mental anguish, or emotional stress when the facility knew or should have known to provide the goods and or services but continued to fail to take actions necessary. Neglect may include, but is not limited to: leaving resident/guest to sit or lie in urine or feces without appropriately intervening, isolating dependent resident/ guest(s) by leaving them in their rooms or other isolated locations (apart from temporary separation occurring in the context of assessment and care planning), deliberate failure to answer call bells to provide needed assistance and performing one person assistance to transfer a resident/ guest when care planned for two person. 1. A Resident Face Sheet indicated the facility admitted Resident #68 on 09/24/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia of unspecified severity with other behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, schizoaffective disorder, and adjustment disorder with depressed mood. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/21/2026, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #68 received antipsychotic and anti-depressant medications during the last seven days. A Resident Face Sheet indicated the facility admitted Resident #42 on 09/16/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of acute myocardial infarction (heart attack) and chronic ischemic heart disease. An annual MDS, with an ARD of 10/02/2025, revealed Resident #42 had a BIMS score of 13, which indicated the resident had intact cognition. Resident #42's Care Plan included a problem area, started 09/17/2024, that indicated the resident exhibited behaviors related to a psychological disorder including: adjustment disorder, hitting other residents, cursing, snapping fingers in other residents' ears, slapping hands on the backs of chairs of other residents, and refusing to take baths. A facility document titled, Alabama Department of Public Health Online Incident Reporting System, dated 09/22/2025 at 5:00 PM, revealed an incident of resident-to-resident Abuse -Physical that occurred on 09/22/2025 at 4:20 PM. The Incident Report indicated that, while sitting in the lobby on the love seat next to Resident #42, Resident #68 told Resident #42 to stop tapping on the side of the love seat. The Incident Report indicated that when Resident #42 did not stop tapping, Resident #68 hit Resident #42 in the face and hand. The Incident Report indicated that Resident #68 was placed on one-on-one observation until Resident #68 was transferred to the emergency room. A facility document titled Verification of Investigation with an incident date of 09/22/2025 at 4:20 PM, indicated that during an interview with the Director of Nursing (DON), Resident #68 stated that they hit Resident #42 because Resident #42 talked too much, and Resident #68 would do it again. During an interview on 08/27/2026 at 11:42 AM, the Family Practice Physician/Medical Director (Physician) stated that the facility had multiple residents with behavioral needs who got into fights. The Physician stated the process was to send the resident out to the behavioral unit for evaluation if they became aggressive and unmanageable. The Physician stated that Resident #68 had true mental health issues and was very angry. The Physician stated that Resident #68 had had medication adjustments with no real changes, with staff monitoring in place. The Physician stated that the county did not have any facilities for the behavioral or mental illness. During an interview on 08/27/2026 at 2:14 PM, the DON stated that on 09/22/2025 Resident #68 hit Resident #42 in the face. The DON stated that the aggression was unprovoked, and that Resident #68 was immediately placed on one-on-one observation until they were transported to the hospital. The DON stated that Resident #68's physical aggression to other residents was situational, with no warning signs. The DON stated that her expectation was that all residents were free from abuse, including resident-to-resident abuse. During an interview on 08/28/2026 at 4:07 PM, the Administrator (ADM) stated that his expectation was that all residents be free from abuse. The ADM stated that the facility was working on residents' mental health needs. 2. A Resident Face Sheet indicated the facility admitted Resident #68 on 09/24/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia of unspecified severity with other behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, schizoaffective disorder, and adjustment disorder with depressed mood. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/21/2026, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #68 received antipsychotic and anti-depressant medications during the last seven days. A Resident Face Sheet indicated the facility admitted Resident #61 on 10/25/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Alzheimer's disease, dementia of unspecified severity with agitation, and anxiety disorder due to known physiological condition. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2025, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #61's Care Plan included a problem statement, initiated 11/24/2025, that indicated the resident exhibited behaviors as evidenced by being aggressive to staff members, altercation with another resident, hitting other residents, and hitting their roommate in the face. Interventions directed staff to approach the wandering resident in a positive, calm, and accepting manner (initiated 11/24/2025); discuss options for appropriate channeling of anger (initiated 11/24/2025); do not argue with the resident (initiated 11/24/2025); identify causes for behaviors and reduce factors that may provoke behaviors (initiated 11/24/2025); provide medication as ordered (initiated 11/24/2025); observe and document target behaviors (initiated 11/24/2025); and place the resident in an area where frequent observation was possible (initiated 11/24/2025). A facility document titled, Event Report, dated 11/26/2025, revealed on 11/23/2025 at 3:45 PM Resident #61 pushed another resident down on the floor during an argument. The Event Report indicated that Resident #68 was placed on one-on-one observation (one staff member monitoring one resident) and received a referral for evaluation. The Event Report indicated that Resident #61 was placed in another room. A facility document titled, Alabama Department of Public Health Online Incident Reporting System, dated 11/23/2025 at 4:49 PM, revealed an incident of resident-to-resident Abuse - Physical that occurred on 11/23/2025 at 3:35 PM. The Incident Report revealed that Resident #61 was using the adjoined bathroom with both doors locked, and Resident #68 tried to get into the bathroom and became angry. The Incident Report revealed when Resident #61 exited the bathroom that Resident #68 grabbed Resident #61. The Incident Report revealed that Resident #61 removed Resident #68's hands off of Resident #61 and pulled Resident #68 to the floor. A facility document titled Verification of Investigation, with an incident date of 11/23/2025 at 3:35 PM, indicated that during an interview Certified Nursing Assistant (CNA) #25 reported that Resident #68 left Resident #68's room and entered Resident #61's room to check the bathroom door, and Resident #61 was in the bathroom with the door locked. The Verification of Investigation revealed that CNA #25 stated that when Resident #61 opened the door, Resident #68 got into Resident #61's face and started arguing, the two residents began to tussle, Resident #61 pushed Resident #68 to the floor, Resident #68 got up and continued to argue with Resident #61, and a staff member intervened and separated the residents. During an interview on 08/26/2026 at 9:10 AM, CNA #25 stated that she saw Resident #68 enter the room and bang on the bathroom door. CNA #25 stated Resident #61 from the adjoining room was using the bathroom and had both doors locked. CNA #25 stated that Resident #68 went around to Resident #61's room and the bathroom door was locked, and Resident #68 began banging on the bathroom door. CNA #25 stated that Resident #61 opened the bathroom door and Resident #68 pushed Resident #61, and Resident #61 pushed Resident #68 to the ground. CNA #25 stated Resident #68 got up off the floor and tried to fight Resident #61. CNA #25 stated staff separated the residents, put Resident #68 on one-on-one observation, and then sent Resident #68 out to the hospital. During an interview on 08/25/2026 at 4:10 PM, Licensed Practical Nurse (LPN) #26 stated that she remembered running to respond to a commotion and saw Resident #68 in Resident #61's room, banging on the bathroom door. LPN #26 stated she saw Resident #61 exit the bathroom, and Resident #68 was aggressive and pushed Resident #61. LPN #26 stated Resident #61 then pushed Resident #68, and Resident #68 fell to the ground. LPN #26 stated that Resident #68 got back up, was still aggressive, and wanted to fight. During an interview on 08/27/2026 at 11:42 AM, the Family Practice Physician/Medical Director (Physician) stated that the facility had multiple residents with behavioral needs who got into fights. The Physician stated the process was to send the resident out to the behavioral unit for evaluation if they became aggressive and unmanageable. The Physician stated that Resident #68 had true mental health issues and was very angry. The Physician stated that Resident #68 had had medication adjustments with no real changes, with staff monitoring in place. The Physician stated that Resident #61 had been his patient for many years, even prior to admission, and had a history of physical aggression toward others. The Physician stated that the county did not have any facilities for the behavioral or mental illness. During an interview on 08/28/2026 at 2:35 PM, the Director of Nursing (DON) stated that the residents had adjoining rooms and a shared bathroom. The DON stated that when Resident #61 used the bathroom, they locked both doors. The DON stated that Resident #68 went to Resident #61's side of the room and grabbed Resident #61, who responded by pushing Resident #68 off them and to the floor. The DON stated Resident #68 got up and tried to continue to fight. The DON stated that immediately Resident #68 was put on one-on-one observation until the resident was sent out to the hospital for evaluation. The DON stated that her expectation was that all residents were free from abuse, including resident-to-resident abuse. During an interview on 08/28/2026 at 4:07 PM, the Administrator (ADM) stated that his expectation was that all residents be free from abuse. The ADM stated that the facility was working on residents' mental health needs. 3. A Resident Face Sheet indicated the facility admitted Resident #61 on 10/25/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Alzheimer's disease, dementia, unspecified severity, with agitation, and anxiety disorder due to known physiological condition. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2025, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #61's Care Plan included a problem statement, initiated 11/24/2025, that indicated the resident exhibited behaviors as evidenced by being aggressive to staff members, altercation with another resident, hitting other residents, and hitting their roommate in the face. Interventions directed staff to approach the wandering resident in a positive, calm, and accepting manner (initiated 11/24/2025); discuss options for appropriate channeling of anger (initiated 11/24/2025); do not argue with the resident initiated (11/24/2025); identify causes for behaviors and reduce factors that may provoke behaviors (initiated 11/24/2025); provide medication as ordered (initiated 11/24/2025); observe and document target behaviors (initiated 11/24/2025); and place the resident in an area where frequent observation was possible (initiated 11/24/2025). A Resident Face Sheet indicated the facility admitted Resident #82 on 08/10/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of type II diabetes mellitus without complications and bipolar disorder. A quarterly MDS, with an ARD of 11/04/2025, revealed Resident #82 had a BIMS score of 13, which indicated the resident had intact cognition. Resident #82's Care Plan included a problem statement, initiated on 08/12/2025, that indicated the resident had a potential for behaviors related to mood disorder. Interventions directed staff to allow the resident opportunities to make choices and participate in care, approach wandering resident in a positive, calm, and accepting manner, and discuss options for appropriate channeling of anger. A document titled, Alabama Department of Public Health Online Incident Reporting System, dated 11/25/2025 that revealed an incident that occurred between Resident #61 and Resident #82 at 4:10 PM. The document indicated that Resident #61 became angry with their roommate (Resident #82) stating that Resident #82 was messing up the restroom. According to the document, staff moved Resident #61 to a new room, but Resident #61 went back to their prior room after about 15 minutes and hit Resident #82. During an interview on 08/25/2026 at 1:10 PM, Certified Nursing Assistant (CNA) #27 stated that Resident #61 was angry about the bathroom not being kept clean by their roommate, Resident #82. CNA #27 said Resident #61 was moved to room [ROOM NUMBER] but came back down to their previous room and hit Resident #82. CNA #27 said staff separated both residents, and Resident #61 was put on one-on-one staff monitoring and was sent to the hospital. CNA #27 stated that for all resident-to-resident fights staff intervened and separated the residents, put the resident who started the altercation on one-to-one staff monitoring until they were seen by the doctor, and then assessed the residents for any injury. During an interview on 08/27/2026 at 11:42 AM, the Family Practice Physician/Medical Director (Physician) stated that the facility had multiple residents with behavioral needs who got into fights. The Physician stated the process was to send the resident out to the behavioral unit for evaluation if they became aggressive and unmanageable. The Physician stated that Resident #61 had been his patient for many years, even prior to admission, and had a history of physical aggression toward others. The Physician stated that the county did not have any facilities for the behavioral or mental illness. During an interview on 08/28/2026 at 4:35 PM, the Director of Nursing (DON) stated that Resident #61 complained that their roommate kept leaving the bathroom a mess, which was not true. To eliminate the issue, Resident #61 had a room change from room [ROOM NUMBER] to room [ROOM NUMBER]. The DON said, after the move, Resident #61 kept pacing the hallway and suddenly pushed Resident #82's room door open, went into the room, and started punching Resident #82. Staff removed Resident #61, and the resident was placed on one-on-one staff monitoring until the resident was transported to the hospital. The DON stated that her expectation was to educate the residents, be fair with residents, and redirect the residents. She stated that she expected every resident to feel safe. During an interview on 08/28/2026 at 4:21 PM, the Administrator (ADM) stated that his expectation was that all residents would be free from abuse. He said if staff heard of or saw abuse, they were to report to him as the abuse coordinator to ensure the abuse policy and procedure was followed. 4. A Resident Face Sheet indicated the facility admitted Resident #68 on 09/24/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia of unspecified severity with other behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, schizoaffective disorder, and adjustment disorder with depressed mood. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/21/2026, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #68 received antipsychotic and anti-depressant medications during the last seven days. Resident #68's Care Plan included a problem area, started 11/23/2025, that indicated the resident exhibited behaviors related to schizoaffective disorder including: hitting other residents without provocation; grabbing and being aggressive to other residents; becoming agitated when another resident sat in the chair Resident #68 used for meals (08/07/2026). Interventions directed staff to:Immediately separate residents, started 11/23/2025:Refer to behavioral health services, started 11/23/2025;Allow the resident the opportunity to make choices and participate in care, 11/24/2025;Approach the wandering resident in a positive, calm, and accepting manner, started 11/24/2025;Discuss options for appropriate channeling of anger, started 11/24/2025;Do not argue with the resident, started 11/24/2025;Elicit family input for best approaches to resident;Identify causes for behaviors and reduce factors that may provoke behaviors, started 11/24/2025;Provide medication as ordered, started 11/24/2025;Observe and document target behaviors, started 11/24/2025;Place the resident in an area where frequent observation is possible, started 11/24/2025;Provide praise for desired behavior, started 11/24/2025;Provide diversional activities, started 11/24/2025;Refer to Social Services for evaluation, started 11/24/2025;Remove from public area when behavior is disruptive and unacceptable, started 11/24/2025;Talk to in a calm voice when behavior is disruptive, started 11/24/2025;When resident becomes combative, leave and try to approach later, started 11/24/2025;Transfer to the geriatric psychiatric hospital as needed, started 11/25/2025;Provide 1 on 1 [one staff member monitoring one resident] monitoring pending discharge to the hospital, started 08/07/2026; andEncourage the resident to sit in another chair, when a different resident is sitting in the chair that Resident #68 uses in the dining room, started 08/10/2026. A Resident Face Sheet indicated the facility admitted Resident #58 on 10/20/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar type, mood disorder due to known physiological condition with depressive features, insomnia, cocaine abuse, generalized anxiety disorder, and unspecified dementia, unspecified severity, with agitation. An annual MDS, with an ARD of 06/30/2026, revealed Resident #58 had a BIMS score of 13, which indicated the resident had intact cognition. Resident #58's Care Plan included a problem statement dated 08/20/2025, that indicated the resident had the potential for physical behavioral symptoms related to psychological disorders as evidenced by hitting other residents. Interventions directed staff to assess whether the behavior endangered the resident or others and intervene if necessary, avoid over-stimulation, avoid power struggles with the resident, and maintain a calm environment and approach to the resident. A document titled, Verification Of Investigation, dated 08/07/2026, revealed an incident occurred at 5:07 PM that involved Resident #68 and Resident #58. The document indicated Resident #68 was upset that Resident #58 was sitting in Resident #68's chair at the table and Resident #68 attempted to push Resident #58 out of the chair. The document indicated Resident #58 sustained a small scratch on their cheek. During an interview on 08/27/2026 at 11:42 AM, the Family Practice Physician/Medical Director (Physician) stated that the facility had multiple residents with behavioral needs who got into fights. The Physician stated the process was to send the resident out to the behavioral unit for evaluation if they became aggressive and unmanageable. The Physician stated that Resident #68 had true mental health issues and was very angry. The Physician stated that Resident #68 had had medication adjustments with no real changes, with staff monitoring in place. The Physician stated that the county did not have any facilities for the behavioral or mental illness. During an interview on 08/28/2026 at 3:35 PM, the DON stated that the Administrator assisted Resident #58 into a seat in the dining room where Resident #68 usually sat, and Resident #68 became aggressive and hit Resident #58. The DON stated that the Administrator separated the two residents and received orders to place Resident #68 on one-on-one staff monitoring until the resident was transported to the emergency room, while Resident #58 was taken to their room to be assessed and found to have a scratch. The DON stated that her expectation was that no residents were in abusive situations and that residents were not fearful to be in their own home. She stated that she expected that staff engage residents and observe for change in their behavior. The DON stated if an altercation happened, staff were to immediately intervene and separate the two individuals, assess both residents for injuries and pain, place the aggressor on one-on-one staff monitoring until the physician made a determination. The DON said sometimes the residents would be sent to the hospital for an evaluation. During an interview on 08/28/2026 at 4:14 PM, the Administrator (ADM) stated that he was in the dining room assisting with getting residents seated and assisted Resident #58 into a chair so they could watch television. The ADM stated Resident #68 entered the dining room and immediately tried to get Resident #58 out of the chair, stating Resident #58 was in their (Resident #68's) seat, then Resident #68 hit Resident #58 in the face. The ADM stated that he was present and immediately intervened and separated the residents. He said staff redirected Resident #68, placed the resident on one-on-one staff monitoring, and notified the physician. The ADM said the physician gave orders to send Resident #68 to the emergency room for evaluation. He stated that Resident #58 was taken to their room by nursing and given first aid. The ADM stated that his expectation was for all residents to be free from abuse, and if staff heard of or saw abuse, they were to report to him as the abuse coordinator to ensure the abuse policy and procedure was followed. 5. A Resident Face Sheet revealed the facility admitted Resident #79 on 06/19/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of acute and subacute infective endocarditis, hypertensive heart and chronic kidney disease with heart failure, acute pulmonary edema, restlessness and agitation, and shortness of breath. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2025, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated Resident #79 was always continent of bowel and bladder, required substantial/maximal assistance from staff with toileting hygiene and partial/moderate assistance with transfers. The MDS indicated Resident #79 had one fall without injury since admission to the facility. Resident #79's Care Plan included a problem statement, dated 06/21/2025, that indicated the resident had a potential for falls. Interventions directed staff to place a landing strip on the right side of the resident's bed while the resident was in bed, to assist with ambulation, toileting and mobility as needed, observe the need for additional assistive devices and positioning devices, to educate the resident to call for assistance when needed to go to the bathroom, encourage use of handrails/appropriate assistive devices, and review for a toileting program as needed. A facility document titled, Verification Of Investigation, revealed that on 07/14/2025 at 5:48 AM, Resident #79 was found on the floor next to their bed. The section of the document titled, Provide Summary and Outcome of Investigation, revealed that Certified Nursing Assistant (CNA) #7 noticed Resident #79 on the floor and alerted CNA #1 (who was assigned to care for the resident) that Resident #79 was on the floor. Per the document, when CNA #1 was asked to assist with the care of the resident, she refused to help and stated, No, my shift is about over I will go there in about 5 minutes right before my shift ends. According to the document, the facility concluded neglect occurred because CNA #1, who was assigned to care for Resident #79, refused to assist with the resident's care and stated the resident was seeking attention. A typed witness statement from the Rehabilitation Director (RDR) dated 07/14/2025, revealed that upon entering the facility, the RDR walked down the hallway and observed Resident #79 partially off their bed with their lower body on the floor and upper body still on the bed. Per the witness statement, the resident was partially unclothed, with no upper body clothing on, and wearing only a brief. Per the witness statement, the resident was lying in urine and feces on the floor with feces also coming from their brief. Per the witness statement, the RDR, Licensed Practical Nurse (LPN) #4, and CNA #6 assisted the resident. The RDR called out to CNA #1 to assist, and CNA #1 stated her shift was about over and that she would go about five minutes before she left. LPN #5 arrived at work and assisted the RDR, LPN #4, and CNA #6 with Resident #79 A typed witness statement from LPN #4 dated 07/14/2025 revealed that when she arrived at the facility, she was approached by the RDR who asked for her assistance with Resident #79. Per the statement, Resident #79 was half on the bed and half on the floor. The witness statement indicated that CNA #1 was standing at the nurses' station and LPN #4 motioned for CNA #1 to come assist and then asked the CNA to come help them put the resident back in bed. Per the statement, CNA #1 replied, I will put [him/her] back in bed five minutes before I leave. Per the statement, LPN #5 and CNA #6 assisted LPN #4 and the RDR. A typed witness statement from CNA #1 dated 07/14/2025, revealed that CNA #1 indicated Resident #79 was on the floor off and on throughout the night and that it took several staff members to keep picking the resident up. Per the witness statement, CNA #1 indicated that she thought Resident #79 was seeking attention. During an interview on 08/26/2026 at 1:35 PM, LPN #4 stated she recalled the RDR asking her to assist with Resident #79. She stated the resident was half on the bed and half on the floor. LPN #4 said she recalled one of the CNA's stating they had just provided care to the resident, and the CNA was informed that it could not wait. LPN #4 stated that the resident was in distress and needed help. LPN #4 stated she and another CNA assisted the RDR care for Resident #79. During an interview on 08/26/2026 at 2:48 PM, the RDR stated Resident #79 was holding onto the bed rail to keep from going onto the floor, the resident was partially nude, and there was blood on the bed rail from a skin tear and urine and feces on the floor. She stated the resident could not say what happened, and no one was in the room with the resident. RDR said LPN #4 clocked in to work and started to assist the RDR with Resident #79. She stated she called CNA 1, who was standing at the nurses' station, to come and help, and CNA #1 said no. During a phone interview on 08/27/2026 at 3:52 PM, CNA #7 stated she walked by Resident #79 and saw the resident on the floor and told CNA #1. She stated she told CNA #1 that she would help her get the resident back to bed, and CNA #1 stated it was not her job. She stated she stayed by Resident #1 but was unable to get the resident up without assistance, and the RDR came in and took over. CNA #7 stated the resident placed themself on the floor a lot. During an interview on 08/28/2026 at 9:38 AM, the Director of Nursing (DON) stated CNA #1 blatantly refused to help. She stated she did not know why CNA #1 did what she did. She stated her expectation was that they educate their staff to make sure they did the right thing for the residents and to think about what the staff member would want. She stated she tried to make staff understand that their job was to help residents and take care of their needs. During an interview on 08/28/2026 at 1:17 PM, the Administrator stated his expectation that if there was an allegation of neglect, they immediately safeguard the resident. He stated they used the same protocol as if there was an abuse allegation. He stated his expectation was that neglect did not occur, and the facility always prevented neglect. He stated the facility was the residents', and staff were to be courteous of the residents.

Based on interview, record review, and facility document and policy review, the facility failed to conduct a thorough investigation for 1 (Resident #79) of 5 residents reviewed for neglect and failed to conduct a thorough investigation for 5 (Residents #58, #65, #12, #80, and #81) of 7 residents reviewed for abuse.Findings included: A facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, effective 05/01/2023, revealed, The facility will investigate and document all incidents and accidents involving resident/guest(s). The policy continued, All of our resident/guest(s) have the right to be free from abuse, neglect, exploitation and misappropriation of resident/guest property. The policy continued, under Investigation and Reporting Steps, and included, The Administrator is responsible for conducting a thorough investigation and obtaining witness statements. A complete and thorough investigation must be conducted on all incidents including suspicious injuries of unknown origin, whether reportable or not, within five working days to determine the cause of the injury or incident. 1. A Resident Face Sheet revealed the facility admitted Resident #79 on 06/19/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of acute and subacute infective endocarditis, hypertensive heart and chronic kidney disease with heart failure, acute pulmonary edema, restlessness and agitation, and shortness of breath. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2025, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated Resident #79 was always continent of bowel and bladder, required substantial/maximal assistance from staff with toileting hygiene and partial/moderate assistance with transfers. The MDS indicated Resident #79 had one fall without injury since admission to the facility. Resident #79's Care Plan included a problem statement, dated 06/21/2025, that indicated the resident had a potential for falls. Interventions directed staff to place a landing strip on the right side of the resident's bed while the resident was in bed, to assist with ambulation, toileting and mobility as needed, observe the need for additional assistive devices and positioning devices, educate the resident to call for assistance when needed to go to the bathroom, encourage use of handrails/appropriate assistive devices, and review for a toileting program as needed. A facility document titled, Verification Of Investigation, revealed that on 07/14/2025 at 5:48 AM, Resident #79 was found on the floor next to their bed. The section of the document titled, Provide Summary and Outcome of Investigation, revealed that Certified Nursing Assistant (CNA) #7 noticed Resident #79 on the floor and alerted CNA #1 (who was assigned to care for the resident) that Resident #79 was on the floor. Per the document, when CNA #1 was asked to assist with the care of the resident, she refused to help and stated, No, my shift is about over I will go there in about 5 minutes right before my shift ends. According to the document, the facility concluded neglect occurred because CNA #1, who was assigned to care for Resident #79, refused to assist with the resident's care and stated the resident was seeking attention. The facility's investigation did not include evidence that any other residents were interviewed to determine whether there had been any additional neglect. During an interview on 08/28/2026 at 9:38 AM, the Director of Nursing (DON) stated for the investigation of a neglect allegation she talked to the nurses and residents around the affected resident's room to see if they heard something or saw something and tried to get as much information because she wanted to get a picture of what was going on. She stated she did not talk to the resident across the hall from Resident #79 because that resident could not respond to her. She stated she did not interview any of the other residents that CNA #1 cared for; she did not think about that. During an interview on 08/28/2026 at 1:39 PM, the Administrator (ADM) stated that for the investigation they were to talk to residents, witnesses, and staff. He stated it would depend on the incident as far as the residents that were interviewed. He stated that for an allegation of caregiver neglect they talked to witnesses and residents that the caregiver was assigned to. 2. A Resident Face Sheet revealed the facility admitted Resident #58 on 02/26/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of schizoaffective disorder bipolar type, mood disorder due to known physiological condition with depressive features, generalized anxiety disorder, and dementia with agitation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2025, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #58 had no behavioral symptoms during the assessment period. Resident #58's Care Plan included a problem statement, initiated 08/20/2025, that indicated the resident had a potential for physical behavioral symptoms related to psychological disorders as evidenced by hitting other residents. Interventions directed staff to assess whether the behavior endangered the resident and/or others and intervene if necessary, avoid over-stimulation (e.g. (exempli gratia, for example) noise, crowding, other physically aggressive residents), and avoid power struggles with the resident. The Care Plan also included a problem statement, initiated 10/20/2023, that indicated the resident had a potential for behaviors related to physiological condition as evidenced by dementia, schizoaffective disorder, and bipolar type. Interventions directed staff to provide one-to-one monitoring as needed, behavioral consult, and to discuss options for appropriate channeling of anger. A Resident Face Sheet revealed the facility admitted Resident #65 on 12/20/2021. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of mood disorder due to known physiological condition with depressive features, mild intellectual disabilities, and generalized anxiety disorder. An annual MDS, with an ARD of 04/10/2025, revealed Resident #65 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #65 had no behavioral symptoms during the assessment period. Resident #65's Care Plan included a problem statement, dated 09/20/2021, that indicated the resident had a potential for behaviors related to physiological disorder as evidenced by a mood disorder. Interventions directed staff to address complaints and concerns timely. A facility document titled, Verification Of Investigation, revealed that on 06/25/2025 Resident #65 took the television remote from Resident #58's bedside table and Resident #58 then hit Resident #65 in the face above their left eye. The facility's investigation documents revealed no evidence that other residents were interviewed as part of the investigation. 3. A Resident Face Sheet revealed the facility admitted Resident #12 on 12/22/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of depression, other symptoms and signs involving appearance and behavior, and hemiplegia and hemiparesis following cerebral infarction affecting their left dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2025, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had no behavioral symptoms during the assessment period. Resident #12's Care Plan included a problem statement, initiated 12/22/2023, that indicated the resident had a potential for behaviors related to psychological disorders as evidenced by hallucinations/bipolar, refused to be weighed, increased sexual behaviors towards staff, and verbal abuse to roommate. Interventions directed staff to discuss options for appropriate channeling of anger, identify causes for behaviors and reduce factors that may provoke behaviors, provide one to one staff monitoring as needed, and place the resident in another room closer to nursing station (02/01/2026). A Resident Face Sheet revealed the facility admitted Resident #65 on 12/20/2021. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of mood disorder due to known physiological condition with depressive features, mild intellectual disabilities, and generalized anxiety disorder. A quarterly MDS, with an ARD of 12/09/2025, revealed Resident #65 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #65 had no behavioral symptoms during the assessment period. Resident #65's Care Plan included a problem statement, dated 09/20/2021 that indicated the resident had a potential for behaviors related to physiological disorder as evidenced by a mood disorder. Interventions directed staff to address complaints and concerns timely. A document titled, Alabama Department of Public Health Online Incident Reporting System, dated 02/01/2026 revealed that Resident #12 and Resident #65 had a verbal altercation the night prior, and Resident #65 said they felt threatened. The document indicated Resident #12 called Resident #65 a racial slur. Per the document, the residents were separated, and Resident #12 was moved to a different room. The facility's investigation documents revealed no evidence that other residents were interviewed as part of the investigation. Furthermore, the facilities investigation documents revealed no evidence that all staff working on the unit where the alleged incident occurred were interviewed as part of the investigation. During an interview on 08/28/2026 at 1:23 PM, the Administrator (ADM) stated he would interview staff and see if they witnessed anything and try to interview the resident's circle of friends and other residents on that hall to see if they had any issues with the residents involved in altercation. He stated that for the altercation between Resident #12 and Resident #65, he talked to other residents, but if the interviews were not in the file, then he could not show that he talked to them. During a follow-up interview on 08/29/2026 at 8:43 AM, the ADM stated he did not know why they did not interview all the staff who worked on Unit 1 on 01/31/2026 and 02/01/2026 as part of the investigation. 4. A Resident Face Sheet indicated the facility admitted Resident #80 on 07/29/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and hepatic encephalopathy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2025, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #80 was frequently incontinent of urine and bowel and required total assistance of staff for toileting hygiene. Resident #80's Care Plan included a problem statement initiated 08/02/2025 that indicated the resident was incontinent of bowel and bladder related to decreased mobility. Interventions directed staff to check and clean the resident every two hours and as needed after each incontinence episode. Resident #80's Care Plan included a problem statement initiated 08/20/2025 that indicated the resident exhibited behaviors related to their disease process as evidenced by: throwing objects on the floor; refusing medications, baths, weights, and to get out of bed; and telling family that staff would not get the resident up. Interventions directed staff to allow the resident to have control over the situation if possible (initiated 08/20/2025) and to maintain a calm, slow, understandable approach with the resident (started 08/20/2025). A Resident Progress Notes, dated 09/11/2025 at 2:34 PM, revealed that at 8:00 AM, a nurse was passing medications when Resident #80 reported they needed some help. The Progress Note revealed Resident #80 was upset and crying and stated they did not want the assigned Certified Nursing Assistant (CNA) back in their room. The Progress Note revealed that Resident #80 said the CNA told the resident that if the CNA had known that they had the resident the CNA would not have come to work. The Progress Note revealed Resident #80 stated the CNA walked out of the room and did not assist them. The Progress Note revealed another CNA took over care of Resident #80 and got them cleaned up and dressed. A facility document titled, Alabama Department of Public Health Online Incident Reporting System, dated 09/11/2025 at 9:04 AM, indicated there was an allegation of Abuse-Verbal for Resident #80. The Incident Report indicated that on 09/11/2025 at 6:15 AM Resident #80 alleged they had been verbally abused by CNA #3 and left with stool [bowel movement] on. The Incident Report indicated CNA #3 was suspended, and staff interviews were obtained. The facility's investigation did not include interviews with cognitively intact residents or assessments of residents who were nonverbal and/or cognitively impaired. During an interview on 08/28/2026 at 1:54 PM, the Director of Nursing (DON) stated she was responsible for the investigation for Resident #80. The DON stated that during the investigation, she did not interview cognitively intact residents. The DON stated she did not assess cognitively impaired residents, and they should have been assessed. The DON stated she did not know until that day that it needed to be done. During an interview on 08/28/2026 at 2:35 PM, the Administrator (ADM) stated he expected the policy to be followed for investigating an allegation of abuse or neglect. 5. A Resident Face Sheet indicated the facility admitted Resident #81 on 08/26/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hemiplegia following cerebral infarction affecting the left non-dominant side and an unstageable pressure ulcer. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/01/2025, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident had range-of-motion impairment to bilateral upper and lower extremities and was totally dependent on staff for rolling left and right. The MDS indicated Resident #81 had one unstageable pressure ulcer. Resident #81's Care Plan included a problem statement initiated 08/27/2025 that indicated the resident had actual skin breakdown related to immobility, diabetes, and hemiplegia. Interventions directed staff to turn and reposition Resident #81 per the resident's individual turning schedule (started 08/27/2025) and assist to reposition the resident to avoid friction and shearing (started 08/27/2025). Resident #81's Care Plan included a problem statement initiated 09/09/2025 that indicated the resident had potential for behaviors related to cognitive communication as evidenced by yelling out instead of using the call light and elevating the bed to the highest position. Interventions directed staff to provide activities of daily living (ADLs) (started 09/09/2025). A nurse's late entry Resident Progress Notes, dated 09/13/2025 at 2:28 PM for 09/13/2026 at 11:23 AM, indicated a report was received that Resident #81 and a caregiver had complaints concerning the care the resident had received the previous night shift. The Progress Note revealed a statement was received from Resident #81 and was discussed with the caregiver. The Progress Note revealed a statement was obtained from the day shift certified nursing assistant (CNA) who was assigned to Resident #81 and who had originally received the complaint. A document titled, Alabama Department of Public Health Online Incident Reporting System, dated 09/13/2025 at 12:24 PM, indicated there was an allegation of Abuse-Neglect for Resident #81. The Incident Report indicated on 09/12/2025 at 12:01 AM Resident #81 had asked CNA #7 to turn the resident, and CNA #7 turned the resident quickly, did not ask the resident if they needed anything else, left the resident all night on a bare mattress without a sheet under them, had an attitude, and was rude. The Incident Report indicated staff interviews were obtained, but the facility's investigation did not include interviews with cognitively intact residents nor assessments of residents who were nonverbal and/or cognitively impaired. During an interview on 08/28/2026 at 9:38 AM, the Director of Nursing (DON) stated that her expectation of conducting a thorough investigation included speaking with all the residents that could talk, all the staff, and all the people in between. During an interview on 08/28/2026 at 1:39 PM, the Administrator (ADM) stated that for a neglect investigation they were to talk to residents, witnesses, and staff. The ADM stated that for an allegation of caregiver neglect, they talked to witnesses and residents the caregiver had been assigned to. The ADM stated they pulled the schedule and made sure that was the only section the caregiver had been assigned to, and, if the caregiver had been in a different section the day before, they talked to those residents too. The ADM stated they talked to the residents the person had cared for to determine a conclusion. During an interview on 08/28/2026 at 1:54 PM, the DON stated she was responsible for the investigation for Resident #81. The DON stated that during the investigation she did not interview cognitively intact residents. The DON stated she did not assess cognitively impaired residents, and they should have been assessed. The DON stated she did not know until that day that those resident interviews and assessments needed to be done. During an interview on 08/28/2026 at 2:35 PM, the Administrator (ADM) stated he expected the policy to be followed for investigating an allegation of abuse or neglect.

Based on interview, record review, and document review, the facility failed to provide timely follow-up orthopedic care for 1 (Resident #62) of 8 residents sampled for accidents. Specifically, the facility failed to reschedule an orthopedic appointment for Resident #62 after the original appointment scheduled for 05/06/2025 was cancelled by the ambulance service.Findings included: A Resident Face Sheet indicated the facility admitted Resident #62 on 06/07/2020. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of intellectual disability, schizophrenia, insomnia, and pain. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/2025, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had limited range of motion of both sides of the lower extremities, required substantial/maximal assistance to roll left and right in the bed, was dependent on staff to transfer to and from a bed to a chair, was incontinent of urine and bowel, received scheduled pain medication, and had two falls with no injury and one fall with major injury. Resident #62's Care Plan included a problem statement initiated 02/23/2018 that indicated the resident had a potential for falls related to muscle weakness, intellectual disability, and osteoarthritis. Interventions directed staff to transfer the resident with a mechanical lift with two-person assist, the resident was placed on a low bed, assist with toileting and mobility as needed, physical therapy to evaluate and treat for functional maintenance program (FMP) update as needed, and to place a landing strip on the left side of the bed when the resident was in bed. Resident #62's Resident Progress Notes, dated 04/13/2025 at 9:49 PM, indicated the resident was lying on the bed when the resident rolled out of the bed onto the floor. The Progress Notes indicated the resident was on top of the floor mat on the right side of the bed, and there were no clutter or cords on the ground. The Progress Notes indicated the resident fell on both of their legs, and x-rays were pending due to possible twisted left ankle. Per the Progress Notes, there were no skin tears or bruises. The Progress Notes indicated as needed pain medication was administered, the physician was called, and an x-ray was ordered. A left ankle x-ray report, dated 04/14/2025 at 7:34 AM, revealed Resident #62 had a fracture involving the distal tibia and fibula with mild displacement with joint alignment maintained. The x-ray report indicated soft tissue swelling and osteopenia was also present. An emergency department (ED) visit record, dated 04/14/2025 at 3:15 PM revealed Resident #62 was contracted, reportedly fell out of bed last night with deformity to left ankle. The ED visit record revealed a splint was applied to the resident's left shin, front of the left ankle, and underneath the left foot. Discharge diagnoses indicated a fracture of lower end of tibia and unspecified fracture of left fibula shaft with instructions to follow up with private physician in two to three days. Resident #62's Resident Progress Notes, revealed a note dated 04/14/2025 at 10:26 PM, that indicated the resident returned to the facility at 6:35 PM by ambulance. The Resident Progress Note indicated the hospital called the facility and reported no surgery was done; an orthosplint was applied, and the resident was to follow up with orthopedic. Resident #62's Order History contained an order, dated 04/25/2025, to check on orthopedic referral. Resident #62's Resident Progress Notes, revealed a note dated 04/29/2025 at 9:29 AM, that indicated the resident had an appointment with the orthopedic surgeon on 05/06/2025 at 10:30 AM. An orthopedic clinical encounter summary for Resident #62, dated 07/23/2025, revealed the resident was seen for a complaint of left ankle problem. The HPI [History of Present Illness] section revealed Resident #62 was seen for a left ankle injury that occurred on 04/13/2025 when the resident fell out of bed. The encounter summary indicated that the resident had x-rays completed on 04/14/2025 at a local hospital, was diagnosed with displaced distal tibia and fibula fractures, was placed in a posterior short leg splint, and had not received any treatment since the incident. The encounter summary indicated that upon review of the paperwork sent with Resident #62 to the orthopedic appointment, an order was found for an orthopedic appointment for the resident for 05/06/2025 at 10:30 AM but indicated the resident did not show up for the appointment. Per the encounter summary, contact was then made with the Director of Nursing (DON) to inquire about the gap in treatment. Per the encounter summary, the DON informed the orthopedic office that the ambulance service had cancelled on the day of the prior orthopedic visit and that no one ever rescheduled the visit. The assessment/plan section of the encounter summary indicated Resident #62 was to return as needed; no surgical intervention was recommended due to too much time having passed, and the fracture had healed in a mis-aligned state. During an interview on 08/27/2026 at 7:57 AM, the DON stated she did not know why the resident missed the orthopedic surgeon appointment. The DON stated that the previous ambulance service cancelled appointments frequently, and if the ambulance service cancelled the 05/06/2025 appointment, it was the facility's responsibility to reschedule the orthopedic surgeon appointment. The DON stated that the orthopedic surgeon appointment should have been rescheduled. During a follow-up interview on 08/27/2026 at 8:55 AM, the DON stated the resident was supposed to go to the orthopedic surgeon on 05/06/2025 but did not go until 07/23/2025. The DON stated she did not know what happened; there was no documentation, and there should have been. The DON stated it was not okay that Resident #62 waited that long to go to the orthopedic surgeon.

Based on interview, record review, and facility document and policy review, the facility failed to assess a resident after a fall for 1 (Resident #9) of 8 residents reviewed for accidents.Findings included: A facility policy titled Fall, effective 11/01/2001, revealed, Purpose: To provide emergency care after a fall and prevent further injury if a facture has occurred. A Resident Face Sheet revealed the facility admitted Resident #9 on 05/12/2016. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of intractable epileptic spasms, unspecified intellectual disabilities, lack of coordination, muscle weakness (generalized), unspecified lack of coordination, difficulty in walking, and unsteadiness on feet. A quarterly Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 10/07/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident had functional impairment in range of motion on both sides of their upper and lower extremities. The MDS also indicated Resident #9 was independent walking 10 feet, walking 50 feet with two turns, and walking 150 feet. The MDS indicated Resident #9 had no falls since the prior assessment. Resident #9's Care Plan included a problem area, initiated 05/12/2017, that indicated the resident had a potential for falls due to a history of falls, weakness, lack of coordination, and difficulty walking. Interventions directed staff to: consult physical therapy as needed, started 09/03/2025; encourage the resident to slow down when the resident was walking fast, started 05/05/2023; encourage the resident to hold on to the nursing station while waiting, started 02/19/2029; assist with ambulation, toileting, and mobility as needed, started 05/31/2017; encourage a clutter free environment, started 05/31/2017; and encourage use of handrails or appropriate assistive devices, started 05/31/2017. Resident #9's Care Plan included a problem area, initiated 05/25/2019, that indicated the resident was at risk for fracture due to unsteady gait, lack of coordination, and muscle weakness. Interventions directed staff to: assist with ambulation as needed, started 05/25/2019; observe for changes in joint mobility, started 05/25/2019; and set up in appropriate chair as tolerated, started 05/25/2019. Resident #9's Nursing admission Review, dated 05/12/2016, included a Falls section, which indicated that the resident had a history of falls without injury. A facility document titled, Alabama Department of Public Health Online Incident Reporting System, dated 11/17/2025 at 7:43 PM, indicated an injury of unknown source for Resident #9, with an event date of 11/17/2025 at 6:00 PM. The Incident Report indicated that Resident #9's left wrist was observed to be swollen, and the resident complained of pain when the left wrist was touched. The Incident Report indicated that an x-ray was completed, and the resident had an acute distal radial fracture of the left wrist. A facility document titled Verification of Investigation, dated 11/17/2025 at 7:30 AM, in the section Summary and Outcome of Investigation indicated that Resident #9 had an unwitnessed fall on 11/16/2025 when a certified nursing assistant (CNA) was preparing to give the resident a bath. Licensed Practical Nurse (LPN) #24's handwritten statement, dated 11/17/2025, revealed the charge nurse assessed Resident #9's hand on the 2-10 [2:00 PM to 10:00 PM] shift because the resident could not close their hand. The statement revealed the charge nurse's assessment included that there was no swelling or bruising to Resident #9's hand. The statement further revealed Resident #9 rested in bed from 10-6 [10:00 PM to 6:00 AM] with no problems noted. A handwritten statement, dated 11/18/2025, revealed Licensed Practical Nurse (LPN ) #29 indicated that on 11/16/2025 CNA #28 reported to her that Resident #9 sat on the floor in the resident's room. LPN #29's statement also indicated that LPN #29 thought that the CNA witnessed Resident #9 sitting down on the floor. LPN #29's statement indicated that no apparent injury was noted and that CNA #28 did not witness the resident sitting on the floor. In an undated handwritten statement, CNA #28 indicated that on Sunday 11/16/2025 she directed Resident #9 to go to the bathroom while she obtained the resident's clothing in preparation for a bath. CNA #28's statement indicated that when CNA #28 went to the bathroom she found Resident #9 on the floor. CNA #28's statement indicated that she asked Resident #9 if they had fallen, and the resident replied, No. CNA #28's statement indicated Resident #9 received a bath with no complaints. CNA #28's statement indicated CNA #28 reported the incident to the charge nurse, LPN #29. Resident #9's left wrist mobile x-ray findings, dated 11/17/2025 at 4:41 PM, revealed, Distal radial fracture with no displacement. Mild tissue swelling. Conclusion: Acute appearing distal radial fracture as noted. A facility document titled, One on One In-Service Education & Training Report, dated 11/18/2025, indicated LPN #29 received training on the topic of falls. The Training Report revealed, Educated the charge nurse on the importance of assessing the resident once a fall or possible fall has occurred. Also [sic] after a fall an event has to be open on that resident. During an interview on 08/26/2026 at 1:38 PM, CNA #28 stated that she had received training that if a resident was found on the floor, the process was to call for help or get an LPN to check the resident out before even moving them to make sure the resident was okay. CNA #28 stated she told Resident #9 to go to the bathroom while CNA #28 went to get clothing items for the resident. CNA #28 stated that she heard something and asked Resident #9 if they were okay, and the resident said yes. CNA #28 stated that when she entered the bathroom, Resident #9 was on the floor. CNA #28 stated she told Resident #9 not to get up, she went to LPN #29, and she told LPN #29 that Resident #9 was on the floor in the bathroom. CNA #28 stated LPN #29 checked out Resident #9. During an interview on 08/26/2026 at 1:52 PM, LPN #29 stated that she was unable to recall any details regarding Resident #9's fall and did not remember completing an incident report. During a concurrent interview on 08/28/2026 at 3:09 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the ADON stated that when a fall occurred, an event form was to be completed right away. The ADON stated that event sheets were reviewed every morning by her, and when she was not on duty a supervising RN would review the event sheets for completion and clarification, check the environment, and do interviews. The ADON stated that she had checked incident reports and confirmed that an event form for Resident #9's fall on 11/16/2025 was not present in the facility. The DON stated that all staff were trained to complete an event form if there was a fall. The DON stated Resident #9's fall was discovered due to the resident having swelling to their wrist the following day. The DON reviewed Resident #9's record for any documentation that would indicate that the resident was assessed after being found on the floor. The DON stated that her expectation was anyone found on the floor should be assessed and treated as needed. During an interview on 08/28/2026 at 4:15 PM, the Administrator (ADM) stated that for all incidents, including falls, his expectation was that the residents were assessed and treated, and all efforts should be documented in the resident's record.

Based on a facility policy titled, Behavior Management Program/Trauma Informed Care/Cultural Preferences, record review, State's online reporting system, facility investigations, and interviews, the facility failed to implement an effective behavior management program that resulted in Resident Identifier (RI) #1 exhibiting aggressive behaviors towards other residents. This affected RI #1, one of three residents sampled for behaviors. Findings Include: A review of a facility policy titled, Behavior Management Program/Trauma Informed Care/Cultural Preferences with an effective date of 10/25/2022, revealed, . STANDARD: Residents/guests who display mental or psychosocial adjustment difficulty should receive appropriate services, in an attempt to correct the problem. PROCESS: I. Assessment . b) Identified behaviors should be evaluated for frequency, duration and intensity for a pattern. RI #1 was admitted to the facility on [DATE], readmitted [DATE] and discharged [DATE]. The resident had diagnoses that included Unspecified Dementia with Agitation, Unspecified Psychosis, Other Mental Disorders, Anxiety Disorders, Pseudobulbar Affect, Alzheimer's Disorder, Delusional Disorders, Major Depressive Disorder, and Mood Disorder. RI#1 was care planned 05/04/2022 for Exhibits Behaviors: Hitting. Interventions included place resident in area where frequent observation possible, talk in calm voice, refer to social services for evaluation, remove from public place when disruptive, praise for demonstrating desired behavior, elicit family input, do not argue with resident, discuss options for appropriate channeling of anger, approach in positive, calm, accepting manner, allow opportunity to make choices, administer behavior medications as ordered, provide diversional activities, identify causes for behaviors and reduce factors that may provoke behaviors, observe target behaviors, leave and reapproach. The care plan also included monitor every hour for 72 hours starting 05/04/2022. On 06/21/2022 the care plan added monitor resident every hour for 72 hours again. On 09/07/2022, one on one monitoring while out of bed and consult from a psychiatric unit were added. On 10/16/22, one on one monitoring, monitoring every hour for 72 hours, move to another hall, move to unoccupied room, collect urinalysis and consult for psychiatric evaluation were added. On 11/17/2022, one on one monitoring during daylight and psychiatric evaluation were added. RI #1 was prescribed Lexapro 10mg (milligram), Trazadone HCL (Hydrochloride) 100mg, and Seroquel 50mg twice a day. The State's agency online reporting system revealed the following incidents with RI #1 as the offender in the facility's investigations: 1. 05/04/2022-RI #1 threw full soda can at another resident. Residents were separated. Investigation initiated. 2. 06/20/2022-RI #1 back-handed another resident. RI #1 escorted to room. 3. 07/03/2022-Another resident entered RI's room. RI #1 hit that resident. Residents separated. Investigation initiated. 4. 09/07/2022-RI #1 hit another resident when RI #1 passed the resident in the hallway. The resident hit RI #1 back resulting in two small scratches on the left side of RI #1's neck. Residents separated. 5. 10/16/2022-RI #1 propelled himself/herself down the hallway in his/her wheelchair to where another resident sat and slapped that resident in the face. Residents were separated. RI #1 was sent to private room with one on one monitoring. 6. 11/16/2022-RI #1 hit another resident and that resident hit RI #1 back while both residents were in the hallway. No injuries. No changes noted in RI #1's behaviors prior to the incident. Further review of the facility's investigations identified the following: 1. On 05/04/2022 another resident hit and kicked RI #1 and RI #1 threw the soda can at the other resident in response. The incident was witnessed. The residents were separated. The other resident was moved to another room on another hall. The allegation was substantiated. 2. On 06/20/2022 another resident tried to give assistance to RI #1 while they were in the hallway. RI #1 hit the other resident in the left upper arm. The residents were separated. No injuries noted. The incident was witnessed. The allegation was substantiated. 3. On 07/03/2022 another resident entered RI #1's room. RI #1 hit the other resident on the head. The incident was witnessed. The residents were separated. A stop sign was placed on RI #1's doorway. 4. The other resident was moved to a different hall. The allegation was substantiated. 4. On 09/07/2022 RI #1 hit another resident when the resident passed RI #1 in the hallway. The other resident hit RI #1 back and placed his/her hand around RI #1's neck. The residents were separated. RI #1 was placed on one on one monitoring before sent to a psychiatric unit on 09/08/2022. The allegation was substantiated. 5. On 10/16/2022 RI #1 was sitting beside another resident in the hallway when RI #1 slapped the other resident on the left side of his/her face. No injuries were noted. The two residents were separated. An order was received to send RI #1 for a psychiatric evaluation. The allegation was substantiated. 6. On 11/16/2022 RI #1 and another resident's wheelchair wheels locked in the hallway. The other resident asked RI #1 to back his/her wheelchair. RI #1 said, Fuck you and punched the other resident on the right side of his/her face. The other resident hit RI #1 in the head. The residents were separated. RI #1 was placed on one on one monitoring. No injuries were noted. The allegation was substantiated. On 09/08/2022, RI #1 was sent to a psychiatric unit for evaluation after his/her fourth incident involving other residents. In addition, the facility implemented one on one monitoring after the fourth incident but it was not reinstated upon his/her return from the psychiatric unit. Therefore, the fifth and sixth incidents occurred. Also there was no evidence that the facility followed their policy to evaluate for frequency, duration and intensity for a pattern of behaviors. In an interview on 12/07/2022 at 04:56PM, Employee Identifier (EI) #3, Social Services Director, reported she was instructed to work on a referral to IBH (Integrated Behavioral Health) for RI #1. EI #3 contacted IBH on 11/18/2022. EI #3 stated she did not contact IBH after her meeting with RI #1 on 11/04/2022 because the resident promised her he/she would not act out and she believed the resident. EI #3 also stated RI #1 refused counseling. EI #3 stated she did not know whether completing the referral to IBH earlier would have prevented the 11/16/2022 incident because the resident would leave the facility, come back and do the same things. RI #1 made a promise to EI #3, Social Services Director, that he/she would not act out and she believed him/her after the resident had exhibited multiple episodes of behaviors. EI #3 identified in her interview that RI #1 would repeat behaviors after his/her psychiatric evaluations. In an interview on 12/08/2022 at 10:12AM, EI #2, Director of Nursing, reported they needed to know their residents and their triggers in order to identify interventions. EI #2 stated they were not able to identify a trigger for RI #1. EI #2 stated her plan when RI #1 returned from his/her psychiatric stay would be to place the resident in a room closer to the lobby and away from other residents. In an interview on 12/08/2022 at 11:28AM, EI #1, Administrator, reported RI #1 was not referred to IBH before the 11/16/2022 incident because of the need for safety of all residents and to stabilize/evaluate RI #1's medications. In an additional interview on 12/08/2022 at 05:12PM, EI #1, Administrator, reported RI #1 was a part of the facility's behavior management program since his/her admission because the resident was on an antipsychotic medication. EI #1 stated the nurses and Social Services were responsible for the behavior management program. They would meet in the mornings to discuss resident behaviors and how the behaviors were addressed. They would try different interventions based on the resident's care plan. Interventions would include medications and non-pharmalogical interventions. EI #1 stated the interventions were effective because RI #1 did not have behaviors every day. RI #1 would do well for awhile and then he/she would have another behavior. EI #1 stated RI #1 was sent to the psychiatric units to determine if his/her medications could be adjusted to address his/her behaviors. EI #1 stated the non-pharmalogical interventions would work for awhile and then RI #1 would have another incident. This deficiency was cited as a result of the investigations of complaint/report numbers AL00042098 and AL00042481.

Based on interview, record review, and review of facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation the facility failed to ensure the abuse policy was implemented on: 1) 07/26/2021 when Employee Identifier (EI) #3, Registered Nurse (RN) and EI #4 (RN) failed to clearly communicate an allegation of verbal abuse which was reported to them by Resident Identifier (RI) #9 regarding RI #7 to the Administrator, Director of Nursing, or Supervisor, and 2) 08/29/2021 when EI #5, Licensed Practical Nurse (LPN) and EI #7, LPN failed to report the allegation of verbal abuse to the Administrator, Director of Nursing, or Supervisor, after RI #6, Screener, reported an allegation of verbal abuse made by RI #7, that was heard by RI #8 on 08/29/2021. This affected three of three residents sampled for abuse. Findings Include: A facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of February 8, 2018 revealed PURPOSE: This Policy (the Policy) is concerned with all incidents . involving resident/guest (s). For the purpose of this Policy, the following terms shall have the following meanings: . Verbal- Verbal abuse is the use of oral . communication . to resident/guest (s) . within hearing distance, regardless of age, abilities to comprehend, . Examples of verbal abuse could include .threatening to hurt and saying things to frighten a resident/guest (s) . IV. Identification of Resident/Guest(s) Incidents . d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse . to the Administrator, Director of Nursing, or the Department Supervisor. Immediately means as soon as possible. Any staff members that witnessed, suspect, or that is reported to, are personally obligated to initiate protection and report to supervisor immediately. RI #7 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility document titled Departmental Notes for RI #7 revealed . 7/26/2021 4:29 PM . Resident went in another resident's room and said he/she was going to kill him/her. Signed by EI #3. A facility document titled Departmental Notes for RI #9 revealed . 7/26/2021 4:36 PM .Resident said resident across hall came in his/her room and threatened him/her. Said he/she is very scared . Signed EI #3. A document from a Geri-psychiatric facility titled History and Physical for RI #7 revealed .admitted : 7/27/2021 18:56 . Patient profile: This is the 2nd admission to facility . Today's date 7/27/2021 . Chief Complaint: . Reports provided by staff at nursing home indicate resident is exhibiting increased agitation, combative toward staff when redirected, . wandering in and out of other resident's rooms threatening other patients . A facility document titled NHS AFFILIATED COMPANIES CONFERENCE REPORT dated 08/31/2021 revealed . Name: EI #3 . RN .NATURE OF VIOLATION: .Failure to report any observed abusive and/or negligent conduct through designated reporting channels. ACTION BEING TAKEN: Suspension pending investigation . signed by EI #1, Administrator and EI #2, Director of Nursing (DON). On 08/31/2021 at 7:05 AM an interview was conducted with RI #9. RI #9 reported that the resident across the hall came into his/her room and when he/she asked the resident to leave, the resident stated he/she was going to kill him/her. RI #9 reported that he/she told the nurse about the incident. RI #9 stated that a person like that should not be there because he/she threatened to kill him/her. On 8/31/2021 at 8:10 AM an interview was conducted with EI #3 RN. EI #3 reported that RI #7's room was on her hall a few months ago and he/she was sent to a Geri-Psychiatric facility a few months ago because aggressive behaviors and the last incident was him/her going into another resident's room and threatening to kill the other resident, and the other resident was very afraid. EI #3 was asked, who was the other resident. EI #3 replied, RI #9. EI #3 was asked, who was aware of the threat. EI #3 replied, RI #9 told her and she told EI #2, Director of Nursing (DON). EI #3 was asked, when did the incident occur. EI #3 replied, it was after lunch, the nursing note was entered on 7/26/21 at 4:29 PM and it was probably 4:00 PM when the incident occurred. EI #3 was asked, was RI #7's comment to RI #9 verbal abuse. EI #3 replied, to threaten to kill someone, she thought it was. On 08/31/2021 at 9:15 AM a follow-up interview was conducted with EI #3. EI #3 reported that she informed EI #2, DON the same day, 7/26/21, or if EI #2 had left for the day then it was on 7/27/21 in the morning, and she could not recall exactly when she reported it to the DON. EI #3 said allegations of abuse should be reported immediately to the DON when it happened. On 08/31/2021 at 9:30 AM an interview was conducted with EI #2, DON. EI #2 was asked, what happened on 7/26/21 that required RI #7 to be transferred to Geri-psych facility. EI #2 replied, he/she was irritable and rambunctious, she did not have any knowledge of EI #7 hitting anyone that day. EI #2 was asked, was she aware of anything occurring between RI #7 and RI #9. EI #2 replied, no, she was not told anything; just that RI #7 was roaming the halls and other residents were afraid, but no specific residents. EI #2 was asked, did anyone report to her that RI #7 went into RI #9's room and stated he/she was going to kill him/her when asked to leave. EI #2 replied, no. EI #2 was asked, if a resident told another resident that he/she was going to kill them, should it be reported to her if staff were aware, and would that be verbal abuse. EI #2 replied, yes it should have been reported immediately and she would call that verbal abuse. On 8/31/2021 at 10:55 AM an interview was conducted with EI #1, Administrator. EI #1 was asked, what knowledge did she have of an incident that occurred between RI #9 and RI #7. EI #1 replied, she did not have any knowledge; and she did not think RI #7 had been sent to Geri-psychiatric facility since 7/2/21 after another incident. On 09/01/2021 at 9:30 AM an interview was conducted with EI #4, LPN. EI #4 reported that a day in July she was leaving for the day around 4:30 -5:00 PM and RI #9 stopped her in the hallway and told her that the resident across the hall, EI #7, told him/her that he/she was going to kill him/her. EI #4 reported that RI #9 was anxious and afraid. EI #4 reported that she went to EI #1, Administrator, and told her that RI #9 told her that RI #7 told RI #9 that he/she was going to kill him/her. EI #4 reported that EI #1 gave her instruction to place a stop sign barrier at RI #9's door. On 9/1/2021 at 1:15 PM a phone interview was conducted with EI #3, RN. EI #3 would not confirm whether she reported the incident to EI #2, DON. EI #3 reported that she did not call the Abuse Coordinator and report the incident as she should have in the timeframe per policy. On 9/2/2021 at 3:30 PM an interview was conducted with EI #1. EI #1 was asked, on 7/26/2021 at 4:36 PM a nursing note was entered by EI #3 which stated, the resident said the resident across the hall came in his/her room and threatened him/her and he/she is very scared, per facility policy was this an allegation of abuse and what actions should have been taken and when. EI #1 replied, it was an allegation of verbal abuse. EI #1 continued, the residents should have been separated immediately and then the abuse coordinator should have been notified; the abuse coordinator would have reported it to state agency within two hours; the alleged perpetrator could have been moved to another hall and had someone monitor him/her; then an investigation would have been started. EI #1 was asked, when was the allegation initially reported to her. EI #1 replied, when the state surveyor reported it this week. EI #1 was asked, why was she not notified immediately. EI #1 replied, she did not know; when it was discussed later, she remembered that EI #4 reported to her that RI #9 told her that RI #7 had been entering and exiting RI #9's room; she told EI #4 to place a stop sign across RI #9's doorway; no one told her anything about RI #7 stating he/she was going to kill RI #9. EI #1 was asked, what was the concern with the allegation not being reported to the abuse coordinator immediately. EI #1 replied, it should have been reported to the abuse coordinator immediately; if not reported to the abuse coordinator the resident could still be in harm or potential for harm. RI #8 was readmitted to the facility on [DATE]. On 9/1/21 at 8:15 AM an interview was conducted with RI #8. RI #8 reported that on 8/29/21 he/she was sitting in the lobby and heard RI #7 say he was going to kill everyone after he/she went to the doors and tried to get out. RI #8 reported about four other residents were in the lobby and EI #6. On 9/1/2021 at 10:07 AM an interview was conducted with EI #6, Screener. EI #6 reported that on 8/29/2021, around lunch she thought, four to six residents were in the lobby and RI #7 got mad that he/she could not get out the front doors at lobby, after trying to exit both doors. EI #6 told RI #7 that he could not get out the doors. EI #6 reported that RI #7 sat down and started hitting the palm of his hand with his other hand's fist. RI #7 stood back up and attempted to exit doors again and got very angry and was mumbling and said he/she would kill everyone up there. EI #6 reported that she was nervous when RI #7 walked near the table she where she was sitting. EI #6 reported the incident to EI #5 and EI #7 and told them exactly what RI #7 said. On 9/1/2021 at 1:55 PM an interview was conducted with EI #5, LPN. EI #5 reported on 7/29/2021 after a late lunch EI #6 reported to her that RI #7 mumbled that he was going to kill everyone. EI #5 reported she went to the front lobby and saw RI #7 pacing at front lobby and EI #7 returned from outside through the lobby doors. EI #5 reported that EI #6 reported to EI #7 and herself that RI #7 said I am going to kill all ya'll but did not direct the statement at anyone. EI #5 reported that she did not report the incident to anyone because she did not feel like it was an actual threat toward any resident or staff. On 9/1/2021 at 2:10 PM an interview was conducted with EI #7, LPN. EI #7 reported she returned from outside through the front lobby around 2:00 to 2:30 PM and EI #7 reported to her that RI #7 said he/she was going to kill everyone. EI #7 reported that RI #8 heard what RI #7 said and was concerned. EI #7 reported that she did not report it to management staff because RI #7 did not make a threat to anyone specifically and was calm each time she observed him/her. On 9/1/2021 at 2:50 PM an interview was conducted with EI #8, Certified Registered Nurse Practitioner (CRNP). EI #8 reported that at the end of July he was notified that RI #7 threatened a resident with bodily harm, and was not sure of the date, but it was before RI #7 was transferred to Geri-psychiatric facility. EI #8 was asked, would he consider a threat by RI #7 to be credible. EI #8 replied, yes. On 9/2/2021 at 9:40 AM an interview was conducted with RI #2. RI #2 reported that over the weekend of 8/29/2021 he/she was in the lobby and RI #7 said he/she was going to kill everyone in the facility. RI #2 reported when she went to the lobby, RI #7 and about 15 other residents were in the lobby, but she could not recall who. RI #7 told everyone in the lobby he/she was hungry and then about a minute later stated he/she was going to kill everyone in there. RI #2 reported that RI #7 stated, I am going to kill everyone in here and all the residents started scattering and leaving the lobby. RI #2 reported that he/she returned to his/her room. RI #2 reported RI #7's statement made her feel unsafe. On 9/2/2021 at 2:30 PM an interview was conducted with EI #2, Abuse Coordinator, DON. EI #2 was asked, on 7/26/2021 at 4:36 PM a nursing note was entered by EI #3 which stated, the resident said the resident across the hall came in his/her room and threatened him/her and he/she was very scared, per facility policy was this an allegation of abuse and what actions should have been taken and when. EI #2 replied, it was an allegation of verbal abuse; and EI #3 should have reported it to her immediately, and she would have reported it to the state agency through online portal and started an investigation. EI #2 was asked, when was the allegation initially reported to her. EI #2 replied, on 8/31/21 at 9:00 AM. EI #2 was asked, why was it not reported to her immediately. EI #2 replied she did not know. EI #2 was asked, what was the concern with the allegation not being reported to her immediately. EI #2 replied, the facility could have some issues with patient safety. EI #2 was asked, since EI #4 was aware, why was she not being held responsible. EI #2 replied, EI #4 reported that she reported to EI #1. EI #2 was asked, why did EI #1 or EI #4 not report the incident to you. EI #2 replied, she did not know. EI #2 was asked, on 8/29/2021, a staff member reported to a nurse that RI #7 was in the lobby with other residents and stated he was going to kill everyone, what should have been done in response to the report to the nurse. EI #2 replied, once the nurse was aware, the staff should have got everyone out of harm's way and safe, once everyone was safe, it should have been reported to her, next the staff should have called the CRNP or physician. None of that was done except moving the resident's out of the lobby. EI #2 was asked, when did she become aware of the incident. EI #2 replied, 9/1/2021 at 10:00 AM. EI #2 was asked, when should the incident have been reported, how, and to who. EI #2 replied, it should have been reported to me immediately, even though we did not have reason to suspect he would carry out the threat, she still would have reported the incident to state agency and began investigation. EI #2 was asked, what was potential harm to other residents when a resident stated that he/she was going to kill everyone, staff were made aware, but no one reported or documented it. EI #2 replied, they should have reported it and documented it because no one can know what might happen and the documentation provides some support if the resident was to act on the threat.

Based on interview, record review, and review of a facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation the facility failed to ensure allegations of verbal abuse were reported to the State Agency within two hours on: 1) 07/26/2021 when Resident Identifier (RI) #9 reported an allegation of verbal abuse to Employee Identifier (EI) #3, Registered Nurse (RN) and EI #4, Licensed Practical Nurse (LPN) and 2) 08/29/2021 when EI #6, Screener reported an allegation of verbal abuse to EI #5, Licensed Practical Nurse (LPN) and EI #7, LPN. This affected three of three residents sampled for abuse. Findings Include: Review of a facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of February 8, 2018 revealed PURPOSE: This Policy (the Policy) is concerned with all incidents . involving resident/guest(s). For the purpose of this Policy, the following terms shall have the following meanings: . Verbal- Verbal abuse is the use of oral . communication . to resident/guest(s) . within hearing distance, regardless of age, abilities to comprehend, Examples of verbal abuse could include .threatening to hurt and saying things to frighten a resident/guest(s) . IV. Identification of Resident/Guest(s) Incidents . d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse . to the Administrator, Director of Nursing, or the Department Supervisor. Immediately means as soon as possible. Any staff members that witnessed, suspect, or that is reported to, are personally obligated to initiate protection and report to supervisor immediately. VI. Investigations and Facility Response to Incidents . a) The facility will report all instances of alleged or suspected abuse, including verbal and mental abuse, .in the following manner: b) Investigation and Reporting Steps . The Administrator/Designee will report to the State Agency and all other required agencies, per regulation. All allegations of abuse . must be reported within two hours. RI #7 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #9 was readmitted to the facility on [DATE]. A review of RI #7's nurses' progress notes dated 07/26/2021 at 4:29 PM revealed RI #7 went into RI #9's room and told RI #9 he/she was going to kill him/her. The note was signed by RI #3 RN. Review of RI #9's nurses' progress notes dated 07/26/2021 at 4:36 PM revealed RI #9 reported the resident across the hall came into RI #9's room and threatened him/her. RI #9 said he/she is very scared. The note was signed by EI #3. Review of a Geri-psychiatric facility History and Physical, with an admitted [DATE] for RI #7 revealed RI #7 was threatening other residents. On 08/31/2021 at 7:05 AM an interview was conducted with Resident Identifier (RI) #9. RI #9 reported that the resident across the hall came into his/her room and when he/she asked the resident to leave, the resident stated he/she was going to kill him/her. RI #9 reported that he/she told the nurse about the incident. RI #9 stated that a person like that should not be there because he/she threatened to kill him/her. On 8/31/2021 at 8:10 AM an interview was conducted with EI #3 RN. EI #3 reported that RI #7's room was on her hall a few months ago and RI #7 was sent to a Geri-Psychiatric facility a because of aggressive behaviors and the last incident was RI #7 going into another resident's room and threatening to kill the other resident, and the other resident was very afraid. EI #3 was asked, who was the other resident. EI #3 replied, RI #9. EI #3 was asked, who was aware of the threat. EI #3 replied, RI #9 told her and she told EI #2, Director of Nursing (DON). EI #3 was asked, when did the incident occur. EI #3 replied, it was after lunch, the nursing note was entered on 7/26/21 at 4:29 PM and it was probably 4:00 PM when the incident occurred. EI #3 was asked if RI #7's comment to RI #9 was verbal abuse. EI #3 replied, to threaten to kill someone, she thought it was. A review of State Agency's, Alabama Department of Public Health, Complaint Tracking System revealed the incident was reported to the facility on [DATE] at 11:15 AM and was reported to the State Agency on 08/31/2021 at 01:17 pm. Review of the summary of the incident reported to the State Agency revealed RI #9 told the surveyor, RI #7 threatened to kill him/her. RI #9 was unsure of when this occurred but said he/she told someone. On 09/1/2021 an interview was conducted with EI #4, Licensed Practical Nurse. EI #4 reported that a day in July she was leaving for the day around 4:30 -5:00 PM and RI #9 stopped her in the hallway and told her that the resident across the hall, EI #7, told him/her that he/she was going to kill him/her. EI #4 reported that RI #9 was anxious and afraid. EI #4 reported that she went to EI #1, Administrator, and reported what RI #9 said. EI #4 reported that EI #1 gave her instruction to place a stop sign barrier at RI #9's door. RI #8 was readmitted to the facility on [DATE]. RI #2 was admitted to the facility on [DATE] On 09/1/21 at 8:15 AM an interview was conducted with RI #8. RI #8 reported that on 08/29/2021 he/she was sitting in the lobby and heard RI #7 say he/she was going to kill everyone after RI #7 went to the doors and tried to get out. RI #8 reported about four other residents were in the lobby and EI #6 was present, the employee who screened those entering the facility. On 09/1/2021 at 10:40 AM an interview was conducted with EI #6, Screener. EI #6 reported that on 08/29/2021, around lunch she thought, four to six residents were in the lobby and RI #7 got mad that he/she could not get out the front doors at the lobby, after trying to exit both doors. EI #6 told RI #7 he/she could not get out the doors. EI #6 reported that RI #7 sat down and started hitting the palm of his/her hand with his/her other hand's fist. RI #7 stood back up and attempted to exit the doors again and got very angry and was mumbling and said he/she would kill everyone up there. EI #6 called EI #5 Licensed Practical Nurse (LPN) and EI #7 LPN, and told them exactly what RI #7 said. On 09/1/2021 at 1:55 PM an interview was conducted with EI #5, LPN. EI #5 reported on 08/29/2021 after a late lunch EI #6 reported to her that RI #7 mumbled that he was going to kill everyone. EI #5 reported she went to the front lobby and saw RI #7 pacing at the front lobby and EI #7 returned from outside through the lobby doors. EI #5 stated that EI #6 reported to EI #7 and herself that RI #7 said I am going to kill all ya'll but did not direct the statement at anyone. EI #5 reported EI #7 was assigned the unit where RI #7's room was located, and she was assigned the other Unit. On 09/1/2021 at 2:10 PM an interview was conducted with EI #7, LPN. EI #7 reported she returned from outside through the front lobby around 2:00 to 2:30 PM and EI #5 reported to her that RI #7 said he/she was going to kill everyone. EI #7 reported that RI #8 heard what RI #7 said and was concerned. EI #5 reported that she did not document or report RI #7's behaviors because RI #7 did not make a threat to anyone specifically and was calm each time she observed him/her. On 09/2/2021 at 9:40 AM an interview was conducted with RI #2. RI #2 reported that over the weekend of 8/29/2021 he/she was in the lobby and RI #7 said he/she was going to kill everyone in the facility. RI #2 reported when she went to the lobby, RI #7 and about 15 other residents were in the lobby, but she could not recall who. RI #7 told everyone in the lobby he/she was hungry and then about a minute later stated he/she was going to kill everyone in there. RI #2 reported that RI #7 stated, I am going to kill everyone in here and all the residents started scattering and leaving the lobby. RI #2 reported that he/she returned to his/her room. RI #2 reported RI #7's statement made her feel unsafe. On 09/2/2021 at 2:30 PM an interview was conducted with EI #2, Abuse Coordinator, DON. EI #2 was asked, on 07/26/2021 at 4:36 PM a nursing note was entered by EI #3 which stated, resident said resident across the hall came in his/her room and threatened him/her. He/she is very scared. When asked, per facility policy was this an allegation of abuse and what actions should have been taken and when, EI #2 replied, it was an allegation of verbal abuse; and EI #3 should have reported it to her immediately, and she would have reported it to the state agency through online portal and started an investigation. EI #2 was asked, when was the allegation initially reported to her. EI #2 replied, on 08/31/21 at 9:00 AM. EI #2 was asked, why was it not reported to her immediately. EI #2 replied she did not know. EI #2 was asked, when was the allegation reported to the State Agency. EI #2 replied, 8/31/21 at 9:28 AM. EI #2 was asked, what was the potential harm to residents when an allegation of abuse was not reported to the State Agency within two hours. EI #2 replied, no one knows what could happen and the resident could act on the threat. EI #2 was asked, when did she become aware of the 08/29/2021 incident with RI #7. EI #2 replied, 09/1/2021 at 10:00 AM. EI #2 was asked, when should the incident have been reported, how, and to who. EI #2 replied, it should have been reported to me immediately, even though we did not have reason to suspect he would carry out the threat, she still would have reported the incident to state agency and began investigation. EI #2 was asked, what was potential harm to other residents when a resident stated that he/she was going to kill everyone, staff were aware, but no one reported or documented it. EI #2 replied, they should have reported it and documented it because no one can know what might happen and the documentation provides some support if the resident was to act on threat. On 09/2/2021 at 3:30 PM an interview was conducted with EI #1, the Administrator. EI #1 was asked, if RI #9's nurses' progress notes dated 07/26/2021 at 4:36 PM, per facility policy was an allegation of abuse and what actions should have been taken and when. EI #1 replied, it was an allegation of verbal abuse. EI #1 continued, the residents should have been separated immediately and then the abuse coordinator should have been notified; the abuse coordinator would have reported it to state agency within two hours; the alleged perpetrator could have been moved to another hall and had someone monitor him/her; then an investigation would have been started. EI #1 was asked, when was the allegation initially reported to her. EI #1 replied, when the state surveyor reported it this week. EI #1 was asked, why was she not notified immediately. EI #1 replied, she did not know; when it was discussed later, she remembered that EI #4 reported to her that RI #9 told EI #4 that RI #7 had been entering and exiting RI #9's room; she told EI #4 to place a stop sign across RI #9's doorway; no one told her anything about RI #7 stating he/she was going to kill RI #9. EI #1 was asked, what was the concern with the allegation not being reported to the abuse coordinator immediately. EI #1 replied, it should have been reported to the abuse coordinator immediately; if not reported to the abuse coordinator the resident could still be in harm or potential for harm. A review of State Agency's, Alabama Department of Public Health, Complaint Tracking System revealed an incident was reported to the facility on [DATE] at 02:00 PM but was not reported to the State Agency until 09/02/2021 at 03:03 PM. Review of the summary of the incident reported on 09/02/2021 revealed that on 8/29/21 RI #7 was observed standing in the front lobby near the window, mumbling, when a staff member thought they heard RI #7 say he/she was going to kill everyone.

Based on interview, record review and review of the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation the facility failed to ensure Resident Identifier (RI) #2 and RI #8 were free from verbal abuse when they and a staff member Employee Identifier (EI) #6, heard RI #7 state he/she was going to kill everyone. The statement by RI #7 made RI #2 and RI #8 feel unsafe. This affected 3 of 11 sampled residents. Findings Include: A facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of February 8, 2018 revealed PURPOSE: This Policy (the Policy) is concerned with all incidents . involving resident/guest (s). For the purpose of this Policy, the following terms shall have the following meanings: . Verbal- Verbal abuse is the use of oral . communication . to resident/guest (s) . within hearing distance, regardless of age, abilities to comprehend, . Examples of verbal abuse could include .threatening to hurt and saying things to frighten a resident/guest (s) . IV. Identification of Resident/Guest(s) Incidents . d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse . to the Administrator, Director of Nursing, or the Department Supervisor. Immediately means as soon as possible. Any staff members that witnessed, suspect, or that is reported to, are personally obligated to initiate protection and report to supervisor immediately. RI #7 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #8 was readmitted to the facility on [DATE]. RI #2 was admitted to the facility on [DATE]. On 9/1/21 at 8:15 AM an interview was conducted with RI #8. RI #8 reported that on 8/28/21 he/she was sitting in the lobby and heard RI #7 say he/she was going to kill everyone after he/she went to the doors and tried to get out. RI #8 reported about four other residents were in the lobby and EI #6, the Screener. On 9/1/2021 at 10:40 AM an interview was conducted with EI #6, Screener. EI #6 reported that on 08/29/2021, around lunch she thought, four to six residents were in the lobby and RI #7 got mad that he/she could not get out the front doors at the lobby, after trying to exit both doors. EI #6 told RI #7 he/she could not get out the doors. EI #6 reported that RI #7 sat down and started hitting the palm of his/her hand with his/her other hand's fist. RI #7 stood back up and attempted to exit the doors again and got very angry and was mumbling and said he/she would kill everyone up there. EI #6 called EI #5 Licensed Practical Nurse (LPN) and EI #7 LPN, and told them exactly what RI #7 said. On 9/1/2021 at 1:55 PM an interview was conducted with EI #5, LPN. EI #5 reported on 8/29/2021 after a late lunch EI #6 reported to her that RI #7 mumbled that he/she was going to kill everyone. EI #5 reported she went to the front lobby and saw RI #7 pacing at front lobby and EI #7 returned from outside through the lobby doors. EI #5 reported that EI #6 reported to EI #7 and herself that RI #7 said I am going to kill all ya'll but did not direct the statement at anyone. EI #7 reported that she did not report the incident to anyone because she did not feel like it was an actual threat toward any resident or staff. On 9/1/2021 at 2:10 PM an interview was conducted with EI #7, LPN. EI #7 reported she returned from outside through the front lobby around 2:00 to 2:30 PM and EI #5 reported to her that RI #7 said he/she was going to kill everyone. EI #7 reported that RI #8 heard what RI #7 said and was concerned. EI #7 reported that she did not report it to management staff because RI #7 did not make a threat to anyone specifically and was calm each time she observed him/her. On 9/1/2021 at 2:50 PM an interview was conducted with EI #8, Certified Registered Nurse Practitioner (CRNP). EI #8 reported that at the end of July he was notified that RI #7 threatened a resident with bodily harm, and was not sure of the date, but it was before RI #7 was transferred to Geri-psychiatric facility. EI #8 was asked, would he consider a threat by RI #7 to be credible. EI #8 replied, yes. On 9/2/2021 at 9:40 AM an interview was conducted with RI #2. RI #2 reported that over the weekend of 8/29/2021 he/she was in the lobby and RI #7 said he/she was going to kill everyone in the facility. RI #2 reported when she went to the lobby, RI #7 and about 15 other residents were in the lobby, but she could not recall who. RI #7 told everyone in the lobby he/she was hungry and then about a minute later stated he/she was going to kill everyone in there. RI #2 reported that RI #7 stated, I am going to kill everyone in here and all the residents started scattering and leaving the lobby. RI #2 reported that he/she returned to his/her room. RI #2 reported RI #7's statement made her feel unsafe.

Based on interview and record review the facility failed to ensure Resident Identifier (RI) #7s care planned interventions to observe and document targeted behaviors were implemented on 8/29/2021 when licensed staff were made aware RI #7 said he/she was going to kill everyone in the presence of staff and residents. This affected one of three residents whose care plans were reviewed. Findings Include: RI #7 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #8 was readmitted to the facility on [DATE]. In an interview with RI #8 on 9/1/20 at 8:15 AM, RI #8 told the surveyor about RI #7 threatening to kill everyone in the lobby on Sunday, (8/29/21) after RI #7 went to the doors and tried to get out. RI #8 stated there were about four residents present and EI #6 who was at the lobby door to perform screening on those who entered the facility. EI #6 then assisted the residents away from the lobby. Review of RI #7's care plans revealed a care plan description of Exhibits Behaviors, wanders, tries to exit doors with a start date of 7/1/21, and an intervention with a start date of 7/1/21 to observe and document target behaviors. Review of RI #7's Administration Record for the month of August 2021 revealed RI #7 had target behaviors to include: threatening others, seeking an exit, agitated behavior, and wandering into other residents' rooms. Review of RI #7s Administration Record for the date 8/29/21 revealed no behaviors occurred for RI #7's target behaviors at any time on 8/29/21. On 9/1/2021 at 10:40 AM an interview was conducted with EI #6, Screener. EI #6 reported that on 8/29/2021, around lunch she thought, four to six residents were in the lobby and RI #7 got mad that he/she could not get out the front doors at lobby, after trying to exit both doors. EI #6 told RI #7 that he/she could not get out the doors. EI #6 reported that RI #7 sat down and started hitting the palm of his/her hand with his other hand's fist. RI #7 stood back up and attempted to exit doors again and got very angry. EI #6 reported the incident to EI #5 and EI #7 and told them exactly what RI #7 said. On 9/1/2021 at 1:55 PM an interview was conducted with EI #5, LPN. EI #5 reported she went to the front lobby and saw RI #7 pacing at front lobby and EI #7 returned from outside through the lobby doors. EI #5 reported EI #7 was assigned the unit where RI #7's room was located, and she was assigned the other Unit. On 9/1/2021 at 2:10 PM an interview was conducted with EI #7, LPN. EI #5 reported that she did not document RI #7's behaviors because RI #7 did not make a threat to anyone specifically and was calm each time she observed him/her. On 9/2/2021 at 1:30 PM an interview was conducted with EI #10, Registered Nurse (RN), Care Plan Coordinator. EI #10 was asked, what did RI #7's care plan guide staff to observe, and document related to behaviors. EI #10 replied, in the exhibits behaviors care plan, it indicated that his behaviors were wanders, tries to exit doors, physically aggressive toward others, history of talking to himself, threatening others, refusing Activity of Daily Living (ADL) care, and agitation; the care plan said to observe and document target behaviors. EI #10 was asked, what were RI #7's target behaviors. EI #10 replied, the behaviors listed in the care plan, wanders, tries to exit doors, physically aggressive toward others, history of talking to himself, threatening others, refusing Activity of Daily Living (ADL) care, and agitation. EI #10 was asked, on 8/29/21 it was reported to a nurse that RI #7 was trying to exit the building through the lobby, should that have been documented. EI #10 replied, yes. EI #10 was asked, on 8/29/21 it was reported to a nurse that RI #7 was heard stating that he was going to kill everyone while in the presence of other residents, should that have been documented. EI #10 replied, yes. EI #10 was asked, why do staff document behaviors. EI #10 replied, so the behaviors can be monitored by social services and nurses to see if there was a changed. On 9/2/2021 at 5:15 PM an interview was conducted with EI #2, RN, Director of Nursing. EI #2 was asked, why was it important that the care plan intervention to observe and document targeted behaviors be followed. EI #2 replied, so nursing staff can determine when behaviors are changing from observation of the resident. EI #2 was asked, if RI #7's behavior on Sunday 8/29/2021 when he/she stated he/she was going kill everyone was documented, would that have changed anything. EI #7 replied, she would have seen the documentation on Monday, 8/30/2021 and followed up to determine what actions needed to be taken.

Based on record review, interview and review of a facility policy titled Distressed Behavior Management Program, the facility failed to ensure licensed staff identified, documented, and communicated Resident Identifier (RI) #7's target behavior of threatening other residents on 8/29/2021. RI #7 was witnessed by Employee Identifier (EI) #6 and other residents present, stating he/she was going to kill everyone. This affected one of one resident reviewed for dementia care. Findings Include: A facility policy titled Distressed Behavior Management Program with an effective date of March 12, 2018 revealed PURPOSE: Identifying resident/guest(s) who currently exhibit some type of distressed behavior symptoms for which additional or new treatment programs may be considered. STANDARD: Resident/Guest(s) who display mental or psychosocial adjustment difficulty should receive appropriate services, in an attempt to correct the problem. PROCESS: Assessment a) Behaviors should be identified through . staff interaction. d) The Care Plan Team should decide which resident/guest(s) need behavior management program vs. resident/guest(s) that are care planned with appropriate interventions. RI #7 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #8 was readmitted to the facility on [DATE]. Review of RI #7's Administration Record for the month of August 2021 revealed RI #7 had target behaviors to include: threatening others, seeking an exit, agitated behavior, and wandering into other residents' rooms. Review of RI #7s Administration Record for the date 8/29/21 revealed no behaviors occurred for RI #7's target behaviors at any time 8/29/21. In an interview with RI #8 on 9/1/20 at 8:15 AM, RI #8 told the surveyor about RI #7 threatening to kill everyone in the lobby on Sunday, (8/29/21) after RI #7 went to the doors and tried to get out. RI #8 stated there were about four residents present and EI #6 who was at the lobby door to perform screening on those who entered the facility. EI #6 then assisted the residents away from the lobby. On 9/1/2021 at 10:40 AM an interview was conducted with EI #6, Screener. EI #6 reported that on 08/29/2021, around lunch she thought, four to six residents were in the lobby and RI #7 got mad that he/she could not get out the front doors at the lobby, after trying to exit both doors. EI #6 told RI #7 he/she could not get out the doors. EI #6 reported that RI #7 sat down and started hitting the palm of his/her hand with his/her other hand's fist. RI #7 stood back up and attempted to exit the doors again and got very angry and was mumbling and said he/she would kill everyone up there. EI #6 called EI #5 Licensed Practical Nurse (LPN) and EI #7 LPN, and told them exactly what RI #7 said. On 9/1/2021 at 1:55 PM an interview was conducted with EI #5, LPN. EI #5 reported on 8/29/2021 after a late lunch EI #6 reported to her that RI #7 mumbled that he was going to kill everyone. EI #5 reported she went to the front lobby and saw RI #7 pacing at the front lobby and EI #7 returned from outside through the lobby doors. EI #5 stated that EI #6 reported to EI #7 and herself that RI #7 said I am going to kill all ya'll but did not direct the statement at anyone. EI #5 reported EI #7 was assigned the unit where RI #7's room was located, and she was assigned the other Unit. On 9/1/2021 at 2:10 PM an interview was conducted with EI #7, LPN. EI #7 reported that the morning of 8/29/2021 RI #7 followed her during medication pass but did not have any behaviors or make any statements; RI #7 did require re-direction that morning after entering another resident's room, but there was no incident, and he/she was easily re-directed. EI #7 reported she returned from outside through the front lobby around 2:00 to 2:30 PM and EI #5 reported to her that RI #7 said he/she was going to kill everyone. EI #7 reported that RI #8 heard what RI #7 said and was concerned. EI #5 reported that she did not document or report RI #7's behaviors because RI #7 did not make a threat to anyone specifically and was calm each time she observed him/her. On 9/1/2021 at 4:05 PM an interview was conducted with EI #9, LPN, Charge Nurse. EI #9 was asked, what was the facility's policy or process for observation and documenting behaviors for residents with dementia and anti-psychotic medication use. EI #9 replied, when electronic charting (e-charting) they could enter nursing notes in the e-chart if the resident had or was having behaviors. EI #9 was asked, was there anywhere on the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/2/2021 at 1:30 PM an interview was conducted with EI #10, Registered Nurse (RN), Care Plan Coordinator. EI #10 was asked, what did RI #7's care plan guide staff to observe, and document related to behaviors. EI #10 replied, in the exhibits behaviors care plan, it indicated that his behaviors were wanders, tries to exit doors, physically aggressive toward others, history of talking to himself, threatening others, refusing Activity of Daily Living (ADL) care, and agitation; the care plan said to observe and document target behaviors. EI #10 was asked, what were RI #7's target behaviors. EI #10 replied, the behaviors listed in the care plan, wanders, tries to exit doors, physically aggressive toward others, history of talking to himself, threatening others, refusing Activity of Daily Living (ADL) care, and agitation. EI #10 was asked, on 8/29/21 it was reported to a nurse that RI #7 was trying to exit the building through the lobby, should that have been documented. EI #10 replied, yes. EI #10 was asked, on 8/29/21 it was reported to a nurse that RI #7 was heard stating that he was going to kill everyone while in the presence of other residents, should that have been documented. EI #10 replied, yes. EI #10 was asked, why did staff document behaviors. EI #10 replied, so the behaviors could be monitored by social services and nurses to see if there was a changed. On 09/2/2021 at 2:30 PM an interview was conducted with EI #2, RN, Director of Nursing (DON). EI #2 was asked, how had the plan of treatment or discharge plan for RI #7 changed since 08/31/2021. EI #2 replied, on 09/1/2021, she started paperwork process for psychiatric commitment for RI #7; today a mental health professional interviewed RI #7 and determined his condition was more medical than mental; a Geri-psychiatric facility called that day and she sent them the medical information for RI #7, and they were going to check if RI #7 could be admitted for short-term treatment. EI #2 was asked, why were those actions taken. EI #2 replied, the facility thought they needed to get a commitment after becoming aware of recent behavior and what happened in the lobby on 08/29/21. EI #2 was asked, what was the facility's policy and procedures for staff monitoring or observing and documenting behaviors for residents with behavioral diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 was asked, who was responsible to review documented behaviors to identify a pattern, decline, or increased frequency of behaviors. EI #2 replied, it should be her and she looked at them every day. EI #2 was asked, what was the facility's behavior management program. EI #2 was replied, residents were identified, and a task was added on EMAR to monitor for behaviors, and a behavioral health provider was consulted and provided services. EI #2 was asked, was RI #7 on Behavioral Management program. EI #2 replied, yes. EI #2 was asked, when did she become aware of the incident that occurred in the lobby with RI #7 on 08/29/21. EI #2 replied, on 09/1/2021 at 10:00 AM. On 09/2/2021 at 5:15 PM a follow up interview was conducted with EI #2, RN, Director of Nursing. EI #2 was asked, why was it important that the care plan intervention to observe and document targeted behaviors be followed. EI #2 replied, so nursing staff can determine when behaviors are changing from observation of the resident. EI #2 was asked, if RI #7's behavior on Sunday 08/29/2021, when he/she stated he/she was going kill everyone, had been documented, would it have changed anything. EI #7 replied, she would have seen the documentation on Monday, 08/30/2021 and followed up to determine what actions needed to be taken. EI #2 was asked, would the actions she took on 09/1/2021 have been taken sooner. EI #2 replied, yes.

Based on observation, interviews, and review of a facility policy titled Hand Hygiene, the facility failed to ensure Certified Nursing Assistants (CNA)s did not clean Resident Identifier (RI) #70, then with the same soiled gloves touch the closet door and the clean brief during the provision of incontinent care. This was observed on 12/4/19 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled Hand Hygiene with an effective date of 9/1/17 revealed: III. Hand Hygiene . The following is a list of some situations that require hand hygiene. After handling soiled . RI #70 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 12/03/19 at 11:40 AM, Employee Identifier (EI) #3, CNA and EI #4, CNA were observed providing incontinent care for RI #70. EI #3 and EI #4, gathered the needed supplies, washed their hands, and put on gloves. EI #4 loosened the soiled brief and folded it from the center down. EI #4 performed the incontinent care. Both assisted RI #70 to turn to the right side. EI #4 wiped the buttock area. EI #4 with the same gloves opened the resident's closet door and removed a clean brief. While the resident was turned to the right side, EI #4 folded the soiled brief in towards the center of the bed and placed the clean brief with the same soiled gloves. Both CNAs assisted the resident to turn towards the left side. EI #3, CNA, removed the soiled brief and discarded it in the trash bag. With the same gloves, EI #3 had touched the soiled brief with, she then unfolded the clean brief, and secured it. On 12/03/19 at 12:00 PM, an interview was conducted with EI #3. EI #3 was asked when should staff wash their hands and change gloves during incontinent care. EI #3 replied, before starting and after finishing. EI #3 was asked if she removed the soiled brief and then with the same gloves unfolded and secured the clean brief. EI #3 replied, yes. EI #3 was asked, when should staff touch a clean brief with soiled gloves. EI #3 replied, they should not. EI #3 was asked, why should staff not touch the clean brief after removing the soiled brief with the same gloves. EI #3 replied, infection control. On 12/03/19 at 12:05 PM, an interview was conducted with EI #4, CN[NAME] EI #4 was asked to recap what she did after she cleaned RI #70 and needed a clean brief. EI #4 replied, after cleaning the resident she noticed she did not have a clean brief. EI #4 said she opened the closet, got a clean brief, and put it under the resident. EI #4 was asked, when should staff change gloves and wash hands during incontinent care. EI #4 replied, before starting, after cleaning, and before she put the clean brief on the resident. EI #4 was asked if she changed gloves and washed her hands before getting the clean brief from the closet and placing it under the resident. EI #4 replied, no. EI #4 was asked, if she touched the closet door and the clean brief with the soiled gloves. EI #4 replied, yes. EI #4 was asked, what would the harm be in touching the closet door and a clean brief with the same gloves worn to clean the resident. EI #4 replied, infection control. On 12/04/19 at 4:41 PM, an interview was conducted with EI #2, Licensed Practical Nurse, Infection Control/ Staff Education Nurse. EI #2 was asked, when should staff change gloves during incontinent care. EI #2 replied, any time staff touch anything dirty; the gloves become contaminated and staff should remove gloves, wash their hands, and put on clean gloves. EI #2 was asked when should the CNAs clean a resident and then with the same gloves touch the closet door, a clean brief, and place the clean brief under the resident. EI #2 replied, they should never do that. EI #2 was asked, what would the harm be in the staff cleaning a resident and with the same soiled gloves touching the closet door and a clean brief before placing the clean brief under a resident. EI #2 replied, infection control and spreading germs.

Based on record review and interview, the facility failed to ensure a care plan was developed addressing hospice following Resident Identifier (RI) #61's admission to hospice services on 8/19/18. This affected one of 21 sampled residents for whom care plans were reviewed. Findings Include : RI #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #61's (MONTH) (YEAR) Physician order [REDACTED]. However, review of RI #61's current comprehensive care plans revealed no care plan addressing hospice services. On 12/13/18 at 10 :35 AM, Employee Identifier (EI) # 7, Registered Nurse (RN)/Minimum Data Set Assistant, was interviewed. EI #7 stated RI #61 was admitted to hospice on 8/19/18. She also confirmed this was reflected on RI #61's most recent assessment. When asked if RI #61's comprehensive care plans included a care plan specific to hospice services, EI #7 said no. When asked what the potential harm could be in not having care plans to address the resident's current status, EI #7 replied, the resident may not get the proper care they need.

Based on observation, interview and review of facility policies titled Perineal Care and Hand Hygiene, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands between glove changes, wiped from front to back during incontinent care and did not touch a clean brief with soiled gloves while providing incontinent care to Resident Identifier (RI) #8. This affected one of one resident observed during the provision of incontinent care. Findings Include: A review of a facility policy titled Perineal Care, with an effective date of 10/1/10, revealed: . PR[NAME]ESS: . II. a) wash the pubic area first . wash downward . Always wash downward toward the anus to prevent the spread of infection. A review of a facility policy titled Hand Hygiene, with an effective date of 9/1/17, revealed: Hand Hygiene . III. After removing gloves . RI #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 12/11/18 at 10:45 AM, Employee Identifier (EI) #4, CNA, was observed assisting the nurse provide wound care to RI #8 by holding the resident. RI #8 was observed with BM (Bowel Movement) in the brief as the brief was removed for the treatment. EI #4 cleaned the BM from RI #8's buttocks only, then changed her gloves without washing her hands. EI #4 continued to hold RI #8 while the nurse completed the wound care. EI #4 placed and secured a clean brief under RI #8. The surveyor asked EI #4 if she had completed the brief change. EI #4 replied, yes. The surveyor asked EI #4 to pull the brief back and wipe the resident. The surveyor observed BM on the wipe. On 12/11/18 at 11:00 AM, an interview was conducted with EI #4. EI #4 was asked what was the policy on hand washing when changing gloves. EI #4 replied, they were supposed to wash their hands when they change gloves every time. EI #4 was asked what was the policy on the direction to wipe during incontinent care. EI #4 replied, wipe down. EI #4 was asked what direction did she wipe. EI #4 replied, up. EI #4 was asked if RI #8 had bowel movement. EI #4 replied, yes. EI #4 was asked what was the harm in wiping in the wrong direction. EI #4 replied, cross contamination. EI #4 was asked what was the harm in not washing hands between glove changes. EI #4 replied, could spread germs or BM. EI #4 was asked what was the harm in touching a clean brief with the same gloves she had on to clean BM from the resident. EI #4 replied, contamination. On 12/12/18 at 2:09 PM, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked what was the policy on when to wash hands during glove changes while performing incontinent care. EI #1 replied, any time staff changes gloves they are to wash their hands. EI #1 was asked what was the policy on which direction to wipe a resident while performing incontinent care. EI #1 replied, they were to wipe in a front to back direction. EI #1 was asked when should a CNA wipe from the buttocks towards the front. EI #1 replied, never. EI #1 was asked what was the harm in staff wiping from the back to the front. EI #1 replied, could introduce bacteria into the urinary tract. EI #1 was asked when should staff touch a clean brief with soiled gloves they had on to clean BM from a resident. EI #1 replied, never. EI #1 was asked what was the harm in a CNA touching a clean brief with the same soiled gloves they had on to clean BM from a resident. EI #1 replied, could spread bacteria.

Based on observation, interview and review of a facility policy titled Contact Precautions, the facility failed to ensure a Certified Nursing Assistant (CNA) wore the proper Personal Protective Equipment (PPE) while providing care for Resident Identifier (RI) #5, a resident on transmission based precautions. This affected one of two residents sampled for transmission based precautions. Findings Include: A review of a facility policy titled Contact Precautions, with an effective date of 9/1/17, revealed: PURPOSE: It is the intent of this facility to use contact precautions in addition to Standard Precautions for resident/guest(s) known or suspected to have serious illnesses easily transmitted by direct resident/guest contact or by contact with items in the resident/guest(s) environment . III. GOWNS A gown should be donned prior to entering the room . RI #5 was admitted to the facility 6/19/18 and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of a hand written order by the physician on a facility form titled physician's orders [REDACTED].#5: .12/7/18 culture right eye . Contact Isolation. On 12/11/18 at 8:40 AM Employee Identifier (EI) #3, Certified Nursing Assistant, was observed providing morning care for RI #5. EI #4 was observed to only have on gloves and no gown. On 12/11/18 at 9:00 AM an interview was conducted with EI #3. EI #3 was asked if RI #5 was on isolation. EI #3 replied, yes for eye infection. EI #3 was asked what PPE should she have on for this type of isolation. EI #3 replied, gown and gloves. EI #3 was asked why she did not have on a gown. EI #3 replied, she just did not put it on. EI #3 was asked what was the harm in not having the proper PPE on while performing care for a resident on isolation. EI #3 replied, spreading germs and infection. On 12/12/18 at 1:55 PM, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked what was the facilty policy for contact isolation. EI #1 replied, staff should wear a gown and gloves. EI #1 was asked if a resident was on contact isolation for the right eye, what type PPE was required. EI #1 replied, a gown and gloves. EI #1 was asked what would the harm be in the staff not using the proper PPE for contact isolation. EI #1 replied, the staff could spread the infection.

Based on interviews and review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure staff implemented one of seven components of the abuse policy. Licensed staff failed to report Resident #23's allegation of physical abuse to the Administrator or designee in accordance with facility policy. This affected one of three residents reviewed for abuse concerns. Findings include: Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, effective 03/24/2017, revealed the following: PURPOSE: . Certain incidents and accidents involving residents . must also be reported to the appropriate state agencies . VI. Investigations and Facility Response to Incidents or Accidents a) The facility will report all instances of alleged or suspected abuse . in the following manner: b) Investigation and Reporting Steps - Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately. - The Administrator/Designee will report to state agency per regulations. All allegations of abuse . are to be reported immediately, but not later than 2 (two) hours after the allegation is made . On 2/21/18 at 11:52 AM Resident #23 reported that a curly-haired lady of medium height pulled the tendons in his/her leg the previous month. Resident #23 indicated he/she reported this to the nurse, Employee Indentifier (EI) #1, Registered Nurse (RN). Resident #23 said the incident made him/her feel belittled. On 2/21/18 at 4:57 PM, EI #1, RN, was asked if Resident #23 told her anything about being mistreated. EI #1 said she thought the day prior the resident reported he/she did not like a particular Certified Nursing Assistant (CNA), EI #2, because she drug him/her out of the bed and broke his/her legs. When asked who she had reported this allegation to, EI #1 said she thought she told EI #3, the Director of Nursing(DON)/Abuse Coordinator. EI #1 then went to discuss the allegation with EI #3. Upon her return, she said the DON was not aware of Resident # 23's allegation. EI #1 said she should have reported the allegation to EI #3 because she is the Abuse Coordinator, and is the one they are to report incidents of abuse to. EI #1 further explained that, even though Resident #23 sometimes says things that are not true, she should have reported it to the DON so she could determine how to handle it. On 2/21/18 at 5:27 PM EI #3, the DON/Abuse Coordinator said she was not aware of Resident #23's allegation of a CNA dragging him/her around and breaking his/her legs the previous day. EI #3 said she was unaware an allegation had been made until a surveyor asked her if they had any ongoing investigations into alleged abuse involving Resident #23.

Based on record reviews, observations, review of facility policy on Three Compartment Sink Sanitization, Food Receipt and Storage, and Sanitation Principles and interviews, the facility failed to ensure: 1) the robo coupe was allowed to air dry before storing away on 1/24/2017, 2) dented cans were not in with regular food cans on 1/24/2017 and, 3) plates were not stained during tray line on 1/25/2017. This had the potential to affect 78 of 79 residents who receives meals from the kitchen. Findings Include: A review of a policy titled, Three Compartment Sink Sanitization with an effective date of April 20, 2007 revealed: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses PROCESS: .Step Three . allow pots/utensils to air dry; Store pots upside down . On 1/24/2017 at 2:45 p.m., the surveyor toured the kitchen. The robo coupe was on the base of the equipment. When the surveyor took the lid off the robo coupe, there was water on the inside around the edge of the robo coupe. On 11/26/2017 at 8:40 a.m., an interview was conducted with (Employee Identifier), dietician, EI #3. EI #3 was asked what was in the robo coupe on 1/24/2017. EI #3 replied, water. EI #3 was asked did the robo coupe have a lid on it. EI #3 relied, yes ma'am. EI #3 was asked why was the water in there. EI #3 replied, they did not inspect it after air drying. EI #3 was asked who was responsible for making sure equipment is dry. EI #3 replied, the dishwashers. EI #3 was asked how should the pan part of the robo coupe be allowed to dry. EI #3 replied, it should air dry. EI #3 was asked what was the potential harm when water was in the robo coupe and the lid was on. EI #3 replied, he did not have an answer for that. On 11/26/2017 at 9:25 a.m., an interview was conducted with the cook, EI #5. EI #5 was asked why was she told to take the robo coupe back to the kitchen dish room. EI #5 replied, the dietician said there was water in it. EI #5 was asked who was responsible for making sure equipment was dry. EI #5 replied, the cook or who ever take it to the dish room and back to store it. EI #5 was asked what was the facility policy on how to dry a blender after washing. EI #5 replied, let it air dry, and turn it face down. On 11/26/2017 at 10:15 a.m., an interview was conducted with EI #4, dietary manager. EI #4 was asked what was in the robo coupe on 1/24/2017. EI #4 replied, water. EI #4 was asked did the robo coupe have a lid on it. EI #4 replied, yes. EI #4 was asked why was the water there. EI #4 replied, it did not drop out. EI #4 was asked who was responsible for making sure equipment was dry. EI #4 replied, the one using it. EI #4 was asked what was the facility policy on how to dry a blender. EI #4 replied, wash it in the dish room and air dry. A review of a facility policy titled, Food Receipt and Storage with an effective date of August 21, 2013 revealed: .PROCESS: I. Receiving Foods: . b. All items delivered should be checked as follows: .cans are intact; free of dents, . II. Storage of Foods: .f. Place dented .in a separate area to be returned to the vendor . On 1/24/2017 at 2:15 p.m., the surveyor toured the dry storage area in the kitchen. There were two six pound cans of sphagetti sauce with dents in them. One can had a dent at the top of the can and the other had a dent at the bottom of the can. On 11/26/2017 at 9:00 a.m., and interview was conducted with the dietician. EI #3 was asked what canned items in dry storage were in with regular cans. EI #3 replied, tomatoes. EI #3 was asked what was the name of these cans. EI #3 replied, sphagetti sauce. EI #3 was asked how many cans were removed from the regular can section. EI #3 replied, two. EI #3 was asked what was the facility policy on dented cans be in with regular cans. EI #3 replied, they should be separated. EI #3 was asked who was responsible for removing dented cans. EI #3 replied, the person who received it, the cook, or the preparation cook. On 11/26/2017 at 11:25 a.m., an interview was conducted with EI #4. EI #4 was asked what canned items were in dry storage on 1/24/2017. EI #4 replied, sphagetti sauce. EI #4 was asked how many cans was removed from the regular can section. EI #4 replied, two. EI #4 was asked what was the facility policy on dented cans in with regular cans. EI #4 replied, they were suppose to put them in the dented can section. EI #4 was asked who was responsible for removing dented cans. EI #4 replied, everyone who check grocery. A review of a facility policy titled, Sanitation Principles with an effective date of February 1, 2002 revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.PROCESS: c. china and glassware that cannot be sanitized, . or loss of glaze, should be discarded . On 1/25/2017 at 11:05 a.m., the surveyor observed during the lunch tray line the cook serving plates with a brown looking stain in them. On 1/26/2017 at 11:05 an interview was conducted with EI #4. EI #4 was asked did you see the plates moved to the side. EI #4 replied, yes. EI #4 was asked what was in the plates. EI #4 replied, specks and stain. EI #4 was asked why was there stains in the plates. EI #4 replied, the plates were used in the microwave and it makes stains. EI #4 was asked what was the facility policy on serving stained plates. EI #4 replied, to de-stain the plates with a de-stainer and if it did not come out throw the plates away. EI #4 was asked who was responsible for making sure residents were not served food on stains plates. EI #4 replied, the person who serve the plate and the person who pulled the dishes. On 1/26/2017 at 11:15 a.m., an interview was conducted with EI #5. EI #5 was asked how many plates did she removed due to stains. EI #5 replied, four or five. EI #5 was asked what was the facility policy on serving stained plates. EI #5 replied, the plates should be deep cleaned and damaged plates should be reordered. EI #5 was asked why was there stains in the plates. EI #5 replied, they use the plates in the microwave. EI #5 was asked how do you think residents would feel eating from stained plates. EI #5 replied, she did not know, they were just stained. On 1/26/2017 at 11:30 a.m., an interview was conducted with EI #6, dishwasher aide. EI #6 was asked did she pull plates on the dry side of the dish room on 1/25/2017. EI #6 replied, yes ma'am. EI #6 was asked did she observed stained plates. EI #6 replied, a few of them. EI #6 was asked what did she do with the stained plates. EI #6 replied, she put them with the other plates. They were out of stain solution. EI #6 was asked what was the facility policy on making sure residents were not served food on stained plates. EI #6 replied, she was not sure. EI #6 was asked who was responsible for making sure residents were not served food on stained plates. EI #6 replied, she was and the cook when they grabbed them.

Based on an observation, interviews, a review of Potter and Perry Fundamental of Nursing, a review of the facility's policy on Perineal Care and record reviews, the facility failed to ensure a Certified Nursing Assistance (CNA) did not wipe feces downwards from the perineum area (closet to the back) towards the rectum. The facility's policy on Perineal Care instructs the staff to wash in the direction of the anus area upward toward the back. Resident Identifier (RI) #1 was identified as having a history of Urinary Tract Infection [MEDICAL CONDITION]. This deficient practice affected RI #1, one of three residents observed for incontinence care. Findings include: A review of POTTER & PERRY Fundamentals of Nursing, 9th Edition with a copyright date of 2013 revealed: .page- 858 . Chapter 40-1 .Perineal Care . (2) . (a) Apply clean gloves . (c) .Use nondominant hand to . wash carefully in skinfolds. Wipe in direction from perineum to rectum. Repeat on opposite side with separate section of washcloth. Rinse and dry thoroughly. (d) . With dominant hand, wash downward from pubic area toward rectum in one smooth stroke . Wash middle and both sides of perineum. Use separate section of cloth for each stroke. Clean thoroughly . Rational . Perineal care involves thorough cleaning of patient's external genitalia and surrounding skin. Skinfolds may contain body secretions that harbor microorganisms. Wash the anal area, moving upward toward the back. (4) If fecal material is present, enclose in a fold of underpad or toilet tissue and remove with disposable wipes. (5) Cleanse buttocks and anus, washing front to back .Cleanse, rinse, and dry area thoroughly. A review of the facility policy titled Perineal Care with an effective date of 10/1/2010 revealed the following: . PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown. PROCESS: I. c) Remove any fecal matter or urine wiping with tissue from front to back II. a) Wash the pubic area first. Always wash downward toward the anus to prevent the spread of infection. b) Rinse, dry and inspect the perineal area and then the anal area. RI #1 was readmitted to the facility on [DATE]. RI #1's [DIAGNOSES REDACTED]. RI #1's quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 12/26/2016 revealed RI #1 was always incontinent of bowel and bladder and was dependent on staff for hygiene. On 1/25/2017 at 4:45 p.m., EI #7 CNA provided incontinent care for RI #1. EI #7 cleaned (BM) bowel movement from RI #1's buttocks and wiped from the back toward front two times before wiping toward the back. On 1/25/2017 at 5:15 p.m., EI #7 was asked what the facility policy was for how to provide incontinent care. EI #7 said, to clean from the front to the back. EI #7 was asked what she had actually done, to which she replied, she had wiped from the back toward the front two times then changed, from front to back. When asked why she wiped from the back to the front when removing BM from the buttocks, EI #7 said, she was nervous. When asked why she should wipe from the front of the perineum toward the back, EI #7 said, to avoid infection because it brings bacteria toward the front.

Based on observations, interviews, and record reviews, the facility failed to ensure: Certified Nursing Assistants (CNAs) washed their hands and changed gloves to prevent the potential for cross contamination during incontinence care observations. These deficiencies affected RI (Resident Identifier) #1, and RI #4, two of three residents sampled for bowel and bladder incontinence. Findings include: A review of the Centers for Disease Control and Prevention recommendations with most recent update of November 9, 2011 revealed: .Protocol for Hand Hygiene and Glove Use Observations . Recommendations Hand hygiene . 3. Examples of situations when hand hygiene is indicated: 1. Before and after direct patient contact . 6. After contact with items/surfaces at patient stations . Glove use 1. In general, gloves should be worn prior to contact with patients at the treatment station and potentially contaminated surfaces ( .environmental surfaces) . Gloves should always be changes between patients and between clean and contaminated sites on the same patient. A review of the facility policy titled: Hand Hygiene with an effective date of 11/14/2016 revealed the following: . STANDARD: Hand washing should be performed between procedures with residents . based upon the principle that all blood, body fluids, secretions, excretions . may contain transmissible infectious agents. A review of RI #4's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly MDS (Minimum Data Set) with a ARD (Assessment Reference Date) of 01/03/17, revealed, RI #4 required total assistance with all activities of daily living. RI #6 was coded as always incontinent of bladder and bowel. On 01/27/16 at 2:35 p.m., an observation was made of incontinence care for RI #4. The incontinence care was performed by EI (Employee Identifier) #1, a second CNA, EI #2 assisted with the care. EI #1 and EI #2 applied gloves without being observed to wash their hands. They removed the adult brief from RI #4's bottom. A small amount of soft brown formed stool was observed on the resident's bottom. EI #1 attempted to remove the stool from RI #4's bottom. The CNAs did not change gloves or wash their hands. They then applied a clean brief for RI #4 with the contaminated gloves. Both staff repositioned the resident on the right side with the contaminated gloves. EI #1 and EI #2 removed their gloves. EI #2 washed her hands. EI #1 took the soiled items to the soiled utility room, and then washed her hands. This was the only time the surveyor observed EI #1 wash her hands. On 01/25/17 at 4:35 p.m., an interview was conducted with EI #2. The surveyor asked EI #2 when should she wash her hands during incontinence care. EI #2 stated, When we knock on the door, go in and wash hands. If we touch the bed rail we wash our hands, and if we touch the sheet we wash hands. If they have a bowel movement, we wash our hands and change gloves again. After was clean them up we wash hands and change gloves again, and put the brief on. The surveyor asked EI #2 when did she wash her hands during the incontinence care observation for RI #4. EI #2 stated, I washed my hands when I got in there and washed when we got through with his/her. I washed my hands and sanitized. The surveyor asked EI #2 when did EI #1 wash her hands during the above incontinence care observation. EI #2 stated, She did not. She did not sanitize. On 01/25/17 at 5:00 p.m., an interview was conducted with EI #1. The surveyor asked EI #1 when should she wash her hands during incontinence care. EI #1 stated, When you first walk in the room, after knocking, and every time we touch something dirty, we wash our hands. The surveyor asked EI #1 when did she wash her hands while providing incontinence care for RI #4. EI #1 stated, I washed them when I went in the restroom and put my gloves on before I got started. The surveyor asked EI #1 when did she wash her hands after she completed the incontinence care. EI #1 stated, I know I was supposed to wash my hands before I left the room. I washed them after I got to the soiled utility room. The surveyor discussed the above incontinence care with EI #1, and asked what was the concern. EI #1 stated, It is a contamination concern. RI #1 was readmitted to the facility on [DATE]. RI #1's [DIAGNOSES REDACTED]. RI #1's quarterly MDS with an Assessment Reference Date of 12/26/2016 revealed RI #1 was always incontinent of bowel and bladder and was dependent on staff for hygiene. On 1/25/2017 at 4:45 p.m., EI #7 CNA provided incontinent care for RI #1. EI #7 cleaned (BM) bowel movement from RI #1's buttocks and without changing gloves or washing her hands she touched the clean brief that was applied to RI #1, fastened the clean brief and repositioned RI #1 in the bed. On 1/25/2017 at 5:15 p.m., EI #7 was asked, when she changed her gloves and washed her hands when she provided perineal care for RI #1. EI #7 said, before starting and after providing perineal care. EI #7 was asked why she touched the clean brief with the soiled gloves, to which she responded, she was not thinking. When asked why she continued with care after her gloves became soiled, EI #7 replied, she forgot to change them. EI #7 was asked what the potential for harm was when care was performed while wearing soiled gloves. She replied, the soiled gloves could spread bacteria. On 1/26/2017 at 1:35 p.m., EI #8 RN (Registered Nurse) Infection Control, was asked how staff were trained to wash their hands and change gloves during incontinent care. EI #8 said, they should wash hands after removing gloves every time. When asked why CNAs did not change gloves and wash their hands after gloves became soiled, before touching clean and continuing care for the resident, EI #8 said, she did not know why and they were all taught how to wash, clean and change gloves. When asked why a clean brief was touched and applied with soiled gloves, EI #8 replied, you do not want soiled to get on a clean brief. When asked what the concern was when handwashing was not done after stool was removed from a resident before continuing with care, EI #8 said, the spread of infection and being unclean.

Based on observation, record review and interview, the facility failed to ensure lettuce in the cooler was labeled, magic cups in the milk box were labeled and frozen on 1 of 1 day of the survey. This had the potential to affect 79 of 81 residents who receive meal from the kitchen. Findings Include: A facility policy titled, Dietary Service Manuel . Policy title: Leftover Food Storage and Use . with an effective date of August 15, 2009 revealed: PURPOSE: To assure that food borne illnesses are avoided. PROCESS: b. Leftover foods should be covered, labeled and dated. Another facility policy titled, Dietary Service Manual .Policy Title: Therapeutic Supplement with an effective date: August 13, 2013 revealed: PURPOSE: Residents may require supplementation of their meal plan in order to attain or maintain acceptable parameters of nutrition. PROCESS: b. Shakes/supplements should be labeled with the date . with a used-by date . On 12/29/15 at 9:00 AM, the surveyor observed lettuce opened, but not in the original container. The lettuce was in a zip lock bag with no open or use by date. On 12/29/2015 at 9:00 AM, The surveyor observed two Magic Cups Ready Care supplement not frozen in the milk box with no label on it. On 12/31/2015 at 3:00 PM, an interview was conducted with the Dietary Manager, EI (Employee Identifier) #4. EI #4 was asked what was the open and use by date on the lettuce that was in the zip lock bag. EI #4 replied it did not have an open date. EI #4 was asked why was there no use by date on the zip lock bag. EI #4 replied staff put it in the cooler without a date. EI #4 was asked what was the facility policy on labeling. EI #4 replied label everything. Put the name on the item, put the time you put it in the cooler, the date you fixed it and the use by date. EI #4 was asked who was responsible for labeling. EI #4 replied the person who was making it or fixing it. EI #4 was asked when should items be labeled. EI #4 replied as soon as they are prepared for storage. EI #4 was asked what was the potential harm when food items were not labeled. EI #4 replied a very bad illness, it could make people sick and you would know how long it was good for. EI #4 was asked where should supplements be kept. EI #4 replied in the freezer. EI #4 was asked who was responsible for putting frozen items in the freezer. EI #4 replied different people. EI #4 said it depended on each person's schedule. EI #4 was asked was the supplement frozen solid. EI #4 replied no ma'am. EI #4 was asked why should frozen items be kept frozen solid. EI #4 replied they could lose consistency and would not be fit to eat. EI #4 was asked what was the potential harm when food items were not at the proper temperature or labeled. EI #4 replied they could make you sick. EI #4 was asked if the supplement had a use by date on it. EI #4 replied no ma'am.

Based on observation, interview and record review, the facility failed to ensure two signatures were present on the November 2015 and December 2015 non-controlled drug Record of Medication Destruction sheets. This affected two of thirteen months of non-controlled drug Record of Medication Destruction sheets that were reviewed. Findings Include: A review of a facility policy titled, NON-CONTROLLED MEDICATION DESTRUCTION with a revised date of 12/06 revealed: .PROCEDURES: . 3. The registered nurse and/or pharmacist witnessing the destruction, or their preparation for environmental service pickup, ensures that the following information is entered on the Record of Medication Destruction form . j. Signature of witnesses, two witnesses required for non-controlled substances (a pharmacist and a registered nurse) in the designated areas of the destruction form. On 12/31/2015 at 1:56 PM, the surveyor reviewed the controlled and non-controlled medication destruction forms from December 2014 to December 2015. The surveyor observed that the November 2015 and December 2015 Record of Medication Destruction forms for non-controlled drugs only had one signature present, the consultant pharmacist. On 12/31/2015 at 2:41 PM, an interview was conducted with EI (Employee Identifier) #2, DON (Director of Nursing). EI #2 was asked how many signatures were on the non-controlled drug Record of Medication Destruction sheet for November and December 2015. EI #2 said just one. EI #2 was asked how many signatures should be on the forms. EI #2 said they generally put three on all of them. EI #2 was asked why there was only one signature on the non-controlled Record of Medication Destruction sheet for November and December. EI #2 said she was not sure because usually when they destroyed drugs, the pharmacist signed and handed it to her. EI #2 was asked who was responsible for making sure two signatures were on the non-controlled drug Record of Medication Destruction sheet. EI #2 said she was. EI #2 was asked if it was an acceptable practice of that facility for only one signature to be present on the non-controlled drug Record of Medication Destruction sheet. EI #2 said no. EI #2 was asked why there was supposed to be more than one signature on the non-controlled drug Record of Medication Destruction sheet. EI #2 said to verify what was destroyed.