Every finding on record at Legacy Park Health and Rehabilitation

Based on facility policy review, review of the facility grievances, review of the facility tray distribution schedules, interviews and observations the facility failed to resolve resident grievances related to the timing of scheduled tray pass distribution for the evening meal service.The findings include:Review of the facility policy titled, Facility Grievance, revised 7/2026 revealed .It is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns to the facility or other agency/entity without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished .and other concerns regarding their facility stay .The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances .Review of the facility grievance form dated 2/3/2026 revealed resident council filed a formal grievance related to timely delivery and distribution of tray passes on the clinical units. The complaint was forwarded to the dietary department on 2/5/2026 and was signed off by the administrator on 2/10/2026. Continued review revealed no resolution date had been listed on the document. Review of the facility grievance logs showed individual residents filed formal grievances related to late tray distribution, missing trays, or omitted food items on trays on 2/3/2026, 2/6/2026, 2/18/2026, 2/26/2026, 3/17/2026, 3/24/2026, 4/1/2026, 4/28/2026, 5/11/20216, 5/28/2026, 6/9/2026, 8/4/2026, 8/11/2026, and 8/12/2026. Review of the facility tray distribution schedules revealed kitchen start times for breakfast distribution was to occur at 7:15 AM starting on the 5th floor at 7:30 AM and ending on the 2nd floor by 9:00 AM. Tray passes for the lunch meal were to begin at 12:00 PM and were to be completed by 1:31 PM. Tray passes for supper were to begin at 5:15 PM and were to be completed by 6:44 PM. During interview on 8/26/2026 at 1:45 PM, the Responsible Party (RP) for Resident #20 (200-unit 2nd floor), reported evening meals rarely received dinner until after 7:30 PM. During interview on 8/26/2026 at 2:12 PM, Resident #19 (400-unit 4th floor) stated .supper is supposedly to be 5 to 6, [5;00 PM to 6:00 PM] it never gets here till around 7:00 [PM] . Resident #19 stated multiple complaints by the residents had been filed related to late tray passes and arrival of items to the units from the kitchen, but the concerns had not been addressed by the facility. During interview on 8/26/2026 at 5:00 PM, Resident #9 (400-unit, 4th floor) stated . it's late constantly [the food] .it [meal trays] just shows up whenever they get it ready . then reported meal distribution times varied and were often inconsistent day to day.During interview on 8/26/2026 at 5:20 PM Resident #18 (300-unit 3rd floor) stated she had filed multiple grievances related to late tray passes on the 300 hallway. Resident #18 reported the problem with late tray passes worsened recently after the facility opened the 5th floor for resident care, then stated .now it's even worse than before . Resident #18 stated .they [the facility] don't do nothing about it [complaint/grievances] . During interview on 8/26/2026 at 7:12 PM, the Director of Nursing (DON) confirmed the facility had received multiple resident complaints related to tray pass times over several months. During interview on 8/31/2026 at 2:07 PM the Administrator acknowledged the facility had received prior grievances related to tray pass distribution times since February 2026 and had not been resolved.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to protect the resident's right to dignity when an indwelling urinary catheter drainage bag was left uncovered and visible to the public for 1 resident (Resident #20) of 27 residents observed for dignity.The findings include: Review of the facility's policy titled, Resident Rights, revised 2/2021, revealed, .treat all residents with .dignity .Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Colon Cancer, Hypertension, and Dementia.Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had an indwelling urinary catheter.Review of an Order Summary report for Resident #20 dated 7/25/2025, revealed . [indwelling urinary catheter] .Review of a comprehensive care plan for Resident #20 revised 7/25/2025, revealed, . [indwelling urinary catheter] .During an observation and interview on 8/11/2025 at 3:15 PM, revealed Resident #20 was lying in bed, the indwelling urinary catheter bag was not covered, and the indwelling urinary catheter bag was visible in the hallway. During an observation on 8/12/2025 at 8:46 AM, revealed Resident #20 lying in bed, the indwelling urinary catheter bag was not covered, and the indwelling urinary catheter bag was visible in the hallway.During an interview on 8/12/2025 at 8:53 AM, Licensed Practical Nurse (LPN) A confirmed Resident #20's indwelling urinary catheter bag was not covered and visible in the hallway.During an interview on 8/13/2025 at 1:45 PM, the Director of Nursing (DON) confirmed all indwelling urinary catheters should be covered with a dignity bag or privacy cover.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, facility policy review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Resident #116) of 27 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual Verson 19.1, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . Review of the facility's policy titled, Resident Assessment, revised 8/2018, revealed .It is the policy of this facility to ensure .assessments accurately reflect the resident's status . Review of the medical record revealed Resident #116 admitted to the facility on [DATE] with diagnoses including Bipolar Disorder and Major Depressive Disorder. Review of a PASRR dated 10/15/2024, revealed Resident #116 had a PASRR Level II Outcome related to a serious mental illness (Bipolar Disorder and Major Depressive Disorder). Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #116 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had active diagnoses of Bipolar Disorder and Depression. Continued review revealed the resident was not coded for a PASRR Level II condition. Review of a Psychiatric Nurse Practitioner Progress Note for Resident #116 dated 6/17/2025, revealed .Chief Complaint/ Nature of Presenting Problem .bipolar disorder .depression . During a medical record review and interview on 8/13/2025 at 2:35 PM, Registered Nurse (RN) MDS Coordinator reviewed the significant change MDS assessment dated [DATE] and the Level II PASRR dated 10/15/2024 for Resident #116. RN MDS Coordinator confirmed the significant change MDS assessment for Resident #116 was inaccurate and did not reflect Resident #116's PASRR level II outcome status. During an interview on 8/13/2025 at 2:42 PM, the Director of Nursing (DON) stated it was the facility's expectation for the MDS assessments to be coded accurately. The DON confirmed the facility failed to ensure the accuracy of the significant change MDS assessment dated [DATE] for Resident #116.

Based on facility policy review, medical record review, and interviews, the facility failed to develop a comprehensive care plan for 1 resident (Resident #116) of 27 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised 12/2023, revealed .the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's .mental and psychosocial needs .any specialized services as a result of PASARR [PASRR] [Pre-admission Screening and Resident Review] recommendation, and resident's goals and desired outcomes . Review of the medical record revealed Resident #116 admitted to the facility on [DATE] with diagnoses including Bipolar Disorder and Major Depressive Disorder. Review of a PASRR dated 10/15/2024, revealed Resident #116 had a PASRR Level II Outcome related to a serious mental illness. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #116 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan revised 6/17/2025, revealed Resident #116's PASRR level II condition and outcome was not addressed on the comprehensive care plan. During a medical record review and interview on 8/13/2025 at 2:37 PM, Registered Nurse (RN) MDS Coordinator reviewed the comprehensive care plan revised 6/17/2025 and the PASRR level II dated 10/15/2024 for Resident #116. The RN MDS Coordinator confirmed the comprehensive care plan for Resident #116 did not reflect the resident's PASRR level II outcome status. During an interview on 8/13/2025 at 2:43 PM, the Director of Nursing (DON) stated it was the facility's expectation for a PASRR level II to be addressed on the comprehensive care plan. The DON confirmed the facility failed to ensure the PASRR level II outcome status dated 10/15/2024 was addressed on the comprehensive care plan revised 6/17/2025 for Resident #116.

Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal trays for 9 residents (Resident #14, #91, #104. #107, #35, #119, #78, #108, and #87) of 1 of 3 dining areas observed for meal tray distribution. The findings include:Review of the facility's policy titled, Hand Hygiene, revised 4/2025, revealed .hand hygiene .most effective measures to prevent the spread of infection .during mealtimes the staff is to use proper hand hygiene .during tray pass .Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Dementia, and Hypertension. Review of the comprehensive care plan for Resident #14 revised 2/12/2025, revealed .ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] limited mobility, weakness, dementia .assist resident on level needed to complete adls .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #14 required setup or clean-up assistance with eating and required substantial/maximal assistance with personal hygiene. During an observation on 8/11/2025 at 12:48 PM, Certified Nursing Assistant (CNA) D delivered the lunch meal tray to Resident #14. CNA D set up tray for Resident #14 and failed to perform hand hygiene. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Dementia, and Hypertension. Review of the comprehensive care plan for Resident #91 revised 3/4/2025, revealed .ADL Self Care Performance Deficit r/t weakness, dementia .assist resident at level needed to complete adl tasks .Review of a quarterly MDS assessment dated [DATE], revealed Resident #91 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #91 required setup or clean-up assistance with eating and substantial/maximal assistance with personal hygiene.During an observation on 8/11/2025 at 12:50 PM, CNA D delivered the lunch meal tray to Resident #91. CNA D set up tray for Resident #91 and failed to perform hand hygiene. Review of the medical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes, and Hypertension.Review of the comprehensive care plan for Resident #104 revised 2/20/2025, revealed .ADL Self Care Performance Deficit r/t Parkinson's Disease .Assist resident at level needed to complete adl tasks .Review of a quarterly MDS assessment dated [DATE], revealed Resident #104 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further record review revealed Resident #104 required supervision or touching assistance with eating and partial/moderate assistance with personal hygiene.During an observation on 8/11/2025 at 12:54 PM, CNA D delivered the lunch meal tray to Resident #104. CNA D set up tray for Resident #104 and failed to perform hand hygiene.Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] with diagnoses including Chronic Pain and Hypertension. Review of the comprehensive care plan for Resident #107, revised 2/2/2025, revealed .ADL Self Care Performance Deficit r/t spinal stenosis .Eating .Personal Hygiene .supervision . Review of the quarterly MDS assessment dated [DATE], revealed Resident #107 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #107 required setup or clean-up assistance with eating and partial/moderate assistance with personal hygiene. During an observation on 8/11/2025 at 12:55 PM, CNA D delivered the lunch meal tray to Resident #107. CNA D set up the tray for Resident #107 and failed to perform hand hygiene.Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes, and Chronic Pain Syndrome.Review of a quarterly MDS assessment dated [DATE], revealed Resident #35 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #35 required setup or clean-up assistance with eating and supervision or touching assistance with personal hygiene.Review of the comprehensive care plan for Resident #35 revised 7/17/2025, revealed .ADL Self Care Performance Deficit r/t Limited Mobility .Assist resident at level needed to complete adl tasks .During an observation on 8/11/2025 at 12:56 PM, CNA D delivered the lunch meal tray to Resident #35. CNA D set up the tray for Resident #35 and failed to perform hand hygiene.Review of the medical record revealed Resident #119 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Hypertension, and Atrial Fibrillation.Review of the comprehensive care plan for Resident #119 revised 1/2/2025, revealed .ADL Self Care Performance Deficit r/t weakness .Assist resident at level needed to complete adl tasks .Review of the quarterly MDS assessment dated [DATE], revealed Resident #119 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #119 required setup or clean-up assistance with eating and supervision or touching assistance with personal hygiene.During an observation on 8/11/2025 at 12:57 PM, CNA D delivered the lunch meal tray to Resident #119. CNA D set up the tray for Resident #119 and failed to perform hand hygiene.Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension, and Anxiety.Review of the comprehensive care plan for Resident #78 revised 3/6/2025, revealed .ADL Self Care Performance Deficit r/t weakness .Assist resident at level needed to complete adl tasks .Review of the quarterly MDS assessment dated [DATE], revealed Resident #78 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #78 required setup or clean-up assistance with eating and partial/moderate assistance with personal hygiene. During an observation on 8/11/2025 at 12:58 PM, CNA D delivered the lunch meal tray to Resident #78. CNA D set up the tray for Resident #78 and failed to perform hand hygiene.Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Kidney Disease, and Atrial Fibrillation.Review of the comprehensive care plan for Resident #108 revised 1/14/2025, revealed .ADL Self Care Performance Deficit r/t Dementia .Assist resident at level needed to complete adl tasks .Review of the quarterly MDS assessment dated [DATE], revealed Resident #108 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #108 required setup or clean-up assistance with eating and supervision or touching assistance with personal hygiene.During an observation on 8/11/2025 at 12:59 PM, CNA D delivered the lunch meal tray to Resident #108. CNA D set up the tray for Resident #108 and failed to perform hand hygiene.Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Hypertension.Review of the comprehensive care plan for Resident #87 revised 1/2/2025, revealed .ADL Self Care Performance Deficit r/t weakness .Assist resident at level needed to complete adl tasks .Review of the quarterly MDS assessment dated [DATE], revealed Resident #87 scored a 99 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #87 was dependent with eating and personal hygiene.During an observation on 8/11/2025 at 1:00 PM, CNA D delivered the lunch meal tray to Resident #87. CNA D set up the tray for Resident #87 and failed to perform hand hygiene.During an interview on 8/11/2025 at 1:03 PM, CNA D confirmed she had not performed hand hygiene while passing the lunch trays to Resident #14, #91, #104, #107, #35, #119, #78, #108, and #87.During an interview on 8/13/2025 at 1:45 PM, the Director of Nursing (DON) confirmed the staff should perform hand hygiene after serving each meal tray. The DON confirmed infection prevention control practices were not maintained during the lunch meal service on 8/11/2025 when the staff failed to perform hand hygiene between passing lunch trays.

Based on facility policy review, medical record review, hospice medical record review, and interview the facility failed to protect the residents right to be free from a significant medication error for 1 resident (Resident #7) of 3 sampled hospice respite residents. The facility's failure to prevent a significant medication error resulted in actual HARM for Resident #7. The facility's failure to prevent a significant medication error resulted in actual HARM for Resident #7 when the resident's order for Morphine Sulfate was transcribed incorrectly by nursing staff and Resident #7 was administered the medication on a scheduled basis instead of as needed, according to the physician order. On the fourth day of Resident #7's respite stay in the facility, she was semi-comatose, had constricted pupils, a weak and irregular pulse, slightly labored respirations of 12 with increased oxygen, and was hypotensive (low blood pressure), after she received the incorrect amount of Morphine for 4 days. The findings include: 1.Review of the facility's undated policy titled, Admission for Respite Care, revealed .Hospice personnel will be responsible for Provider (Medical Doctor/Nurse Practitioner) services and be available 24 hours a day for clinical consultation to the facility's personnel . 2.Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] for 5 days of respite care with diagnoses including Normal Pressure Hydrocephalus (A rare condition that occurs when too much cerebrospinal fluid builds up in the brain), Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease, Dementia, and Hospice Status. Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #7 dated 8/8/2024, revealed a score of 9 which indicated the resident had moderate cognitive impairment. Review of the Hospice Physician Orders for Resident #7 dated 8/8/2024, revealed Morphine Concentrate 100 milligrams (mg) per 5 milliliters (ml) or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours orally as needed (PRN) for shortness of breath (SOB) Review of a Drug Receipt/Record/Disposition Form for Resident #7 dated 8/8/2024, revealed Morphine Sulfate 100 milligrams (mg) per 5 milliliters (ml) or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours routine was removed from the emergency narcotic box for administration to Resident #7. Review of the Medication Administration Record (MAR) for Resident #7 dated August 2024, revealed Morphine Sulfate oral solution 20 mg per 5 ml place and dissolve 0.25 ml (1 mg) buccally (inside the cheek) every 2 hours for pain/shortness of breath (SOB). Resident #7's MAR should have documented Morphine Sulfate oral solution 100 mg per 5 ml place and dissolve 0.25 ml (5 mg), instead of 20 mg per 5 ml place and dissolve 0.25 ml (1 mg). The order was transcribed incorrectly by nursing staff with the incorrect concentration and as a scheduled order instead of a PRN order, as ordered by the Physician. Further review of Resident # 7's MAR revealed 5 mg doses of morphine were administered: A. On 8/9/2024 at midnight, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. A. On 8/10/2024 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. A. On 8/11/2024 at midnight, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. A. On 8/12/2024 at midnight, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, and 8:00 PM. Review of the Medication Administration Record (MAR) for Resident #7 dated August 2024, revealed Morphine Sulfate oral solution 20 mg per 5 ml give 0.25 ml (1 mg) by mouth scheduled at bedtime for pain. Resident #7's MAR should have documented Morphine Sulfate oral solution 100 mg per 5 ml, give 0.25 ml (5 mg), instead of 20 mg per 5 ml give 0.25 ml (1 mg). The order was transcribed incorrectly by nursing staff with the incorrect concentration, and not as ordered by the Physician. Further review of Resident # 7's MAR revealed 5 mg doses of morphine were administered at 8:00 PM on 8/9/2024, 8/10/2024, and 8/11/2024. Review of an undated, untimed Client Medication Report revealed Licensed Practical Nurse (LPN) B performed a medication verification for Resident #7's hospice morphine. LPN B placed check marks beside each morphine order indicating she verified the order was correct on the MAR but the concentration on both morphine orders were incorrect and the frequency of one order was incorrect. Review of a facility progress note for Resident #7 dated 8/8/2024, revealed Resident #7 was at the facility for 5 days of respite. Resident #7 was able to make needs known, respirations were even and unlabored on 3 liters of oxygen via nasal cannula .continue to monitor and report any changes . Review of a facility social services and initial assessment dated [DATE], revealed Resident #7 was alert, communicated verbally, was oriented to person, place and time and usually understood and responded adequately to simple, direct communication. Review of a Medical Regimen Review (MRR) for Resident #7 dated 8/9/2024, revealed Pharmacist A did not identify the incorrect order transcription when the pharmacist completed the MRR for Resident #7. Review of a Medication Error Report for Resident #7 dated 8/13/2024, revealed Morphine Sulfate oral solution, 20 mg/5 ml 0.25 ml every 2 hours, was ordered and transcribed as scheduled, not PRN. The outcome of the investigation indicated no harm came to the resident and Resident #7's daughter reported her mother had increased drowsiness. The corrective action revealed the facility attempted to correct the morphine order on 8/13/2024 prior to Resident #7's discharge. The person making the error was LPN A, an agency nurse. The type of error listed the medication was ordered every 2 hours instead of every 2 hours PRN, and the reason for the error was listed as a transcription error. The form was signed by LPN B and the Director of Nursing (DON). Review of the Medication Administration Record (MAR) for Resident #7 dated August 13, 2024, revealed a corrected order for Morphine Sulfate oral solution was documented as Morphine Sulfate 20 mg per 5 ml give 0.25 ml (1 mg) by mouth every 2 hours as needed for pain. The concentration on the corrected order for Morphine Sulfate was still documented incorrectly as 1 mg and should have been 5 mg. Review of facility documentation of vital signs in the Electronic Medical Record (EMR) revealed there were no vital signs documented on Resident #7 from 8/8/2024 - 8/13/2024. 3.Review of the hospice medical record dated 8/5/2024, revealed Resident #7 was on Morphine Sulfate, a quantity of 30 MS Con (MS Contin, Morphine Sulfate controlled-release) was dispensed on 7/7/2024 and the quantity that remained on 8/5/2024 was 28. Further review revealed Resident #7 was administered 2 doses of Morphine in 24 hours and Resident #7 was not residing in a nursing facility at the time. Resident #7 had no communication deficits, was calm, alert, oriented to person and place with minimal verbiage (wording on dictation) and periods of confusion. Further review revealed Resident #7 slept 10 out of 24 hours per day and ate 50 percent (%) of meals if someone prepared them for her. Review of a hospice visit note dated 8/12/2024 at 10:38 AM, revealed Resident #7 resided in the facility, had a pulse of 75 beats per minute (BPM) with an irregular pulse and respirations of 12 on 3 liters of oxygen with shortness of breath with normal respirations. Further review revealed Resident #7 was on Morphine Sulfate which was managed by the facility. Resident #7 was asleep but easily awakened, was alert to person, confused, difficult to understand, ate 50-75% of her meals, and slept 12 of 24 hours per day. Review of a Hospice visit note dated 8/12/2024 at 5:56 PM, revealed Resident #7 was visited in the facility a second time on 8/12/2024 at the request of the family for changes in behavior. Resident #7's pulse was 71, weak and irregular, she was hypotensive (low blood pressure) with blood pressure of 86/70, her respirations were 12 and slightly labored, and her oxygen saturation was 91% on 5 liters via (by way of) nasal cannula. Further review revealed Resident #7 was lethargic, minimally arousable but would open her eyes, her pupils were constricted, was semi-comatose (in a state of partial coma or almost comatose), confused, unable to understand and participate in care, and constantly sleeping. Continued review revealed the Hospice nurse documented Resident #7 received Morphine Concentrate 0.25 ml every 2 hours scheduled, instead of PRN and contacted a provider who advised discontinuing the morphine and continuing to monitor the resident. Review of a Hospice visit note dated 8/13/2024, after Resident #7 was discharged home from the facility, revealed an irregular pulse of 94 and shallow respirations of 20 on 3 liters of oxygen via nasal cannula. Resident #7 was alert and oriented to person, place and situation with confusion and minimal speech. Further review revealed Resident #7 slept 12 out of 24 hours and ate 0-25 % of meals. Resident #7 was unable to assist with positioning her legs during transfer, feed herself or bring liquids to her mouth as she did prior to admission to the skilled nursing facility. 4.During an interview on 2/18/2025 at 10:30 AM, LPN B stated the hospice respite admission process was to transcribe orders provided by Hospice into the EMR. LPN B stated medications transcribed into EMR populate the MAR. LPN B stated when respite hospice patients are admitted the only assessments completed are the skin and initial nursing assessment. LPN B stated she recalled Resident #7, she did not admit her but did complete her MAR although she was unsure of the date/time it was completed. LPN B stated she recalled 2 orders for Morphine, one scheduled every 4 hours and one scheduled for every 4 hours PRN. LPN B stated she questioned the order because the resident had scheduled morphine and was not actively dying, so she spoke to her Supervisor, Registered Nurse (RN) A. LPN B stated RN A said, That's not right, I'll take care of it. LPN B stated she assumed RN A took care of it by writing it in the Doctor's Book or talking to the provider. LPN B stated any time facility nurses have questions about medications, the questions are placed in the Doctor's Book. LPN B emphasized they do not call the provider. When asked to clarify what she would do about a medication question, LPN B stated again she would write the question in the book and would not call the provider. LPN B stated Resident #7 was alert/oriented and after she had given the dose of morphine Resident #7 asked what she had taken. LPN B stated she explained to Resident #7 it was her morphine and Resident #7 stated she only takes that at bedtime. LPN B stated she told Resident #7 she could refuse the morphine any time she didn't want it. LPN B stated she also told all the other nurses to make sure they asked Resident #7 before giving her morphine. LPN B stated she was not able to recall Resident #7's level of consciousness after that evening because Resident #7 was discharged before she came back to work. LPN B stated she only gave her a few more doses of morphine and didn't give it to her routinely (scheduled). During an interview on 2/20/2025 at 3:30 PM, the Hospice Staff Nurse (RN B), stated he was not able to recall everything from his visits with Resident #7 in August but reviewed the medical record. RN B stated he saw Resident #7 in the facility on 8/12/2024 and at home on 8/13/2024. RN B stated he had only seen her a few times and was not her routine nurse, so he was unsure of her baseline. RN B stated his note said she was asleep, easily awakened, confused, speech was unintelligible, and she was able to answer simple questions. RN B stated they had a visit the next day at her home, and she recognized him from the day before because she had not had any morphine. RN B stated he noted no pain but an increase in tremors and she was able to make her needs known. RN B stated when she was transferred to the wheelchair at home, she was not able to assist at all with positioning her legs, feeding herself or bringing liquids to her mouth. RN B stated she was able to do these things before her admission to the nursing facility. RN B stated he does not complete medication reconciliation for hospice patients (residents) in nursing facilities. During an interview on 2/21/2025 at 3:45 PM, the Hospice Medical Director (MD) stated he reviewed Resident #7's medical record, and Resident #7 was administered 2 doses of Morphine in the 24 hours prior to her admission to the nursing facility. The Hospice MD stated jumping from 0.25 ml a couple of times a day to every 2 hours is significant and he would be concerned with drowsiness and decreased respiratory effort. The Hospice MD stated this patient had COPD and that was significant as well. The Hospice MD stated administration (of Morphine) every 2 hours scheduled would be appropriate for someone who was actively dying. The Hospice MD stated this was not the case for this patient and a jump from 2 doses a day to every 2 hours was cause for concern and he wouldn't recommend it. The Hospice MD stated if there had been a question about a medication, he would expect facility staff to reach out because hospice has providers available 24 hours a day 7 days a week. During an interview on 2/21/25 at 4:00 PM, the Facility MD stated she was not the medical director until January 2025. The facility MD stated the facility had an on-call service to utilize after hours and there was a nurse practitioner at the facility on day shift during the week. The Facility MD stated if a nurse had a question about a medication, her expectation would be to receive a phone call, especially about Morphine because it was a significant drug. The Facility MD stated she received notes from nurses about patients but for something minor. The Facility MD stated she expected phone call verification of any medicine. The Facility MD stated even an antibiotic, if it was not available, should be called so they could find a possible alternative. The Facility MD stated if there was a question about a hospice patient, the hospice provider should be notified. The Facility MD stated if they were not able to reach hospice staff, the facility should reach out to the facility's on call provider. The Facility MD stated someone receiving Morphine on a schedule after only receiving PRN doses twice in 24 hours, would cause concern for over sedation and respiratory compromise. During an interview on 2/21/2025 at 3:45 PM, Resident #7's daughter stated she was traveling home from Ohio on 8/12/2024 and received a call from Resident #7's sitter that her mother was going from out of control, to out of it. Resident #7's daughter stated her mother had Dementia but was mostly calm unless she had a urinary tract infection (UTI). She stated typically Resident #7's sitter could calm her mother (Resident #7) if she got upset, but when her sitter was not able to console her, she called her (Resident #7's Daughter). Resident #7's Daughter stated she wasn't able to calm her mother and when her sister tried and wasn't successful, she called hospice. Resident #7's Daughter stated hospice went out the day she called (8/12/2024) to check on her mother. Resident #7's Daughter stated she saw her mother at the facility the next day and her mother was out of it and couldn't speak. Resident #7's Daughter stated her mother was not able to feed herself or give herself a drink. Resident #7's Daughter stated she told Resident #7's nurse she was only supposed to receive Morphine at bedtime to relax her lungs before she takes her inhaler. Resident #7's Daughter stated the nurse told her that she (Resident #7's Daughter) couldn't tell the nurse what to do; (the nurse) goes by the order. Resident #7's Daughter stated she was very upset, and it took her mother a few days to start making sense and to start feeding herself again. Resident #7's Daughter was asked if her mother was diagnosed with UTI, and she stated she was not. During an interview on 2/21/2025 at 4:10 PM, Resident #7's Sitter stated she saw Resident #7 for a few hours every day while her daughter was gone. Resident #7's Sitter stated she recalled Resident #7 was confused and she thought Resident #7's Daughter figured out they were giving her too much Morphine. Resident #7's Sitter stated she recalled Resident #7 went from out of it to hallucinating and then was difficult to arouse. Resident #7's Sitter stated she was there when Resident #7's Daughter spoke to the nurse on her phone. Resident #7's Sitter stated Resident #7's Daughter tried to explain Resident #7 wasn't supposed to get Morphine every 2 hours, only at bedtime. Resident #7's Sitter stated the nurse told Resident #7's Daughter she had to keep giving the medication until there was an order to change the medication. Resident #7's Sitter stated Resident #7's Daughter was yelling at the nurse and told the nurse to stop giving Resident #7 anything. Resident #7's Sitter stated she believed the facility wrote Resident #7's order for Morphine down wrong. During an interview on 2/21/25, at 4:30 PM, the Director of Nursing (DON) stated the Hospice Medication Orders listed Morphine Sulfate 100 mg per 5 ml or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours by mouth as needed for shortness of breath (SOB). The DON stated there was another order for Morphine Sulfate 100 mg per 5 ml or 20 mg per 1 ml give 0.25ml or 5 mg at bedtime for pain. The DON stated LPN A entered Morphine Sulfate 20 mg per 5 ml give 0.25 ml or 1mg buccally (inside cheek) every 2 hours for pain/SOB and another order for Morphine Sulfate 20 mg per 5 ml give 0.25 ml or 1mg by mouth at bedtime for pain into the EMR. The DON confirmed she had not realized at the time of the incident that the concentration and the dose of Morphine LPN A entered into the EMR was incorrect. The DON stated when Resident #7 entered the building staff contacted her because of concerns the liquid in the Morphine bottle Resident #7's family brought to the facility was water instead of Morphine. The DON stated she instructed staff to obtain Morphine from the emergency narcotic box and to lock the suspicious vial of Morphine from the family in the medication room. The DON stated staff obtained Morphine Sulfate 100 mg per 5 milliliters or 20 mg per 1 ml from the emergency narcotic box. The DON confirmed a 0.25 ml or 5 mg of this morphine concentration was administered to Resident #7 on a schedule every 2 hours, instead of PRN. The DON confirmed Resident #7 did not receive the concentration transcribed on the MAR. The DON stated the facility process is to have medication orders transcribed into the EMR by a nurse, have it double checked by another nurse, then checked by the pharmacy. The DON stated the orders were checked off by LPN B using the orders hospice sent to the facility. The DON confirmed the sheet LPN B used to check the medication off was not dated or timed so she is unsure if the orders were checked off within 24 hours, as should be done. The DON confirmed an additional check was completed by Pharmacist A and the incorrect concentration and frequency were not identified. This surveyor and the DON reviewed the corrected order LPN B put into the EMR. The DON had not identified that the morphine concentration on the corrected order was still incorrect. The DON stated the medication error was identified by the facility on 8/13/2024 by LPN C who discussed the issue with Resident #7's daughter. The DON stated the Facility MD was notified, a Medication Error Form was completed, an investigation was conducted, and a Performance Improvement Plan (PIP) was put in place. The DON stated her investigation revealed Morphine Sulfate oral solution 20 mg/5 ml 0.25 ml every 2 hours was ordered and transcribed as scheduled, not PRN. This surveyor and the DON discussed all assessments completed on Resident #7 as well as what symptoms Resident #7 demonstrated related to getting Morphine 5mg every 2 hours instead of PRN. The DON stated the service hospice pays for gives patients a certain number of respite days per year. She confirmed the facility only conducts a skin assessment and administers medications and treatments on respite hospice patients admitted to the facility. The DON confirmed there were no nursing assessments or vital signs completed on Resident #7 and no indication of how getting 5 mg of Morphine every 2 hours effected Resident #7. This surveyor and the DON reviewed Hospice documentation. The DON was not aware the hospice service had been in the facility twice on 8/12/2024, once for a routine visit and again at the family's request due to concerns regarding Resident #7's behavior and level of consciousness (LOC). This surveyor asked the DON why she was not aware the hospice agency was in the facility the day prior Resident #7's discharge, the DON stated hospice should have communicated the fact they were in the facility to staff, and this was not done. Refer to F684, F756, F760 and F867

Based on facility policy review, medical record review, and interview the facility failed to ensure resident medical records were complete and accurate for 5 residents (Residents #2, #17, #18, #19, and #10) of 19 resident records reviewed. The findings include: Review of the facility's policy titled, Emptying a Urinary Collection Bag, dated 2001, revealed .The following information should be recorded in the resident's medical record .The amount of urine emptied from the drainage bag . Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 2001, revealed .promptly notifies .his or her attending physician .changes in the resident's medical/mental condition and/or status .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including .information prompted by the Interact SBAR [situation, background, assessment, recommendation] Communication Form . Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Neuromuscular Dysfunction of Bladder, Hemiplegia/Hemiparesis, and Vascular Dementia. Review of a baseline care plan dated 11/21/2024, revealed Resident #2 had an indwelling urinary catheter. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated moderate cognitive impairment. Continued review revealed Resident #2 had an indwelling urinary catheter. Review of a 7:00 PM-7:00 AM shift report dated 12/4/2024, revealed Resident #2's indwelling urinary catheter was changed during the shift. Review of a nurse's note for Resident #2 dated 12/5/2024 at 11:30 AM, revealed Resident #2 reported the indwelling urinary catheter had been replaced on 12/4/2024 at approximately 11:00 PM. Review of the medical record for Resident #2 from 11/21/2024-12/5/2024 revealed no documentation the resident's indwelling urinary catheter had been replaced. Review of the medical record for Resident #2 revealed there was no documentation of the resident's urine output from 11/21/2024-12/5/2024. Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Pressure Ulcer of Sacral Region, Unspecified Stage. Review of a significant change in status MDS assessment for Resident #17 dated 2/9/2025, revealed the resident had an indwelling urinary catheter. Review of a comprehensive care plan for Resident #17 dated 2/20/2025, revealed .[indwelling urinary] catheter and is at risk for complications and UTI [urinary tract infection] .Monitor and document intake and output as per facility policy . Review of the medical record for Resident #17 for 1/2025-2/2025 revealed there was no documentation of the resident's urine output. Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. Review of a comprehensive care plan for Resident #18, dated 1/24/2025, revealed .Indwelling [urinary] Catheter related to Pressure Ulcer .Monitor intake and output as per facility policy . Review of an annual MDS assessment dated [DATE], revealed Resident #18 had an indwelling urinary catheter. Review of the medical record for Resident #18 dated 1/1/2025-2/21/2025 revealed no documentation of the resident's urine output. Review of the medical record for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses included Neuromuscular Dysfunction of Bladder and Stage 3 Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #19 had an indwelling urinary catheter. Review of a comprehensive care plan for Resident #19 dated 1/21/2025, revealed .Indwelling [urinary] Catheter related to urinary retention .Monitor/record/report to MD [medical doctor] for .no output . Review of the medical record for Resident #19 dated 1/1/2025-2/21/2025 revealed no documentation of the resident's urine output. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Neuromuscular Dysfunction of the Bladder, Retention of Urine, Urinary Tract Infection (UTI), and Functional Quadriplegia. Review of a comprehensive care plan for Resident #10 dated 3/14/2024, revealed .Potential for UTI R/T [related to indwelling catheter]. Recent CAUTI [catheter associated urinary tract infection] with sepsis, neuromuscular dysfunction of the bladder .Observe for confusion, temp [temperature], decreased output, c/o [complaint of] abd. [abdominal] or flank [either side of lower back] pain, abdominal distension, clamminess, change in LOC [level of consciousness] qs [every shift] and prn [as needed]. Report abnormal to m.d. [medical doctor] prn . Review of a quarterly MDS assessment dated [DATE], revealed Resident #10 had an indwelling urinary catheter. Review of an alert note (nurse's note) dated 7/12/2024 at 1:47 PM, revealed Resident #10 reported extreme discomfort in the resident's genital area and reported a pain level of 10 (pain rating score 1-10, with 10 being highest level of pain). The nursing supervisor was notified of the resident's complaint.Offered to change [indwelling urinary catheter] and resident declined, requesting to be transported from facility to ER [emergency room ] . Review of the medical record for Resident #10 revealed a SBAR communication tool was not in the medical record. During an interview on 2/21/2025 at 2:20 PM, the Director of Nursing (DON) confirmed staff were expected to document resident's urine output and indwelling catheter changes in the medical record and confirmed staff were expected to complete a SBAR communication tool for resident's who were transferred to the ER. The DON confirmed Resident #2's urine output, and a catheter change performed for Resident #2 on 12/4/2024 had not been documented in the medical record and confirmed a SBAR communication tool was not completed when Resident #10 was transferred to theER on [DATE]. During an interview on 2/21/2025 at 4:00 PM, the Assistant Director of Nursing (ADON) confirmed urine output had not been documented in the medical record for Resident's #17, #18, and #19.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure medications were administered according to Physician Orders for 1 resident (Resident #7) of 3 residents reviewed for hospice respite care. The findings include: Review of a facility policy titled, Medication and Treatment Orders, revised April 2019, revealed .Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in the state .Orders for medication should include .name and strength of the drug; dosage and frequency of administration; route of administration; clinical condition or symptoms for which the medication is prescribed .therapeutic medication monitoring . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], for 5 days of respite care with diagnoses including Normal Pressure Hydrocephalus (A rare condition that occurs when too much cerebrospinal fluid builds up in the brain) , Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease, Dementia, and Hospice Status. Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 9 which indicated the resident had moderate cognitive impairment. Review of the Hospice Physician's Orders for Resident #7 dated 8/8/2024, revealed Morphine Concentrate 100 milligrams (mg) per 5 milliliters (ml) or 20 mg per 1 ml, give 0.25 ml or 5 mg every 2 hours orally as needed (PRN) for shortness of breath (SOB). Review of a Drug Receipt/Record/Disposition Form for Resident #7 dated 8/8/2024, revealed Morphine Sulfate 100 mg per 5 ml or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours routinely was removed from the facilities emergency narcotic box for administration to Resident #7. Review of the Medication Administration Record (MAR) for Resident #7 dated August 2024, revealed Morphine Sulfate oral solution 20 mg per 5 ml place and dissolve 0.25 ml (1 mg) every 2 hours for pain/Shortness of Breath (SOB) (scheduled and not PRN). The MAR for Resident #7 revealed doses of morphine were administered 8/9/2024 every 2 hours routinely from 12:00 AM to 10:00 PM (12 doses); on 8/10/2024 from 12:00 AM to 10:00 PM (12 doses); on 8/11/2024 from 12:00 AM to 10:00 PM (12 doses); on 8/12/2024 from 12:00 AM to 8:00 PM (11 doses). Resident #7 ' s MAR should have documented Morphine Sulfate oral solution 100 mg per 5 ml place and dissolve 0.25 ml (5 mg), instead of 20 mg per 5 ml place and dissolve 0.25 ml (1 mg). The order was transcribed incorrectly by nursing staff with the incorrect concentration and as a scheduled order instead of a PRN order, as ordered by the Physician. During an interview 2/21/2025, at 4:30 PM, the Director of Nursing (DON) stated the Hospice provider ordered Morphine Sulfate 100 mg per 5 ml or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours by mouth as needed for SOB. The DON stated Licensed Practical Nurse (LPN) A transcribed the order as Morphine Sulfate 20 mg per 5 ml give 0.25 ml or 1mg (and not the ordered 5 mg) buccally every 2 hours for pain/SOB (scheduled and not PRN). The DON confirmed the concentration and dose of Morphine that LPN A entered into the electronic medical record was incorrect. The DON stated staff obtained Morphine Sulfate 100 mg per 5 milliliters or 20 mg per 1 ml from the emergency narcotic box. The DON further confirmed the resident ' s order for the Morphine was transcribed incorrectly by LPN A (order for 5 mg and transcribed as 1 mg and ordered PRN and not routinely) and the Morphine Sulfate 5 mg was administered every 2 hours routinely to Resident #7. The DON confirmed the correct concentration of Morphine Sulfate 5 mg was administered; however, the frequency was transcribed as scheduled and not PRN as the provider had ordered. The DON confirmed Resident #7 received the correct dose of morphine but not the correct frequency and the morphine was not administered as prescribed according to the physician's order.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure the Pharmacist identified an order for Morphine Concentrate was transcribed to Point Click Care (PCC) correctly on 1 resident (Resident #7's) of 3 sampled hospice respite residents ' Medication Administration Record (MAR) for accurate transcription of physician orders. The findings included: Review of the facility policy titled, Medication Regimen Review, effective 1/08/2024, revealed .A Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication .review includes preventing, identifying, reporting and resolving medication-related problems .medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] for 5 days of respite care with diagnoses including Normal Pressure Hydrocephalus (A rare condition that occurs when too much cerebrospinal fluid builds up in the brain) , Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease, Dementia, and Hospice Status. Review of a Brief Interview for Mental Status (BIMS) evaluation for Resident #7 dated 8/8/2024, revealed a score of 9 indicating the resident had mild cognitive delay. Review of the Hospice Physician's Orders for Resident #7 dated 8/8/2024, revealed Morphine Concentrate 100 mg per 5 ml or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours orally as needed (PRN) for shortness of breath (SOB) Review of a Drug Receipt/Record/Disposition Form for Resident #7 dated 8/8/2024, revealed Morphine Sulfate 100 mg per 5 ml or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours routine was removed from the emergency narcotic box for administration to Resident #7. Review of the Medication Administration Record (MAR) for Resident #7 dated August 2024, revealed Morphine Sulfate oral solution 20 mg per 5 ml place and dissolve 0.25 ml (1 mg) buccally every 2 hours for pain/SOB. Resident #7 ' s MAR should have documented Morphine Sulfate oral solution 100 mg per 5 ml place and dissolve 0.25 ml (5 mg), instead of 20 mg per 5 ml place and dissolve 0.25 ml (1 mg). The order was transcribed incorrectly by nursing staff with the incorrect concentration and as a scheduled order instead of a PRN order, as ordered by the Physician. Further review of Patient # 7's MAR revealed 5mg doses of morphine were administered 8/9/2024 at midnight, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM. 8/10/2024 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM. 8/11/2024 at midnight, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM. 8/12/2024 at midnight, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM. Review of the Medication Administration Record (MAR) for Resident #7 dated August 2024, revealed Morphine Sulfate oral solution 20 mg per 5 ml give 0.25 ml (1 mg) by mouth at bedtime for pain. Resident #7 ' s MAR should have documented Morphine Sulfate oral solution 100 mg per 5 ml, give 0.25 ml (5 mg), instead of 20 mg per 5 ml give 0.25 ml (1 mg). The order was transcribed incorrectly by nursing staff with the incorrect concentration, as ordered by the Physician. Further review of Resident # 7's MAR revealed 5mg doses of morphine were administered 8/9/2024 at 8:00 PM, 8/10/2024 at 8:00 PM, and 8/11/2024 at 8:00 PM Review of a Medication Removal Form Emergency Kit After Hours form for Resident #7 dated 8/8/2024 and faxed to the pharmacy on 8/8/2024 at 11:46 PM, revealed Morphine 20 mg/1 ml 0.25 by mouth routine. Review of a Medical Record Review (MRR) for Resident #7 dated 8/9/2024, revealed Pharmacist A completed a MRR for Resident #7 listing no recommendations. Pharmacist A failed to identify the inaccurate transcription of Resident #7's Morphine Sulfate order. During an interview on 2/21/25 at 4:30 PM, the Director of Nursing (DON) stated Licensed Practical Nurse (LPN) A transcribed Morphine Sulfate 20 mg per 5 ml, give 0.25 ml or 1mg buccally every 2 hours for pain/SOB and another order for Morphine Sulfate 20 mg per 5 ml give 0.25 ml or 1 mg by mouth at bedtime for pain into the electronic medical record (EMR), and this was incorrect. She stated the facility nurse faxed the Drug Receipt/Record/Disposition Form and Medication Removal From Emergency Kit After Hours form to the pharmacy with the correct concentration dose but incorrect frequency on 8/8/2024 and the MRR conducted by Pharmacist A did not catch the morphine error despite receiving orders from the hospice agency, the Drug Receipt/Record/Disposition Form and Medication Removal From Emergency Kit After Hours form from the facility. During an interview on 2/27/24 AT 11:00 AM, Pharmacist A stated the process for hospice patients is for the pharmacy to put orders into a profile. The orders the pharmacy puts into the profile populates into a web-based program the contracting pharmacists use to complete the MRR. Pharmacist A confirmed the profile entered by the pharmacy into the shared program was Morphine 100 mg/5 ml give 0.25 ml or 5 mg every 2 hours PRN. Pharmacist A stated on 8/8/2024 the facility removed Morphine 100 mg/ 5 ml or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours routinely from the emergency narcotic box. Pharmacist A stated this was faxed to the pharmacy and considered a new order. Pharmacist A stated the facility has 7 days to send the pharmacy a new signed prescription (script) by the provider to have on file. Pharmacist A stated he performed his MRR on 8/9/2024 and the MAR in the EMR reads Morphine 20 mg per 5 ml give 0.25 ml q 2 hours routine. Pharmacist A confirmed he should have caught the incorrect concentration, and he missed it. Pharmacist A stated he didn't question the frequency because a hospice patient going from PRN to scheduled morphine is not unusual. Pharmacist A stated he is not certain if the MAR is rechecked once the facility sends the signed script to the pharmacy, or if the order in the profile is changed. Pharmacist A stated once he completes his original admission MRR his portion is finished, and he doesn't see any other orders.

Based on facility policy review, medical record review, facility document review, Quality Assurance and Performance Improvement (QAPI) Plan review, and interview, the facility's QAPI committee failed to ensure an effective QAPI program that identified quality deficiencies, implemented performance improvement activities to address quality concerns, and performed a root cause analysis related to medication errors. The QAPI committee failed recognize, identify, develop and implement corrective systems to ensure appropriate care and safety by all disciplines involved in the medication transcription error. The QAPI committee failed to ensure facility wide education was conducted to ensure understanding of the transcription of hospice admission orders after a significant medication error was identified for 1 resident (Resident #7) related to the resident's Morphine orders. The QAPI committee failed to identify and implement an effective action plan to correct deficiencies when hospice orders were incorrectly transcribed on admission, and failed to identify, educate, and put action steps in place with the facility, agency and hospice staff. The QAPI committee failed to implement effective processes, to include effective training, for all facility staff nurses responsible for medication transcription orders and all agency staff nurses responsible for transcription of medication orders, as well as, education and coordination with hospice staff to ensure clear concise provider orders are sent on admission to mitigate transcription errors. The findings included: Review of the medical record revealed Resident #7 admitted to the facility on [DATE] for 5 days of respite care. The hospice agency orders in place at the time of admission revealed Resident #7 was to receive Morphine Concentrate 100 milligrams (mg) per 5 milliliters (ml) or 20 mg per 1 ml, give 0.25 ml or 5 mg, every 2 hours orally as needed (PRN) for shortness of breath (SOB). On admission to the facility, Licensed Practical Nurse (LPN) A incorrectly transcribed Resident #7's order for Morphine Sulfate and the facility administered the medication on a 2-hour schedule instead of as needed. Resident #7 was administered 12 doses of morphine on 8/9/2024, 8 doses of morphine on 8/10/2024, 12 doses of morphine on 8/11/2024 and 11 doses on 8/12/2024. When Resident #7's daughter returned from her trip, Resident #7 was out of it and couldn't speak. The facility identified the medication error when it was brought to the Director of Nursing (DON) and Assistant Director of Nursing's (ADON) attention by Resident #7's daughter and LPN B changed the order to PRN but did not change the concentration. The facility was unaware the concentration they had documented on the Medication Administration Record was still incorrect until it was brought to their attention on survey. Review of a Performance Improvement Plan (PIP) for the medication error put into place to address significant medication errors related to errors in transcription dated 8/13/2024, was as follows: a. Identification of resident involved or likely to be affected. b. Education to LPN B the staff nurse who missed the error in transcription by LPN A. c. Interdisciplinary Team meeting to discuss hospice orders, noted the format of hospice orders and made note to look at the PRN column. d. Process for admission orders was to ensure they are checked off by the DON or ADON. During an interview on 2/21/25 at 4:30 PM, the DON stated the medication error was identified by the facility on 8/13/2024 by LPN C who discussed the issue with Resident #7's daughter. The DON stated the facility Medical Director (MD) was notified, a Medication Error Form was completed, an investigation was conducted, and a PIP was put in place. The DON stated her IDT team met for QAPI to include the DON, ADON, Unit Manager, MDS Nurse, and Wound Care Nurse. The DON stated her investigation revealed Morphine Sulfate oral solution 20 mg/5 ml 0.25 ml every 2 hours was ordered and transcribed as scheduled, not PRN. The DON stated no harm came to the resident except that the patient's daughter reported her mother was drowsy. The DON stated her corrective action was to correct the Morphine order on 8/13/2024 prior to discharge but just realized today the concentration on the corrected order was incorrect. The DON stated measures taken to prevent recurrence of this incident were to educate LPN B, note the format of hospice orders and to ensure staff were looking at the PRN column. The DON stated orders were still transcribed by a staff nurse, checked by another nurse, an MRR was still completed within 3 days and now the DON and ADON check all resident orders. The DON stated they perform routine random audits as well, but these audits were not documented anywhere, and she had no record of audits being completed. The DON stated LPN B was educated on her mistake. The DON stated she did not educate the agency nurse who transcribed the morphine incorrectly because she was not her (facility) employee. The DON stated she did not educate any other staff nurses on medication errors and did not include hospice, agency or pharmacy in her PIP. The DON confirmed the QAPI Committee had identified a significant medication error as an area of concern for the facility but was not aware of the extent of the problem. Continued interview confirmed the facility failed to perform a root cause analysis or thorough investigation for the significant medication error as the errors in morphine concentration were not identified even after the error was caught. Further interview confirmed the facility failed to implement an effective plan to mitigate errors in transcribing orders by not including facility or agency staff nurses responsible for transcribing orders and not communicating the need for clear concise hospice orders with the hospice agency. The QAPI Committee failed to ensure an effective Quality Assurance Program was in place to monitor and evaluate concerns related to significant medication errors. Refer to F684, F756, and F760.

Based on facility document review, medical record review, and interviews, the facility failed to provide written information to the resident and/or resident representative concerning the right to formulate an advance directive for 22 residents (Resident #103, #156, #34, #5, #69, #45, #14, #102, #356, #67, #31, #47, #73, #99, #96, #8, #65, #3, #22, #12, #21,and #49) of 35 residents reviewed for advanced directives. The findings include: Review of the undated facility document titled, Advanced Directives revealed .On admission the Nurse Liaison inquires if the .resident has any advanced directives. If so, they request a copy and one is placed in the .medical chart .The Social Worker assists .resident .family with obtaining advance directives if requested .Copies are .placed in the .medical chart . Medical record review revealed Resident #103 was admitted to the facility on [DATE] with diagnoses including Hypertension, Anxiety Disorder, and Severe Protein-Calorie Malnutrition. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #103 scored a 5 on the Brief Interview for Mental status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of Resident #103's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #156 was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Hypertension, and Atrial Fibrillation. Review of an admission MDS assessment dated [DATE], revealed Resident #156 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of Resident #156's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Anxiety Disorder, and Type 2 Diabetes. Review of an annual MDS assessment dated [DATE], revealed Resident #34 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #34's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease (COPD). Review of a quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #5's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, COPD, and Pulmonary Hypertension. Review of a quarterly MDS assessment dated [DATE], revealed Resident #69 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #69's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Hypertension, Type 2 Diabetes, and Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #45 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #45's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Lung, Hypertension, and Adult Failure to Thrive. Review of an annual MDS assessment dated [DATE], revealed Resident #14 was rarely or never understood. Review of Resident #14's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with diagnoses including Hypertension, Adult Failure to Thrive, and Neoplasm of Prostate. Review of an admission MDS assessment dated [DATE], revealed Resident #102 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of Resident #102's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #356 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Congestive Heart Failure, and Abdominal Aortic Aneurysm. Review of a 5-day admission MDS assessment dated [DATE], revealed Resident #356 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #356's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, and Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #67 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of Resident #67's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, End Stage Renal Disease, and Dementia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #31 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #31's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Atrial Fibrillation, and Type 2 Diabetes. Review of a quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of Resident #47's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Dementia, Heart Failure, and Visual Hallucinations. Review of a quarterly MDS assessment dated [DATE], revealed Resident #73 scored a 00 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of Resident #73's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Type 2 Diabetes, and Hypertension. Review of an admission MDS assessment dated [DATE], revealed Resident #99 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of Resident #99's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Hypertension, and Obesity. Review of a quarterly MDS assessment dated [DATE], revealed Resident #96 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #96's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including COPD, Heart Failure, and Alzheimer's Disease. Review of an annual MDS assessment dated [DATE], revealed Resident #8 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of Resident #8's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Hypertension, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #65 scored an 8 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of Resident #65's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Prostate, Old Myocardial Infarction, and Hypertension. Review of a quarterly MDS assessment dated [DATE], revealed Resident #3 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of Resident #3's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including COPD, Heart Failure, and Hypertension. Review of a quarterly MDS assessment dated [DATE], revealed Resident #22 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of Resident #22's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Delusional Disorders, Alzheimer's Disease, and Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of Resident #12's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (stroke), COPD, Vascular Dementia, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #21 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of Resident #21's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including COPD, Hyperkalemia (High level of potassium), and Bacterial Infection. Review of a quarterly MDS assessment dated [DATE], revealed Resident #49 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of Resident #49's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. During an interview on 5/29/2024 at 1:00 PM, Nurse Liaison H stated she was responsible to complete the admission paperwork with residents and/or the resident's representative. The Nurse Liaison confirmed she did not provide written information to the resident and/or resident representative concerning the right to formulate an advance directive. During an interview on 5/29/2024 at 4:45 PM, the Social Worker confirmed the facility did not provide written information to the residents and/or resident representative concerning the right to formulate an advance directive. During an interview on 5/31/2024 at 10:20 AM, the Director of Nursing confirmed the facility did not provide written information to the residents and/or resident representative concerning the right to formulate an advance directive.

Based on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Resident #21 and #34) of 35 residents reviewed. The findings include: Review of the RAI Manual 3.0 dated 10/1/2023 revealed . primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan .the assessment [MDS] accurately reflects the resident's status .registered nurse conducts or coordinates each assessment .One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status .Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring .during the 7-day look-back period . Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Cerebral Infarction (stroke), Delusional Disorders, Chronic Obstructive Pulmonary Disease (COPD), Vascular Dementia, Anxiety Disorder, and Depression. Review of hospital discharge documentation for Resident #21 dated 3/17/2024, revealed the resident's discharge diagnoses included Acute Encephalopathy, COPD, Chronic Respiratory Failure, Acquired Obstructive Hydrocephalus, Cervical Stenosis of Spinal Canal, HTN, Dementia with Psychosis, and history of Cardiovascular Accident (stroke). Review of the quarterly MDS assessment dated [DATE], revealed Resident #21 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. Continued review revealed the resident had an active diagnosis of Pneumonia. Review of Resident #21's medical record revealed a diagnosis of Pneumonia had not been documented. During an interview on 5/31/2024 at 11:41 AM, the MDS Coordinator confirmed Resident #21 did not have a diagnosis of Pneumonia and confirmed the quarterly MDS assessment dated [DATE] was inaccurate for Resident #21. 50216 Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Anemia, Diabetes Mellitus, Hypothyroidism, and Generalized Muscle Weakness. Review of nurse's note for Resident #34 dated 3/6/2023, revealed the resident had natural lower teeth and no upper teeth. Review of the admission MDS dated [DATE], revealed Resident #34's had no dental issues. Review of the annual MDS dated [DATE], revealed Resident #34 had no dental issues. Review of the medical record for Resident #34 revealed no documentation showing the resident had been asked about seeing a dentist or been seen by a dentist. During an interview on 5/30/2024 at 11:00 AM, the DON stated there was no documentation that showed Resident #34's oral condition had been assessed by a nurse or a dentist since the admission assessment. During an interview on 5/30/2024 at 2:25 PM, the MDS Coordinator stated the facility failed to assess the resident oral status. The MDS Coordinator stated it is the MDS Coordinator's responsibility to assess the oral cavity for the MDS and mark the MDS accordingly.

Based on medical record review and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) after a new mental health diagnoses was identified to the state-designated authority for 1 resident (Resident #73) of 14 residents reviewed for PASRR. The findings include: Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, Panic Disorder and Adult Failure to Thrive. Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #73 scored a 3 on the Brief Interview for Mental Status Score (BIMS) which indicated the resident had severe cognitive impairment. The resident had a diagnoses of psychosis. Review of a PASRR for Resident #73, dated 5/1/2020, revealed .the following mental health conditions that are diagnosed .for this individual .Anxiety Disorder .Panic Disorder .If changes occur or additional information suggests .mental illness .rescreening should occur . Review of Resident #73's medical record revealed a new diagnoses of Psychosis was dated 6/12/2020. During an interview on 5/30/2024 at 8:38 AM, the Director of Nursing confirmed a new PASSR should have been submitted after the new mental health diagnosis of Psychosis was added on 6/12/2020.

Based on facility policy review, medical record review, observation and interviews, the facility failed to revise a comprehensive care plan with new interventions after falls for 2 residents (Residents #37 and #306) of 35 resident care plans reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, revealed .comprehensive, person-centered care plan .reflects currently recognized standards of practice for problem areas and conditions .interdisciplinary team reviews and updates the care plan .when the desired outcome is not met . Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Dementia, Pneumonia and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 scored a 7 on the Brief Interview for Mental Status Score (BIMS) which indicated the resident had severe cognitive impairment and had 2 falls with no injury since last assessment. Review of Resident #37's care plan reviewed on 4/3/2024, revealed the resident was at risk for falls related to generalized weakness and difficulty walking. Interventions included keeping the bed in lowest position dated 9/2/2021, and mats to the bedside dated 11/13/2021. There was no intervention documented on the care plan for a fall on 5/9/2024. Review of Resident #37's medical record revealed a Falls Investigation Report dated 5/9/2024 which revealed the resident had an unwitnessed fall. The resident was found in the floor, was assessed, and no injuries were found. Fall interventions were documented to be in place at the time of the fall. Review of a Nurse's Notes for Resident #37 dated 5/9/2024, revealed the resident .was observed sitting on buttocks with back against the side of bed .on mats .No injuries .Informed house supervisor .Neuro [neurological] checks . During an interview on 5/29/2024 at 4:01 PM, the MDS Coordinator stated Resident #37 had a falls care plan but no new interventions were added to the care plan after the fall on 5/9/2024. The Coordinator stated it was her job to update the care plan interventions after a fall. 49568 Medical record review revealed Resident #306 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation. Review of a Baseline Care Plan dated 5/16/2024, revealed Resident #306 had a .History of falls/At risk - Interventions .nonskid socks when out of bed . Review of an admission MDS assessment dated [DATE], revealed Resident #306 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the Falls Investigation Report dated 5/27/2024, revealed Resident #306 was found sitting on the floor beside his bed after falling from wheelchair. The immediate intervention was to place anti roll backs (device prevents wheelchair from rolling back as the user attempts to sit or stand) to wheelchair. Review of the Physician's Orders for Resident #306 dated 5/27/2024, revealed anti roll backs applied to wheelchair for safety. Review of the comprehensive care plan dated 5/27/2024, revealed no documentation anti roll backs had been added to the care plan. During an observation on 5/28/2024 at 12:20PM, revealed Resident #306's wheelchair with anti roll backs in place. During an observation on 5/29/2024 at 9:05 AM, revealed Resident #306's wheelchair with anti roll backs in place. During an observation on 5/30/2024 at 9:10AM, revealed Resident #306's wheelchair with anti roll backs in place. During an interview on 5/30/2024 at 2:20 PM, the Director of Nursing (DON) stated anti roll backs were added to Resident #306's wheelchair after fall on 5/27/2024. The DON stated it fall risk interventions were added to prevent falls, the resident's plan of care should be revised to reflect those additions. The DON confirmed Resident #306's care plan had not been updated to reflect the fall prevention intervention for anti roll backs after the fall on 5/27/2024.

Based on review of facility policy, observations, and interviews the facility failed to provide personal grooming for 1 resident (Resident #79) of 35 residents reviewed. The findings include: Review of the facility's policy titled Activities of Daily Living (ADL), Supporting, revised 3/2018, revealed .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living .Residents who are unable to carry out activities of daily living independently will receive .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .Hygiene (bathing, dressing, grooming .) . Medical record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses including Anemia, Candidiasis (yeast), and Bacterial Infection. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #79 scored a 13 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. The resident was dependent on staff for toileting, bathing, and required partial to moderate assistance with personal hygiene. Review of a comprehensive care plan for Resident #79 dated 7/7/2021, revealed staff .Assist [Resident #79] with dressing, grooming, hygiene care daily and prn [as needed] . Review of Resident #79's medical record revealed no documentation the resident had refused nail care. Observation of Resident #79 on 5/28/2024 at 11:38 AM, revealed the resident had long fingernails with brown debris under the nails. Observation of Resident #79 on 5/29/2024 at 9:26 AM, revealed the resident had long fingernails with brown debris under the nails. Observation of Resident #79 on 5/29/2024 at 4:10 PM revealed the resident had long fingernails with brown debris under the nails. Observation of Resident #79 on 5/30/2024 at 10:07 AM revealed the resident had long fingernails with brown debris under the nails. During an observation and interview on 5/30/2024 at 2:15 PM, Resident #79's fingernails were long and had brown debris under the nails. The resident stated she would like to have her nails trimmed.I don't like them [fingernails] to be long .don't do anything but get dirty . During an interview and observation of Resident #79 on 5/30/2024 at 3:07 PM, Certified Nursing Assistant (CNA) J confirmed Resident #79 had brown debris under her fingernails. During an interview and observation of Resident #79 on 5/30/2024 at 3:10 PM, Licensed Practical Nurse (LPN) C confirmed Resident #79 had brown debris under her fingernails. During an interview on 5/31/2024 at 11:41 AM, the Director of Nursing stated she expected nail care to be provided for residents with daily care and when resident's nails were long or dirty.

Based on facility policy review, safety data sheet review, medical record review, observations, and interviews the facility failed to ensure chemicals were secured for 1 resident (Resident #25) and failed to ensure medications were secured for 1 resident (Resident #27) of 35 residents observed. The findings include: Review of the facility policy titled Self-Administration of Medications, revised 2/2021 revealed .the interdisciplinary team (IDT) assesses each resident's cognition and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Review of the facility's undated policy titled, Hygiene and Grooming Supplies, revealed .The resident's grooming needs are met while addressing . personal preferences and daily routine .all supplies are kept secured .if a resident has a BIMS [Brief Interview for Mental Status] score of 8 or above .may utilize a locked drawer in .room to store .grooming supplies . Review of the facility's undated policy titled, Chemical Handling and Storage, revealed .Store all hazardous material in containers .segregate .by hazard class .flammable .do not leave chemicals unattended .all chemicals are kept behind .closed locked door when not in use . Review of a Safety Data Sheet dated 9/2/2015, revealed .Nail Polish Remover .Hazard Identification .flammable liquid . Review of a Safety Data Sheet revised 3/2016, revealed .Glade Aerosol .Flammable . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Atrial Fibrillation, and Chronic Congestive Heart Failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. During an observation in Resident #25's room on 5/28/2024 at 1:15 PM, revealed an unsecured full 10- fluid ounce (oz) bottle of nail polish remover and an 8 oz aerosol can of Glade air freshener unsecured on the resident's bedside dresser. Further observation revealed Resident #25 had a private room. During an interview on 5/20/2024 at 2:42 PM, Licensed Practical Nurse (LPN) F confirmed a full 10 oz bottle of nail polish remover, and an 8 oz aerosol can of Glade air freshener was left unsecured on Resident #25's bedside dresser. LPN F stated there were no wandering residents observed going into the resident's room. During an interview on 5/29/2024 at 4:00 PM, Certified Nursing Assistant (CNA) G, reported Resident #25 kept her door closed when she was not in the room. CNA G further reported she had not witnessed residents wandering into Resident #25's room. During an interview and observation on 5/30/2024 at 1:45 PM, Resident #25 stated she was aware to keep the nail polish remover and aerosol air freshener in a secure location and not to drink the nail polish remover. Resident #25 also stated she kept her door closed to the room and no other residents had wandered into her room. During observations from 5/28/2024-5/31/2024 at various times of the day showed no wandering residents on the 300-hallway (hallway Resident #25 resides). During an interview on 5/30/2024 at 3:45 PM, the Director of Nursing (DON) stated chemicals should not be left unsecured in a resident's room. The DON confirmed the nail polish remover and aerosol air freshener observed in Resident #25's room should be stored in a secure location and not left on the bedside dresser. 50216 Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Presence of Left Artificial Hip Joint, Pain in Left Hip, Atrial Fibrillation, and Anemia. Review of the Physician's Orders for Resident #27 dated 3/6/2023 revealed there was not an order for a multivitamin. Review of an admission MDS assessmen dated 3/13/2024, revealed Resident #27 scored 15 on the BIMS which indicated the resident was cognitively intact. During an observation and interview on 5/28/2024 at 2:30 PM, in Resident #27's room an unsecured 200-count bottle of multivitamins was observed on the sink counter. During an interview Resident #27 stated she had not been assessed for self-administering medications. Resident #27stated she brought the vitamins in when she admitted to the facility, and she kept the bottle on her counter. During an observation on 5/29/2024 at 3:45 PM, revealed the multivitamin bottle was unsecured in Resident's #27 room. During an interview and observation on 5/29/2024 at 3:50 PM, LPN I stated residents had to be assessed and monitored to self-administrater medication. LPN I stated a resident's medications should be locked up in the room if the resident has been assessed to be safe to self-administer their medications. LPN I stated Resident #27 had not been assessed to self administer medications. LPN I went to Resident #27's room and verified there was a 200-count bottle of multivitamins in the resident's room. LPN I removed the multivitamins from the room after permission was given from Resident #27. During an interview on 5/29/2024 at 4:00 PM, Registered Nurse (RN) K stated Resident #27 had not been assessed for self- administration of medication and the multivitamin bottle should not have been left in the room. During an interview on 5/29/2024 at 4:15 PM, the DON stated medications are not supposed to be left unsecured in a resident 's room. Medications should have been picked up and taken to the nurses' station.

Based on facility policy review, medical record review, and interview, the facility failed to document the fluid restriction amount and the amount consumed by the resident each shift on the Medication Administration Record (MAR) for 1 resident (Resident #31) of 1 resident reviewed for fluid restrictions. The findings include: Review of the facility's policy titled, Fluid Restriction, revised 5/10/2023, revealed .The fluid restriction amount .amount designated for each department .will be documented in the Physician order .and on the MAR .Fluid amount consumed .will be documented each shift .placed on the MAR . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Edema, Acute Kidney Failure, and End Stage Renal Disease Requiring Renal Dialysis. Review of the Physician's Orders for Resident #31 dated 11/30/2023, revealed the resident was on a fluid restriction of 960 ml (milliliter)/day. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #31 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an interview on 5/30/2024 at 1:38 PM, Licensed Practical Nurse (LPN) F stated Resident #31 was on a 960 ml/day fluid restriction, nursing provided 120 ml of the fluid ordered per shift, and dietary provided the remainder. LPN F confirmed the amount of fluid consumed by the resident was not documented on the MAR. During an interview on 5/30/2024 at 2:08 PM, Certified Nursing Assistant (CNA) L stated Resident #31 was on a fluid restriction, the resident did not have a water pitcher at her bedside, the CNAs do not offer fluids, and hydration was provided by dietary and nursing. During an interview on 5/31/2024 at 9:21 AM, Resident #31 stated she was aware of her fluid restriction of 960 ml/day. She stated the CNAs do not offer her fluids and she did not have a water pitcher at her bedside. The resident stated she received fluids from dietary on her tray and nursing. The resident also stated she knew how much fluid she was allowed to have daily, and staff did not offer her more fluid than she was allowed. Review of the MAR for Resident #31 dated 5/1/2024-5/31/2024 revealed no documentation of the fluid restriction amount and the amount consumed by the resident each shift. During an interview on 5/31/2024 at 12:15 PM, the Director of Nursing (DON) confirmed the facility failed to document Resident #31's fluid restriction and amount consumed on the MAR.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a Dementia care plan for 2 residents (Resident #12 and #21) of 5 residents reviewed for Dementia Care. The findings include: Review of the facility policy titled, Dementia- Clinical Protocol, revised 11/2018, revealed .For the individual with confirmed dementia, the IDT [Interdisciplinary Team] will identify a resident-centered care plan to maximize remaining function and quality of life . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychotic Disturbance, Alzheimer's Disease, and Vascular Disorder of the Intestine. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Active diagnoses for Resident #12 included Alzheimer's Disease and Non-Alzheimer's Dementia. Review of the comprehensive care plan revealed Resident #12 was not care planned for Dementia. During observations from 5/28/2024 - 5/30/2024, no concerns were observed related to the resident's behaviors or Dementia diagnosis. During an interview and review of Resident #12's medical record on 5/30/2024 at 2:32 PM, the Director of Nursing (DON) confirmed Resident #12 had a diagnosis of Dementia and Alzheimer's Disease. The DON confirmed Resident #12's care plan did not address the resident's Dementia or Alzheimer's disease diagnoses. The DON confirmed it was her expectation that residents with Dementia were care planned for Dementia with person-centered interventions to address Dementia behaviors/needs. During an interview on 5/30/2024 at 3:04 PM, the MDS Coordinator stated she was responsible for care plans. The MDS Coordinator confirmed Resident #12 had a diagnosis of Alzheimer's Disease and Dementia on the quarterly MDS assessment dated [DATE], and should have been care planned for both diagnoses. The MDS Coordinator confirmed Resident #12 did not have a Dementia or Alzheimer's Disease care plan. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Delusional Disorder, and Severe Vascular Dementia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #21 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Active diagnoses for Resident #21 included Non-Alzheimer's Disease and Vascular Dementia. Review of the comprehensive care plan revealed Resident #21 was not care planned for Dementia. During observations from 5/28/2024 - 5/30/2024, no concerns were observed related to the resident's behaviors or Dementia diagnosis. During an interview and review of Resident #21's medical record on 5/30/2024 at 2:39 PM, the DON confirmed Resident #21 had a diagnosis of Vascular Dementia and was not care planned for the diagnosis. The DON confirmed residents with Dementia were to have a person-centered care plan for Dementia. During an interview on 5/30/2024 at 3:02 PM, the MDS Coordinator confirmed Resident #21 had a diagnosis of Dementia on the quarterly MDS assessment dated [DATE]. The MDS Coordinator confirmed the resident did not have a Dementia care plan and stated .if it's on the MDS, it should be on the care plan .we must have thought it was already on there [the care plan] .

Based on facility policy review, medical record review and interviews the facility failed to provide evaluation and rational for continued use of a PRN (as needed) antianxiety medication for 1 resident (Resident #16) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Use, revised 7/2022, revealed .Residents will not receive medications that are not clinically indicated to treat a specific condition .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Drugs in the following categories are considered psychotropic medications .Anti-anxiety medications .psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition document in the medical record .PRN orders for psychotropic medications are limited to 14 days . Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Anxiety. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the Physician's Orders for Resident #16 dated 10/23/2023, revealed .ATIVAN [drug affecting the brain used to treat anxiety] 0.5MG [milligram] TABLET .every 6 hours as needed for anxiety x [times/for] 14 days .Discontinue Date: 10/27/2023 . Review of the Physician's Orders for Resident #16 dated 10/27/2023, revealed .ATIVAN 0.5MG TABLET .1/2 tablet [0.25 mg] .every 6 hours as needed . Further review revealed there was no stop date for the PRN anti-anxiety medication. During a telephone interview on 5/30/2024 at 4:45 PM, Nurse Practitioner (NP) Q confirmed Resident #16's PRN Ativan 0.25 mg order did not have a stop date, the resident had not been evaluated for continued use of the anti-anxiety medication, and a rationale had not been documented. During an interview on 5/30/2024 at 5:17 PM, the Director of Nursing (DON) confirmed Resident #16's PRN Ativan 0.25 mg order did not have a stop date. During a telephone interview on 5/31/2024 at 1:45 PM, the Pharmacist Consultant confirmed Resident #16 did not have pharmacy recommendations to discontinue the use of the PRN Ativan 0.25 mg.

Based on facility policy review, observations, and interviews the facility failed to label and date 1 medication on 1 medication cart of 3 medication carts observed, failed to assure medications were secure on 1 medication cart of 3 medication carts observed, failed to secure medications in 1 medication room of 2 medication rooms observed, and failed to remove expired supplies from 1 medication room of 2 medication rooms observed for medication storage. The findings include: Review of the facility's policy titled, Medication Labeling and Storage, revised ,d+[DATE], revealed .Compartments .including .carts .containing medications .are locked when not in use and .carts used to transport such items are not left unattended if open or .potentially available to others .Controlled substance .subject to abuse are separately locked in permanently affixed compartments .Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .The medication label includes .medication name . expiration date .resident's name .Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial . During an observation of medication administration on the 400 hall on [DATE] at 8:37 AM, with Licensed Practical Nurse (LPN) C revealed an insulin pen was observed in the medication cart with other vials of medications. The insulin pen did not have a pharmacy label, a resident name, or an open date. The LPN was prepared to use the unlabeled insulin pen, and surveyor stopped LPN C before the insulin pen was used. LPN C confirmed she did not know when the insulin pen was opened and it should not have been used. During an observation of medication administration on the 300 Hall on [DATE] at 8:40 AM, with Licensed Practical Nurse (LPN) N revealed the LPN prepared medications for Resident #16. Further observation revealed, the LPN left the cart against the wall, walked away from the unlocked medication cart, entered the resident's room, and administered Resident #16's medications. During an interview on [DATE] at 8:45 AM, LPN N confirmed she walked away from the unlocked medication cart, entered Resident #16's room to administer medications, and the medication cart was left unsecured and out of sight. During an interview on [DATE] at 4:00 PM, Registered Nurse (RN) K confirmed insulin pens were to be dated when opened and labeled with the resident's information. During an interview on [DATE] at 4:15 PM, the Director of Nursing (DON) confirmed when the insulin pen or vial was opened, the nurses were responsible to date the pen or vial when opened and ensured it was labeled with the resident's information. During an observation on [DATE] at 4:40 PM, the medication room door was propped open, left unattended, and 2 packs of medications were left on a table inside the medication room unsecured. During an observation and interview on [DATE] at 4:45 PM, with LPN O revealed the medication room door was propped open with 2 packs of medications lying unsecured on a table in the medication room. LPN O confirmed 1 pack of the medication was .Hydrocodone 7.5 mg [milligram]/ 325mg APAP [Acetaminophen] .30 tablets . LPN O also confirmed the second pack of medication was .Oxycodone 5mg XXX,d+[DATE] tabs [tablets] .14 tablets . LPN O confirmed Hydrocodone APAP 30 tablets and Oxycodone 14 tablets were left unsecured and the medications were not in her visual site. During an observation and interview on [DATE] at 4:51 PM, with LPN P in the medication room revealed: 59- 1 ml (milliliter) 27 gauge x (by) ,d+[DATE] inch syringes with an expiration date of [DATE] available for resident use. 2- 24 gauge x 0.75 inch Instaflash (to start an IV) needle with an expiration date of [DATE] available for resident use. 2- IV (intravenous) Start Kits with the following contents, 1 Tourniquet, 1 PVP (Povidone-Iodine Prep) prep pad, 1 Alcohol prep pad, 2 non-woven gauze 2 x 2 inch, 1 transparent bandage dressing 2.37 x 2.75 inch, 1 roll of 2 inch tape with an expiration date of [DATE] available for resident use. 5- C&S (culture and sensitivity) Transfer straw kit (used to collect urine specimen) 4.0 ml with an expiration date of ,d+[DATE] available for resident use. During an interview on [DATE] at 4:50 PM, LPN P confirmed 59 syringes, 2 Instaflash needles, 2 IV start kits with contents, 5 C&S transfer straw kits were expired, stored in the medication room, and available for use. During an interview on [DATE] at 5:15 PM, The Pharmacy Director and the Pharmacist confirmed Hydrocodone APAP 30 tablets and Oxycodone 14 tablets were scheduled 2 narcotics and were to be secured behind 2 locked areas. They also confirmed 59 syringes, 2 Instaflash needles, 2 IV start kits with contents, 5 C&S transfer straw kits were expired. During an interview on [DATE] at 5:17 PM, the Director of Nursing (DON) confirmed during medication administration observation on [DATE] the medication cart should not have been left unsecured on the 300 hall. The DON also confirmed Hydrocodone APAP 30 tablets and Oxycodone 14 tablets were to be secured behind 2 locked areas and the 59 syringes, 2 Instaflash needles, 2 IV start kits with contents, 5 C&S transfer straw kits were expired.

Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to protect 3 residents from abuse (Resident #2, Resident #3, and Resident #9) of 9 residents reviewed for abuse when Licensed Practical Nurse (LPN) #1 yelled at and threatened Resident #2, and Certified Nursing Assistant (CNA) #4 refused to provide needed care to Resident #3 and Resident #9. This resulted in Resident #2 and Resident #3 sustaining psychosocial Harm. The findings include: Review of the facility policy titled, Resident Abuse, Mistreatment and Neglect, last revised 4/28/2023, showed .It is the policy of this facility that each resident has the right to be free from staff-to-resident abuse .Alleged Violation - is a situation or occurrence related to mistreatment .neglect or abuse .Abuse- the willful or deliberate .intimidation, or punishment resulting in physical harm, pain or mental anguish, derivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Mental Abuse- includes .threats of punishment or deprivation .Neglect- the failure of the facility, its employees .to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish, or emotional distress .Mistreatment- inappropriate treatment .of a resident . Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Polyosteoarthritis, Cellulitis, Encounter for Other Orthopedic Aftercare, Chronic Obstructive Pulmonary Disease, Displaced [NAME] Fracture of Right Tibia, Other Fracture of Upper and Lower Right Fibula, History of Falling, and Type 2 Diabetes Mellitus. Review of Resident #2's comprehensive care plan dated 9/20/2022, showed .Self care deficit rt [related to] weakness .Assist with dressing, grooming, hygiene care .Assist with toileting .Potential for social isolation related to impaired mobility .Act [Activity] staff will offer assistance to and from resident choice of events .Act staff will document response to interventions .At Risk for Falls r/t [related to] generalized weakness and difficulty walking .Assist with all ambulation/transfer attempts . Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 9, indicating she had moderate cognitive impairment. She had no mood problems and no behavior problems. She required extensive assistance of 1 staff member for bed mobility, transfers, walking in the room, dressing, toilet use, and personal hygiene. Review of the facility's investigation showed an incident occurred on 5/24/2023 on the evening shift, 3:00 PM- 11:00 PM, between Resident #2 and LPN #1. Review of the Director of Nursing (DON)'s witness statement dated 5/25/2023, showed .The nursing supervisor [Registered Nurse #1] .notified me that [Resident #2] told her that the nurse on 3-11 [3:00 PM-11:00 PM] had told her that if she didn't stop yelling that she would have her moved to a different floor. I spoke with the nurse who stated that the resident was sitting up in the hallway and wanted to be put to bed before dinner. The nurse stated she told her she would have the CNA lay her down before dinner but she would have to wait a few minutes because they were all in other rooms right then. The nurse stated that the resident was yelling in the hallway to any visitors that walked by they won't take care of me, they won't put me to bed The nurse told her again they would lay her down in just a few minutes. The nurse [LPN #1] stated that she never made the statement about her [Resident #2] moving to a different floor and that they had the resident in bed by 4:30 [4:30 PM] and the resident was in bed before dinner which was her request. There were no other concerns reported and the resident is to be put to bed at her requested time . Review of the activity calendars dated 5/1/2023-6/26/2023, showed the facility had bingo at 3:30 PM on 5/4/2023, 5/11/2023, 5/19/2023, 5/25/2023, 6/1/2023, 6/8/2023, and 6/15/2023. Review of Resident #2's activity participation sheets dated 5/1/2023-6/26/2023, showed the resident had missed bingo on 6/1/2023. Review of the Activity Director's witness statement dated 6/6/2023, showed .Upon my return from vacation on May 30th [5/30/2023], during my staff meeting. I was informed of a situation that occurred the prior week between Nurse [LPN #1] and [Resident #2] by [the Activity Assistant]. As she was not a witness to the occurrence, and because she was under the impression that it was reported to the nurse supervisors, I decided to file it as reported. When .[Activity Assistant] reported the conversation between herself and [Resident #2] on the resident's decision to not attend activities and be put to bed in the afternoon before [LPN #1] arrived, I asked her to write a statement and notified [Social Services Director] our social worker so she could go speak with [Resident #2] . Review of the Social Service Director's witness statement dated 6/6/2023, showed .SW [Social Worker] spoke with [Resident #2] .re: bedtime preference. Resident voiced that she would like to return to bed around 4 pm, before dinner is served because she gets up every morning at 7:30 am. She shared with SW that she had asked to return to bed the other day (could not tell me exact date) and was told they had to get blood pressures first. She said she was told by [LPN #1] that if she did not stop talking so loud she was going to have her sent to another floor. Resident said she was now asking [CNA #1] .(CNA's) on 1st shift to put her to bed before they leave at 3pm to avoid asking 2nd shift. She voiced that she enjoys going to bingo and is missing that now. (Bingo is at 3pm) SW offered to move her to a different floor, Resident declined, stating she did not want to leave her CNA's. SW requested Psych services to see the Resident . Review of LPN #2's witness statement dated 6/7/2023, showed .[Resident #2] seemed upset upon entering her room. Resident stated that she was upset because the nurse the night before told her that if she did not stop yelling that she [LPN #1] would get her kicked off of the floor. I informed her [Resident #2] that she had nothing to worry about and she would not be kicked off of the floor . Review of CNA #1's witness statement dated 6/7/2023, showed .I went to [Resident #2's] room in the morning to take her vitals and asked her If she wanted to get dressed she asked me how come the other CNA couldn't do the same thing. Then she started telling me about what happened the night before she asked [LPN #1] could someone put her to bed, this was right after activity was over. So I guess around 4:30-4:45 [4:30 PM- 4:45 PM] she went in the hall and asked [LPN #1] again could someone put her to bed, she told her that they had to do virus [vital signs- blood pressure, temperature, pulse and respirations] first, the [then] according to [Resident #2] they both [LPN #1 and Resident #2] got loud with each other. [LPN #1] told her [Resident #2] if she don't shut up she would move her to another floor . Review of CNA #2's witness statement dated 6/7/2023, showed .[Resident #2] wanted to go to bed. CNA's [CNAs] on the floor told her that we [the CNAs] had something to do then we were coming to help her get in bed. All I witnessed was [Resident #2] and nurse [LPN #1] yelling at each other in the hallway. I cannot recall exactly what was said but pt [patient] was extremely upset and told me and another CNA that nurse [LPN #1] threatened to send her to another floor . Review of CNA #3's witness statement dated 6/7/2023, showed .May 24th 2023 [5/24/2023] .Activitys [Activity's] lady rolled [Resident #2] upstairs & [and] said when we get a chance to put [Resident #2] to bed before dinner I told her that was fine that I would do it [LPN #1] said I had to do vitals first so I told [Resident #2] I had to do vitals once done told her I was going to get her a gown then [LPN #1] said no put [Resident #10] to bed first & said [Resident #2] can wait so I went & put [Resident #10] to bed like she told me to after telling [Resident #2] she [Resident #2] said ok & I came out of putting [Resident #10] to bed to hearing screaming & [LPN #1] saying she [Resident #2] needed to shut her mouth & saying she needed to act right that no one would want to take care of her acting like that. I immediately took [Resident #2] to her room & [and] shut her door & me & [CNA #2] talked to [Resident #2] to calm her down as she had tears in her eyes and she told me that [LPN #1] told her that if she didn't act right she was going to move her to another floor. I finally got her [Resident #2] calm & told her that in the morning she needed to report it & if she needed me to tell them what I saw that I would & if she [LPN #1] said anything else to her or in wrong tone to call me on light [call light] . Review of Registered Nurse (RN) #1's witness statement dated 6/7/2023, showed .On 5/25/23 [5/25/2023] I was called to the 3rd floor by the nurse [LPN #2] she stated that [Resident #2] was upset about an incident that occurred on 5/24/23 [5/24/2023] on the evening shift and wanted to speak to a supervisor. I went into [Resident #2's room] and asked if she was having an issue that she needed to see a supervisor. [Resident #2] started crying & saying that the nurse [LPN #1] and herself was yelling at each other because she asked if she could lay down before 4:30 [4:30 PM] because she gets up early. She [Resident #2] said that she talks loud because she is hard of hearing. She proceeded to say that [LPN #1] told her that if she didn't be quiet that she was going to have her moved to another floor. I reassured her that we would lay her down @ [at] her preferred time for her to not to worry that we would take care of the situation I then went to the nursing office & reported the incident to the DON . Review of the Activity Assistant's witness statement, undated, showed .The week of May 22nd [5/22/2023]. I believe it was Thursday May, 25, 2023, [5/25/2023] there was an incident that occurred with [Resident #2] . I did not witness the events that occurred between nurse [LPN #1] and [Resident #2], the resident did confide in me, and told me what happened the next day, Friday May 26 [5/26/2023], when I returned to work. [Resident #2] informed me that she told nurse [LPN #1] that she had been up since 7 am [7:00 AM] that morning and would like to be put to bed by 4pm [4:00 PM] and or before dinner was served, she told me that [LPN #1] told her that 'the staff is busy and they will put you to bed when they can'. [Resident #2] stated that it would be great if they could put her down ASAP [As Soon As Possible] cause it wouldn't be till after dinner they could put her down if they didn't do it ASAP. She then stated, [LPN #1] told her she was being demanding and that she was being too loud, and [LPN #1] told her to shut up, and if she didn't stop, that [LPN #1] would have her moved to a different floor. I observed that [Resident #2] was upset while telling me. The second incident [Resident #2] told me about was that she asked [CNA #1] to put her to bed before 3:00 [3:00 PM] so she wouldn't have to deal with [LPN #1] yelling at her or being mean. That her being put to bed before [LPN #1] arrived would give her peace of mind. I observed that [Resident #2] looked anxious and scared whenever [LPN #1] arrived for her shift. This incident happened the week of June 1st, 2023 [6/1/2023]. Everything in this statement is things I have observed or a resident has informed me of . Review of Resident #2's Nurse Practitioner (NP) progress note dated 6/7/2023, showed .seen to evaluate her current mental/psychosocial wellbeing. There was apparently a [an] incident with a staff member and the resident felt intimidated. She tells me she did not feel afraid, however the nurse was 'mean'. She tells me she does not feel fearful or afraid to leave her room at this time .No increased nervousness or depression .Denies feeling afraid or threatened .Resident currently appears to be stable from a psychological standpoint . Review of Resident #2's Psychiatric Evaluation dated 6/7/2023, showed .seen today for further evaluation of situational anxiety and depression. Patient relayed to staff that there was a staff member who had been 'mean' to her, and had told her she would be moved to another floor. The staff member is no longer taking care of this patient. Patient frequently wants to go to bed around 4 PM, after afternoon activities. The staff member was telling patient that she needed to stay up. Because of this, patient had stopped going to activities in the afternoon so she could go to bed before new staff came on to take care of her. Staff state patient is generally very pleasant and cooperative. No behavioral issues. She has been anxious since this happened, as she is afraid of making somebody angry. She has been reassured multiple times that everything is okay. Staff report mood and behavior remain at baseline. Social services following up with patient as well .On exam, patient is up in wheelchair. She is alert and pleasant. She reports that she is doing 'okay'. She recounts incident, in which nurse told her that she was unable to go to bed as early as she wanted and needed to wait until it was time to go to bed. Patient states that she then was afraid to make anybody upset, so she asked morning staff, who leaves at 3 PM, to put her to bed prior to their departure. Patient states she likes to get up very early and has most of her life. Because of this, she likes to get in bed early, and go to sleep right after dinner. She enjoys participating in activities. She reports some depression initially, when she was unable to participate in activities. However, she is doing well now. She states she feels bad for getting somebody in trouble. Informed that she did the right thing and that staff were concerned about her. She feels she is ultimately very well taking care of and feels safe in that environment at this time. She states 'that is the only thing I have ever had a problem with'. She is thankful for everyone's help in dealing with the situation. No other complaints . Review of LPN #1's employee file showed she was hired on 8/22/2019. Review of the LPN's Employee Performance Evaluation dated 9/16/2022, showed .Complains .Difficult to get people to work with her. Rude! Discussed on last review with no improvement .Attitude and behavior have not improved. Rude to co-workers, department heads etc. Final warning will be done along with this review . Review of a Disciplinary Warning Notice dated 9/16/2022, showed .Despite numerous conversations regarding [LPN #1's] negative attitude there continues to be no improvement. [LPN #1] has been rude, hateful and extremely negative to co-workers and department heads, even going as far as to say she had thought about putting a sign out front that reads 'Welcome to Hell'. This will no longer be tolerated. Any future conduct of this nature will lead to additional disciplinary action, up to and including termination . Review of a Disciplinary Warning Notice dated 6/6/2023, showed .Suspended effective immediately pending complaint investigation . Review of a handwritten letter dated 6/7/2023, showed .I resign my position as LPN with [name of facility] effective immediately . and signed by LPN #1. During a telephone interview on 6/20/2023 at 2:44 PM, Adult Protective Services (APS) stated she had received a report about neglect and stated it had been reported to her .the resident [Resident #2] had words with the nurse [LPN #1] and the nurse said she would move her [Resident #2] to a different floor . She stated she had visited the resident and stated .[Resident #2] said she likes to go to bed around 4 [4:00 PM] .she asked the nurse to put her to bed .it was getting later and she asked again .the nurse was frustrated and said if it didn't stop she would be moved . [Resident #2] had since been asking another CNA to put her to bed . the resident did know of abuse towards others . The APS worker stated she had called back to the facility and had been told the nurse resigned .on the 9th of June 2023 [6/9/2023] . She stated .In talking with the DON, they knew of an incident but they had not reported it .according to the DON because it was resolved, although they didn't know the nurse had said she would move the resident to another floor but knew the resident had asked to be put to bed but was not aware of the verbal abuse .She [Resident #2] said she did cry for that time and she had since avoided the nurse .She was just fearful of asking to be put to bed at 4 [4:00 PM] and had a CNA that she was close to put her to bed at 3 [3:00 PM] so she could avoid asking anybody else .the CNA I spoke to said she has missed activities and felt it wasn't right that she had missed activities because she was being put to bed at 3 instead of 4 .the CNA said her favorite thing is bingo and the activity director was working with staff to make sure she was not missing bingo .the DON now has in her chart for all staff members to know that she wants to go to bed at 4 .from my understanding it did not reach the Administrator because he didn't know about it when I arrived. The DON was aware of the resident not getting put to bed but not aware of the resident's discomfort of going to bed early to avoid the nurse . During a telephone interview on 6/20/2023 at 3:28 PM, the Ombudsman stated his assistant had spoken to Resident #2 on 6/6/2023 with the APS worker. He stated .she [Resident #2] wanted to go to bed .[LPN #1] stated the CNA's were doing vitals and would put her to bed later .she [Resident #2] asked again and [LPN #1] became angry and yelled at her [Resident #2] the resident then was afraid to ask anyone but dayshift to put her to bed and had missed bingo .the resident said this was the only incident she had with [LPN #1] and had not witnessed any other incidents with other residents . The Ombudsman stated the resident had been trying to avoid LPN #1 and had been asking CNA #1 to put her to bed and because of this the resident would miss some afternoon activities. During an interview on 6/20/2023 at 3:41 PM, CNA #2 stated the incident had probably occurred 2 weeks prior to her witness statement which was dated 6/7/2023. CNA #2 stated .I was in orientation at this time and working along with another CNA [CNA #3] .the first thing we do is go around and take vital signs .the nurse [LPN #1] told the resident [Resident #2] that she would have to wait [to go to bed], just until we get the vital signs which is usually 15-20 min [minutes] max [maximum] .we did our vital signs and then [LPN #1] told us someone that was sitting up in the dining room and needed to go to bed first because they would fall out of their chair according to [LPN #1] .we went and grabbed the other patient .what the issue was is you had to go right by [Resident #2's] room to lay her down [to put the other resident to bed] .She [Resident #2] started getting nervous because she thought she wasn't going to get laid down before supper .she literally was just saying I've been up for 7 or 9 hours and saying she wasn't gonna get to go to bed until after dinner and saying she did not want left up until after dinner . CNA #2 stated the resident was not being loud .not at this time no .she was in her room but facing out into the hallway and was talking in a normal tone .we laid the resident down that [LPN #1] told us to lay down [Resident #10] and got her night clothes on and got her in bed and situated, and then we were at the last few steps of finishing [with Resident #10] and [CNA #3] looked at me and says who is screaming .I was thinking it was a resident .we opened the door to come out and see what's going and see that is nurse [LPN #1] and [Resident #2] yelling at each other .I can't exactly recall who said what .but [CNA #3] the best way she knew to diffuse the incident was to get the resident away from [LPN #1] because it seemed [LPN #1] was doing more of the yelling than the resident .the resident was getting loud too though .they were in the hallway [Resident #2] had come out of her room a little bit and [LPN #1] was standing in the hall outside of her room .so we get the resident into her room and shut the door and [Resident #2] was still saying 'I was afraid I was gonna be left up until after dinner' and [CNA #3] explained we didn't forget about her and said she [LPN #1] had no reason to tell me [Resident #2] I was gonna be moved to another floor .she's was crying at this time .[Resident #2] said 'I'm crying because I'm upset I'm mad' .she said [LPN #1] threatened if she didn't stop she was going to move her to a different floor .so we [CNA #2 and CNA #3] got [Resident #2] in the bed and situated and we came out of the room .I don't know if it was right after that or later in the evening .I heard [LPN #1] say that she didn't threaten to move her [Resident #2] to another floor but if she [LPN #1] had that power she would have already moved her a long time ago .[Resident #2] is very set in her ways but if you do your job and what she asks of you then your fine .you don't have to yell at her [Resident #2] .just communicate with her . During an interview on 6/21/2023 at 10:03 AM, Resident #2 stated . I asked to be laid down before supper and she [LPN #1] said the girls had to get blood pressures . The resident stated she does talk loud due to being hard of hearing and stated .but I didn't think I was being too loud .maybe she was having a bad night . The resident stated LPN #1 had not been hateful or verbally abusive to her prior to this incident but she had been upset after the incident .It hurt my feelings .I went to my room and cried .I like to get up early about 7 am [7:00 AM] .just because I like to .she [LPN #1] said to be quiet or I'll put you on another floor .it wasn't too nice .she said it real hateful .maybe she was having a bad night .it just hurt my feelings I just came to my room and I cried .[CNA #3] came in my room and she was my CNA that night .she heard me crying she didn't want me to cry . Resident #2 stated CNA #3 had assisted her to bed and LPN #1 had continued to be her nurse that evening .after that when she would come in here she was nice but she didn't say she was sorry, she gave me my medicine .I don't want anybody to hate me, I try to be good to people and I would like to think they'd be good to me . The resident stated she has been requesting to go to bed earlier since the incident and CNA #1 had been assisting her to bed before she left her shift at 3:00 PM .so there wouldn't be no trouble with people taking blood pressures . She stated she preferred to go to bed about 4:00 PM or 4:30 PM. The Resident stated CNA #1 would sometimes work late and she would then assist her to bed at 4:00 PM or 4:30 PM. During an interview on 6/21/2023 at 10:31 AM, RN #1 stated .she [Resident #2] would get up early in the morning and would want to go to bed before dinner .the charge nurse on the floor [LPN #2] called me and asked if I could come talk to her [Resident #2] that she had a complaint .she said last night she wanted to go to bed before dinner and she has asked the nurse if someone could put her to bed and the nurse [LPN #1] started yelling and said if she [Resident #2] didn't be quiet she would move her to another floor .the resident said she [Resident #2] does talk loud because she is hard of hearing .she said she was just going to start having [CNA #1] put her to bed and said [CNA #1] works over a lot and would have [CNA #1] lay her down before 3 [3:00 PM] .she said I just don't want [LPN #1] to be mad at me .she [Resident #2] said she [LPN #1] was yelling at me .I told the resident she had choices she said well I just don't want to be in trouble .I told her don't worry about it and she said I don't want to be moved and I said she [LPN #1] can't move you [Resident #2] . RN #1 confirmed the resident did have anxiety about the incident and did not want it to happen again. She stated the resident wanted to be assisted to bed between 4:30 PM and 5:00 PM .but she said just to make it easier I will have [CNA #1] lay me down before she leaves .I went downstairs and reported it to my supervisor the DON .I think that happened on a Wednesday [day of the incident] and it was reported to me on a Thursday which would have been the .25th of May [5/25/2023] .and I told her [the DON] she's [Resident #2] up there telling everybody .because I think the night shift CNAs told her [Resident #2] to report it the next day .she reported it to [CNA #1] and [CNA #1] reported to [LPN #2] and [LPN #2] reported it to me . RN #1 stated she had reported the incident to the DON because it was an allegation of abuse .yes .I was telling the DON the I feel like [LPN #1] is just burned out .I thought It was a verbal threat to say 'I'm gonna have you moved to another floor .she [Resident #2] said we both [Resident #2 and LPN #1] was yelling but I was yelling because I'm deaf .she said I just don't want [LPN #1] to be mad' .she just kept telling everybody and I thought this had to happen because she just kept telling the same story . RN #1 stated LPN #1 was not friendly with other staff and staff members had complained about her .I never witnessed her be mean to the residents but she would say stuff inappropriate to the staff . During an interview on 6/21/2023 at 10:50 AM, CNA #1 stated .she [Resident #2] liked to go to bed between 4:15 PM and no later than 4:30-4:45 PM because she is an early riser but she don't want to be up all night .if I go home at 3 o'clock [3:00 PM] then she won't go to activity .she will go to bed .cause she's afraid especially now since the incident happened that they won't lay her down .she's [Resident #2] a one person [takes 1 staff member to transfer her to the bed] .she takes less than 5 minutes to put into bed .she's ok to lay down at 3 [3:00 PM] but I think she would rather lay down at 4 [4:00 PM] because activities is her high point .she don't really want to miss activities .I don't think she really wants to [be assisted to bed by 3:00 PM] .I think she really is [scared to ask evening shift to assist her to bed] .she just don't want nobody to be mad .she just wants to please everybody .she don't mind asking me [to assist her to bed] . CNA #1 stated the resident had missed a few afternoon activities since she had been asking to be assisted to bed prior to CNA #1 leaving her shift .maybe one or two but not bingo because I refuse to let her miss bingo .I wasn't here the night it happened but that morning I came and was taking her vitals and just asked her do you want to get up .then she asked me how can you do vitals and get me up and they can't do it of the evening .then she started crying and she was telling me about [LPN #1] was yelling at her she was saying [LPN #1] had threatened to move her to another floor .told her [LPN #1] couldn't move her .she said [LPN #1] told her to get back in the room .she did say her and [LPN #1] were yelling at each other .said the girl [CNAs] finally laid her down about 5 [5:00 PM] .she was more upset .said she wasn't going to say anything to anyone else because she didn't want [LPN #1] to put her on another floor .I told her [LPN #1] has no authority to put you on another floor .after she [Resident #2] finished [telling CNA #1 about the incident] she said I don't want to get anyone in trouble then I told my nurse [LPN #2] .because she [Resident #2]was that upset that I felt someone should talk to her .to me it was a threat .and she was that upset so I knew it had to affect her . During an interview on 6/21/2023 at 1:08 PM, the Activity Assistant stated .bingo is her [Resident #2] favorite .any kind of game .crafts not a big fan .anything with food too .I bring her [to and from the activity] .I let her wheel herself to the elevator and then I move her onto the elevator . The Activity Assistant stated the resident had been missing some afternoon activities due to being in bed at an earlier time .or I would go to get her and she would tell me she didn't want to go through the trouble because of a certain nurse on night shift .her words to me was that staff would tell her that she would have to wait if they had other things to do to put her to bed .she says she wants to be in bed any time before 4:30 PM before they pass out food trays for the evening .she stresses about it daily but has not been as stressed the last week or 2 but before it was a big deal .there would be times before [LPN #1 was suspended] that she wouldn't even get up for the day because she felt like a burden .felt like she was asking too much . The Activity Assistant stated this had been happening .when nurse [LPN #1] was here, it was before she was suspended .but I didn't know that was going on .she would tell me she did not want to get up because she wasn't feeling good .she said she was afraid of [LPN #1] getting upset with her . The Activity Assistant stated the resident had told her about the incident that occurred between Resident #2 and LPN #1 .it was the day after it had happened I went to [Resident #2's] room and she told me what had happened .I first went and asked the nurse [LPN #2] if she was aware .and [CNA #1] told me it had already been reported downstairs to nursing .to [the DON] .the days after [LPN #1's] suspension she seemed more at peace .she is not refusing activities .she been doing really good .very positive and social .she gets put to bed before I leave at 430 . She stated the facility had not had her write her witness statement until after she reported the incident and her concerns of the resident going to bed early and missing activities to the Activity Director. She stated the Activity Director had notified the Social Services Director due to the resident's change of routine. During an interview on 6/21/2023 at 2:11 PM, the Activity Director stated .I was on vacation and when I came back we have our morning meeting .[the Activity Assistant] brought up the situation .she said it was brought to the attention of the nurse supervisor .she was talking about the conversation between her [the Activity Assistant] and [Resident #2] so I decided to have social services go speak to her .she [Resident #2] was yelled at and she was missing activities by going to bed before the next shift came on to not have that happen again .I don't think she felt comfortable or safe with that nurse [LPN #1] that was on that oncoming shift [3:00 PM- 11:00 PM] . The Activity Director confirmed there was a period between when the resident reported the incident (5/25/2023) and when the facility suspended LPN #1 (6/6/2023) and the nurse was still caring for the resident .she didn't feel comfortable .I feel like she's a lot more comfortable now, she loves the floor she's on, she loves her CNA . During an interview on 6/21/2023 at 2:55 PM, CNA #3 stated .she [Resident #2] started wanting to be put to bed before dinner time .that day I came in and she was with the activity's lady and they came up from bingo .and she [the Activity Assistant] said out loud [Resident #2] would like to be put to bed and I said that's fine because I knew I was gonna have her [be assigned to care for Resident #2] .but then [LPN #1] said that we would have to do our vitals first .there is only one machine [to take vital signs with] so if someone is using it then others can go ahead and start making rounds [checking on residents] .but [LPN #1] has a way of wanting things to be done the way she wants .I went ahead and done my vitals .I was training [CNA #2] .I finished my vitals and I went to go get her [Resident #2] a gown and [LPN #1] stopped me and said she is gonna have wait because [Resident #10] has to be put to bed first .when I asked her [LPN #1] why she said she [Resident #10] had been up longer .and then we put her [Resident #10[TRUNCATED]

Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to timely report allegations of abuse to the State Survey Agency for 3 residents (Resident #2, Resident #3, and Resident #9) of 9 residents reviewed for abuse when a Licensed Practical Nurse (LPN) #1 yelled at and threatened Resident #2, and a Certified Nursing Assistant (CNA) #4 refused to provide needed care to Resident #3 and Resident #9. This resulted in Resident #2 and Resident #3 sustaining psychosocial Harm. The findings include: Review of the facility policy titled, Resident Abuse, Mistreatment and Neglect, last revised 4/28/2023, showed .It is the policy of this facility that each resident has the right to be free from staff-to-resident abuse .Alleged Violation - is a situation or occurrence related to mistreatment .neglect or abuse .Abuse- the willful or deliberate .intimidation, or punishment resulting in physical harm, pain or mental anguish, derivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Mental Abuse- includes .threats of punishment or deprivation .Neglect- the failure of the facility, its employees .to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish, or emotional distress .Mistreatment- inappropriate treatment .of a resident .Employees are required to report incident of alleged/suspected staff-to-resident abuse .The Administrator and/or DON [Director of Nursing] will report to the State Agency .2 hours after the allegation is made . Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Polyosteoarthritis, Cellulitis, Encounter for Other Orthopedic Aftercare, Chronic Obstructive Pulmonary Disease, Displaced [NAME] Fracture of Right Tibia, Other Fracture of Upper and Lower Right Fibula, History of Falling, and Type 2 Diabetes Mellitus. Review of Resident #2's comprehensive care plan dated 9/20/2022, showed .Self care deficit rt [related to] weakness .Assist with dressing, grooming, hygiene care .Assist with toileting .Potential for social isolation related to impaired mobility .Act [Activity] staff will offer assistance to and from resident choice of events .Act staff will document response to interventions .At Risk for Falls r/t [related to] generalized weakness and difficulty walking .Assist with all ambulation/transfer attempts . Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 9, indicating she had moderate cognitive impairment. She had no mood problems and no behavior problems. She required extensive assistance of 1 staff member for bed mobility, transfers, walking in the room, dressing, toilet use, and personal hygiene. Review of the facility's investigation showed an incident had occurred on 5/24/2023 on the evening shift, 3:00 PM- 11:00 PM, between Resident #2 and LPN #1. Review of the Director of Nursing (DON)'s witness statement dated 5/25/2023, showed .The nursing supervisor [Registered Nurse #1] .notified me that [Resident #2] told her that the nurse on 3-11 [3:00 PM-11:00PM] had told her that if she didn't stop yelling that she would have her moved to a different floor. I spoke with the nurse who stated that the resident was sitting up in the hallway and wanted to be put to bed before dinner. The nurse stated she told her she would have the CNA lay her down before dinner, but she would have to wait a few minutes because they were all in other rooms right then. The nurse stated that the resident was yelling in the hallway to any visitors that walked by they won't take care of me, they won't put me to bed The nurse told her again they would lay her down in just a few minutes. The nurse [LPN #1] stated that she never made the statement about her [Resident #2] moving to a different floor and that they had the resident in bed by 4:30 [4:30 PM] and the resident was in bed before dinner which was her request. There were no other concerns reported and the resident is to be put to bed at her requested time . Review of LPN #2's witness statement dated 6/7/2023, showed .[Resident #2] seemed upset upon entering her room. Resident stated that she was upset because the nurse the night before told her that if she did not stop yelling that she [LPN #1] would get her kicked off of the floor. I informed her [Resident #2] that she had nothing to worry about and she would not be kicked off of the floor . Review of CNA #3's witness statement dated 6/7/2023, showed .May 24th 2023 [5/24/2023] .Activitys [Activity's] lady rolled [Resident #2] upstairs & [and] said when we get a chance to put [Resident #2] to bed before dinner I told her that was fine that I would do it [LPN #1] said I had to do vitals first so I told [Resident #2] I had to do vitals once done told her I was going to get her a gown then [LPN #1] said no put [Resident #10] to bed first & said [Resident #2] can wait so I went & put [Resident #10] to bed like she told me to after telling [Resident #2] she [Resident #2] said ok & I came out of putting [Resident #10] to bed to hearing screaming & [LPN #1] saying she [Resident #2] needed to shut her mouth & saying she needed to act right that no one would want to take care of her acting like that I immediately took [Resident #2] to her room & shut her door & me & [CNA #2] talked to [Resident #2] to calm her down as she had tears in her eyes and she told me that [LPN #1] told her that if she didn't act right she was going to move her to another floor. I finally got her [Resident #2] calm & told her that in the morning she needed to report it & if she needed me to tell them what I saw that I would & if she [LPN #1] said anything else to her or in wrong tone to call me on light [call light] . Review of the Social Service Director's witness statement dated 6/6/2023, showed Resident #2 said she was told by [LPN #1] that if she did not stop talking so loud, she was going to have her sent to another floor. Resident said she was now asking [CNA #1] . (CNA's) on 1st shift to put her to bed before they leave at 3pm to avoid asking 2nd shift. She voiced that she enjoys going to bingo and is missing that now. (Bingo is at 3pm) SW offered to move her to a different floor, Resident declined, stating she did not want to leave her CNA's. SW requested Psych services to see the Resident . Further review of the facility's investigation showed date and time the facility became aware of the incident was 5/25/2023 at 3:02 PM. Review of a Disciplinary Warning Notice dated 9/16/2022, showed .Despite numerous conversations regarding [LPN #1's] negative attitude there continues to be no improvement. [LPN #1] has been rude, hateful and extremely negative to co-workers and department heads, even going as far as to say she had thought about putting a sign out front that reads Welcome to Hell. This will no longer be tolerated. Any future conduct of this nature will lead to additional disciplinary action, up to and including termination . Review of a Disciplinary Warning Notice dated 6/6/2023, showed .Suspended effective immediately pending complaint investigation . Review of a handwritten letter dated 6/7/2023, showed .I resign my position as LPN with [name of facility] effective immediately . and signed by LPN #1. During a telephone interview on 6/20/2023 at 2:44 PM, Adult Protective Services (APS) stated she had received a report about neglect and stated it had been reported to her .the resident [Resident #2] had words with the nurse [LPN #1] and the nurse said she would move her [Resident #2] to a different floor . The APS worker stated she had called back to the facility and had been told the nurse resigned .on the 9th of June 2023 [6/9/2023] . She stated .In talking with the DON, they knew of an incident, but they had not reported it .according to the DON because it was resolved, During an interview on 6/20/2023 at 3:41 PM, CNA #2 stated the incident had probably occurred 2 weeks prior to her witness statement which was dated 6/7/2023. CNA #2 stated .I was in orientation at this time and working along with another CNA [CNA #3] . I heard [LPN #1] say that she didn't threaten to move her [Resident #2] to another floor but if she [LPN #1] had that power she would have already moved her a long time ago .[Resident #2] is very set in her ways but if you do your job and what she asks of you then your fine .you don't have to yell at her [Resident #2] .just communicate with her . CNA #2 stated she was aware the incident was an abuse occurrence but had been afraid to report the incident and stated .a lot of CNA's on the floor will say they are afraid to report abuse because when you do they are the ones that end up getting fired instead of the abuser .they said they watch people go and report and they get fired instead of the person they reported on .and that is exactly why [CNA #3] handled that situation the best way she knew how to get the situation diffused was to get the resident away from [LPN #1] . During an interview on 6/21/2023 at 10:03 AM, Resident #2 stated . I asked to be laid down before supper and she [LPN #1] said the girls had to get blood pressures . The resident stated she does talk loud due to being hard of hearing and stated .but I didn't think I was being too loud .maybe she was having a bad night . The resident stated LPN #1 had not been hateful or verbally abusive to her prior to this incident but she had been upset after the incident .It hurt my feelings .I went to my room and cried .I like to get up early about 7 am [7:00 AM] .just because I like to .she [LPN #1] said to be quiet or I'll put you on another floor . she said it real hateful .maybe she was having a bad night .it just hurt my feelings I just came to my room and I cried .[CNA #3] came in my room and she was my CNA that night .she heard me crying she didn't want me to cry . Resident #2 stated CNA #3 had assisted her to bed and LPN #1 had continued to be her nurse that evening. The resident stated .I don't want anybody to hate me, I try to be good to people and I would like to think they'd be good to me . The resident stated she has been requesting to go to bed earlier since the incident and CNA #1 had been assisting her to bed before she left her shift at 3:00 PM .so there wouldn't be no trouble with people taking blood pressures . During an interview on 6/21/2023 at 10:31 AM, RN #1 confirmed Resident #2 did have anxiety about the incident and did not want it to happen again. She stated the resident wanted to be assisted to bed between 4:30 PM and 5:00 PM .but she said just to make it easier I will have [CNA #1] lay me down before she leaves .I went downstairs and reported it to my supervisor the DON .I think that happened on a Wednesday [day of the incident] and it was reported to me on a Thursday which would have been the .25th of May [5/25/2023] .and I told her [the DON] she's [Resident #2] up there telling everybody .because I think the night shift CNAs told her [Resident #2] to report it the next day .she reported it to [CNA #1] and [CNA #1] reported to [LPN #2] and [LPN #2] reported it to me . RN #1 stated she had reported the incident to the DON because it was an allegation of abuse. RN #1 stated .I thought It was a verbal threat to say I'm gonna [going to] have you moved to another floor .she [Resident #2] said we both [Resident #2 and LPN #1] was yelling but I was yelling because I'm deaf .she said I just don't want [LPN #1] to be mad .she just kept telling everybody and I thought this had to happen because she just kept telling the same story . RN #1 stated LPN #1 was not friendly with other staff and staff members had complained about her .I never witnessed her be mean to the residents but she would say stuff inappropriate to the staff . During an interview on 6/21/2023 at 2:55 PM, CNA #3 stated .I could hear screaming back and forth .like an argument .before I turned the corner I could hear 'you need to shut your mouth' .[LPN #1] said if she [Resident #2] doesn't start acting right then no one's gonna take care of her .I took [Resident #2] and wheeled her into her room and asked her what was happening .I could see tears in her eyes .she's [LPN #1] been rude to all of us [staff members] .I knew she [LPN #1] wouldn't come in there [Resident #2's room] because she [LPN #1] knew she had upset her [Resident #2] .me and [CNA #2] went in there and she told us that [LPN #1] said if she didn't start acting right she was going to move her to another floor .I told her [Resident #2] to report it [the incident] because it would be better to hear it from her .she said she didn't want to get anyone in trouble .I got her calmed down and she wasn't crying anymore .the next day [CNA #1] said she had reported it and I asked if I needed to do anything .[LPN #2] .had asked her [LPN #1] about it and [LPN #1] opened the door and asked me if I had heard her say for her [Resident #2] to shut her mouth or she would move her to a different floor .I didn't want to tell everything because I was gonna have to work with her [LPN #1] the rest of the day .when[LPN #1] went to give medicines [to the residents] I told [LPN #2] everything that had happened . CNA #3 stated staff members had reported LPN #1's attitude toward other staff members multiple times and she had been afraid to report the incident at the time it happened so she had told the resident to report it the next day .I just felt like if I reported it, it would just fall back on me .and then we would have to work with [LPN #1] and she would treat us [CNA #2 and CNA #3] worse than she had .I just felt like nothing would be done .and felt it would be better if she [Resident #2] reported it because it actually happened to her . CNA #3 stated resident #2 had been .upset and felt she was being picked on by [LPN #1] .and I think she was embarrassed because she was out in the hallway in front of other residents [when the incident occurred] .I think she was kinda hurt .[CNA #1] had talked to her [Resident #2] about she needs to feel comfortable in her own home and she doesn't need to feel like she needs to go to bed early and miss out on things .I told her that she doesn't need to feel like she has to go to bed early and miss out on bingo . During a telephone interview on 6/22/2023 at 10:07 AM, LPN #1 stated .I did ask her to stop yelling at me .I was frustrated the night she was up there screaming and cussing .I get frustrated .I've been frustrated a lot of times .and I quit [resigned from the facility] .I can't do this anymore [work at the facility] .I just couldn't understand why she kept doing it [asking to be assisted to bed] . LPN #1 stated she did talk loudly to the resident .she can't hear you if you don't [raise your voice] she won't quit talking .she will talk over you .to say I was yelling at her, no .I've never tried to get her [Resident #1] moved that's not up to me but I do believe she would have been better [on a different floor] . LPN #1 stated on another occasion Resident #2 had not wanted her brief to be changed before dinner and then after the dinner trays had been delivered to the residents and CNAs were assisting residents to eat, Resident #2 had turned her call light on and wanted her brief changed. LPN #1 stated .I called the supervisor and told her to come deal with her that I wasn't going back in there . LPN #1 stated she had been frustrated with her job and stated .I've been pinched, kicked, and spit on by these people [residents at the facility] for 2 years . During an interview on 6/22/2023 at 11:26 AM, the Human Resources (HR) Director stated .she [LPN #1] was difficult with her coworkers and department heads .never any issues with residents . She confirmed LPN #1 had been written up due to her attitude towards co-workers and department heads prior to the incident. The HR Director stated LPN #1 had been suspended on 6/6/2023 pending an investigation into the incident that occurred on 5/24/2023 but had sent in a letter of resignation on 6/7/2023 and was no longer employed at the facility. During an interview on 6/23/2023 at 11:04 AM, the Social Services Director (SSD) stated she had been told that APS and the Ombudsman had visited the facility to investigate a report they had received about the incident. The SSD stated .I feel like she [Resident #2] is doing better. She still continues to apologize .she didn't want anybody to lose their job because of her .[the residents responsible party] was notified and said she [Resident #2] told her [the Responsible Party] that I [the SSD] had assured her [Resident #2] she had did a good thing . The SSD confirmed the incident was verbal abuse and did cause the resident to sustain psychosocial harm and stated .I think so in my opinion [caused harm] .the Psych [Psychiatric] Nurse Practitioner is seeing her as well . During an interview on 6/26/2023 at 11:17 AM, the DON stated .back on 5/25/2023 the supervisor [RN #1] came down [to the DON's office] that morning and said you're not gonna believe what they told me that [LPN #1] said to [Resident #2] .and I said 'oh my goodness surely she [LPN #1] wouldn't tell her [Resident #2] something like that' .I said I'll talk to [LPN #1] about that .when [LPN #1] came in I asked her if she told [Resident #2] if she didn't be quiet she would send to her to a different floor .I didn't have any indication the resident was upset . The DON stated she had not interviewed Resident #2 about the allegation .I didn't, the supervisor [RN #1] had [interviewed the resident] and I didn't realize she [Resident #2] was upset .and I didn't realize anything about it .as soon as I found out the resident was upset I did everything I needed to do [initiated an abuse investigation] .I found out [Resident #2 was upset] when the Ombudsman and APS came in .the APS worker said that she had received complaint that the resident was being put to bed at a time prior to the time she wanted put to bed .and she [Resident #2] stated that [LPN #1] told her [Resident #2] she [LPN #1] would have her moved to another floor .nobody told me that the resident had been asking to be put to bed early or the resident was missing bingo .I had no knowledge of that but the second I found out I did everything . The DON confirmed Resident #2 was upset about the incident and had sustained psychosocial harm due to being put to bed early and missing bingo. The DON confirmed the CNAs had not reported the allegation of abuse at the time of the occurrence on 5/24/2023 and the facility had reported or investigated the incident when the DON was made aware on 5/25/2023, until the Ombudsman and APS had come to the facility on [DATE] and stated .if I had recognized it [as an allegation of abuse] .I should have recognized it . The DON confirmed the incident had not been reported to the State Survey Agency timely. Record review showed Resident #3 was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Bladder-Neck Obstruction, Chronic Kidney Disease, [NAME] Systolic Hear Failure, Other Specified Anxiety Disorders, and Peripheral Vascular Disease. Review of Resident #3's current Physician's Orders showed an order dated 10/19/2022, for .Trazadone [an antidepressant medication] 50 MG [milligrams] Tablet. Give 1/2 tab= 25mg by mouth everyday at bedtime for insomnia [difficulty sleeping] . and the order was discontinued on 6/21/2023. Review of Resident #3's quarterly MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 15, indicating she was cognitively intact. She had no mood or behavior problems. She required extensive assistance of 1 staff member for bed mobility and required limited assistance of 1 staff member for transfers, walking, dressing, eating, toilet use, and personal hygiene. She was totally dependent of 1 staff member for bathing. Review of Resident #3's comprehensive care plan dated 5/19/2022, showed .Self care deficit rt increased weakness .Assist with dressing, grooming, hygiene care daily and prn [as needed] .Assist with all mobility needs . Review of the facility investigation showed the DON had been notified of an incident that occurred between Resident #3 and CNA #4 on 6/19/2023. Review of LPN #3's witness statement dated 6/19/2023 showed, .Patient [Resident #3] .Reported to this nurse that she felt like she had been bullied and she had a complaint and if nothing got done about it she was going to the director. This nurse asked the pt. whats [what's] going on I can try to help or I can get you a nurse supervisor. Patient stated [CNA #4] .never changes my shirt or clothes or even asks if I wanted to be cleaned up. That when [CNA #4] brought me the lunch tray I asked her if she could pull me up in bed. Patient stated [CNA #4] said to me you can pull yourself up in bed. I said [CNA #4] I can't do it by myself I can't put pressure on my heels. Pt. stated [CNA #4] walked out of the room and said I'm not doing it. Patient stated to this nurse my brief hasn't been changed all day the last time it was checked was 3AM [3:00 AM] this morning. Patient then stated to this nurse in tears that 'I pay money to live here and for services and no one should be treated like this that the CNA just came in and said what she was going to do and never asked what I even needed assistance with . Review of the DON's witness statement dated 6/19/2023, showed .Received a message from the nursing supervisor, [RN #2], that the resident in room [Resident #3's room] had voiced a complaint regarding her care given by the C.N.A. [CNA #4]. The resident stated that she just comes into her room and hands her a washcloth and her toothbrush items and expects the resident to do it herself. The resident stated she can do it [wash her face and brush her teeth] but that the C.N.A. doesn't do anything else for her. The resident also stated the C.N.A. would not reposition her for lunch and she had to eat her lunch propped over on her side, She further stated that the C.N.A. did not change her brief all day. The resident does have a foley catheter and also stated she had not had a bowel movement during the day. The resident did state the C.N.A. is a bully. When asked to elaborate on that the resident stated that the C.N.A. tells her what to do and its just the way she makes her feel .The C.N.A. was already gone for the day and the resident was assured by the nursing supervisor that the situation would be addressed and that she would not have her for care the following day .At 5:12 p.m. notified [Administrator] of the concerns voiced by the resident . Review of Resident #3's Psychiatric Periodic Evaluation dated 6/20/2023, showed .seen today for follow up due to increased anxiety. Per social services, patient has made allegation toward a CNA, stating the CNA bullied her, and refused to provide care at times. Patient informed staff of these occurrences. CNA is no longer caring for patient, and investigation is ongoing. Staff have noted some increase in anxiety over the last few days since situation occurred .On exam patient is resting in bed. She is alert and pleasant. She states she is doing better now. She reports recent increase in anxiety over decision to Turn in the CNA. She states the actions presented have been gradually worsening over the past few months. She states last week she became so upset she worked up the courage to stand up for myself. Review of Resident #3's NP progress note dated 6/21/2023, showed .Resident also made allegation that she felt bullied by a CNA. She was seen by psych services yesterday he recommended increasing her trazodone to help with sleep. This morning she tells me she feels okay and is worried about the outcome of the CNA . During an interview on 6/21/2023 at 11:15 AM, Resident #3 stated .I didn't want trouble for anybody and I try to be kind to everybody .she just ignored me [when she asked for assistance] .when the morning would come and I would think am I gonna [going to] have [CNA #4] today and my body was just a nervous wreck .I've just had so much anxiety and I can't sleep .my NP came in this morning and he said he was gonna increase my medications .at night to give me some rest . Resident #3 stated CNA #4 had been refusing to assist her with care for a few months but when she had to lay on her side to eat her lunch on 6/19/2023 she decided she needed to report the incident. During an interview on 6/22/2023 at 11:26 AM, the Human Resources (HR) Director stated CNA #4 had been terminated by the facility on 6/21/2023 .she was terminated yesterday .failure to follow facility policy .the last day she worked was June 19th [6/19/2023] and called in on the 20th [6/20/2023] and came in yesterday [6/21/2023] for a meeting .and was terminated The HR Director confirmed the employee was terminated due to patient care concerns when Resident #3 was not repositioned for lunch During an interview on 6/22/2023 at 1:44 PM, the Nurse Practitioner (NP) stated .I heard she [Resident #3] felt like she was bullied .the ADON called me as soon as they found out . The NP confirmed the Psych NP had increased the resident's Trazadone to help her sleep due to the incident. The NP confirmed Resident #3 had sustained psychosocial harm from the incident .yeah if we are having to increase her medicine and she's tearful . During an interview on 6/23/2023 at 11:04 AM, the Social Services Director (SSD) stated .when I found out about that [the incident between Resident #3 and CNA #4] was Tuesday [6/20/2023] morning . The SSD stated the resident had become tearful while talking about the incident .she was wiping away tears from the corners of her eyes .she was definitely scared to report it [the incident] .I called her [Family Member] and talked to her about it and she [Resident #3] had not shared any of it with her family, she was keeping it all in .she [Resident #3] said she didn't sleep well at night because she was worrying about her [CNA #4] being her CNA . During a telephone interview on 6/23/2023 at 1:10 PM, the Psych NP confirmed Resident #3 had sustained psychosocial harm from the incident with CNA #4 and she planned to continue to see the resident on a weekly basis and would make further medication adjustments if needed to ensure the harm was resolved. During a telephone interview on 6/23/2023 at 2:49 PM, CNA #4 stated on 6/19/2023 Resident #3 had asked to be pulled up in the bed at lunch .she [Resident #3] said she couldn't [pull herself up in the bed] .when I got done passing the second cart [cart of meal trays] it just blew my mind that she needed to be pulled up because I thought she could [pull herself up in bed] .she [Resident #3] said I want to talk to the supervisor .I left her room and went and told my nurse [LPN #4] .[RN #3] was the supervisor .she [Resident #3] asked if I want to sit there while she talked to the nurse .it did slip my mind about going back because I didn't know she couldn't pull herself up anymore .then after lunch when I went to do my rounds [to check on the residents] that's when she told me [that she couldn't pull herself up] .I knew her heels had been wrapped [had a dressing on them] for some time . During an interview on 6/26/2023 at 1:07 PM, the ADON stated she had been notified by the DON on 6/19/2023 of Resident #3's complaint against CNA #4. She stated Resident #3 had reported the incident to LPN #3 who had then reported to RN #2. The ADON stated .[Resident #3] had multiple complaints about her CNA [CNA #4] .she [Resident #3] said that [CNA #4] would not pull her up in bed for lunch, did not change her brief, and that she felt bullied and intimidated by her .she [Resident #3] stays with her head pretty elevated and lays toward the right side .she was telling [RN #2] that was how she had laid for lunch .she [CNA #4] probably didn't position the table as it should have been . The ADON stated .she [CNA #4] didn't pull her [Resident #3] up for lunch and she [Resident #3] felt bullied and intimidated . The ADON stated when the facility had spoken to CNA #4, she had admitted to not pulling the resident up in bed for lunch on 6/19/2023 after the resident had requested assistance. The ADON confirmed the facility had terminated CNA #4's employment at the facility on 6/21/2023 due to the CNA had neglected to provide care the resident had needed. The ADON confirmed Resident #3 .was really bothered by it [the incident] and she [Resident #3] did have some psychosocial harm from this .she [Resident #3] had anxiety thinking she [CNA #4] was gonna be her caregiver for the day .but that was kinda her [Resident #3] breaking point when she [CNA #4] didn't pull her up for lunch .the nightmares .the anxiety .she was afraid [CNA #4] was gonna come back in the facility and kill her with a gun .she anxious by nature .they increased the Trazadone for sleep .the NP and MD [Medical Director] have been seeing her .our staff have been checking on her and reassuring her she did the right thing . The ADON confirmed the facility had been aware of the incident on 6/19/2023 but had not reported the allegation to the State Survey Agency until 6/20/2023 and confirmed the allegation of abuse had not been reported timely. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Acute on Chronic Systolic Congestive Heart Failure, Anxiety Disorder, Polyosteoarthritis, Insomnia, and Dysphagia. Review of Resident #9's care plan dated 7/31/2019, showed .The resident has a potential problem with nutritional status .Allow resident ample time to consume food. Provide assistance as needed (cueing, feeding assist) .Self care deficit rt increased weakness .Assist with meals as needed .Resident prefers to be fed by staff, staff encourages resident to assist with meals . Review of Resident #9's significant change of status MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 8, indicating she had moderate cognitive impairment. She required extensive assistance of 1 staff member for bed mobility, transfers, dressing, and toilet use. She required limited assistance of 1 staff member for eating. Review of Resident #9's monthly summary dated 5/8/2023, showed the resident was totally dependent for eating. Review of facility's feeding assignments showed CNA #4 was assigned to assist Resident #9 with her meals on the following dates: 4/12/2023, 4/13/2023, 5/11/2023, and 5/16/2023. Review of the facility's investigation dated 6/22/2023 showed a witness statement signed by the ADON and the QA [Quality Assurance] Director. The witness statement showed .I .[the ADON] and [the QA Director] .visited with [Resident #9] regarding notification of a CNA .[CNA #4] .refusing to feed her breakfast 'a couple of weeks ago'. Resident stated that [CNA #4] told her that she was 'not going to feed her because she was not going to treat her like a baby, she was going to help people who needed help. Resident stated that this is the only time this has happened .[Resident #9] has the ability to feed herself, but prefers staff to assist her. A staff member is assigned to feed her, at every meal. [Resident #9]'s average intake is between 76%-100%, but often complains of food 'not tasting right' after having COVID . Review of LPN #4's witness statement dated 6/23/2023, showed .Approx. more than 6 weeks ago, in the AM .[Resident #9] .had received a breakfast tray- of unlike foods, (not her normal) The CNA [CNA #4] was assign [assigned] to feed resident. Expressed 'She [Resident #9] didn't get her food right. This nurse called the kitchen & obtained correct foods- of choice. Tray w/pancake, strawberries, yogurt. Choc. [chocolate] Milk- per choice of pt. Nurse con't [continued] med [medicat[TRUNCATED]

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent abuse for 1 resident (Resident #1) of 6 residents reviewed for abuse, when a Certified Nursing Assistant (CNA) had a verbal argument with Resident #1 and then kicked the resident's room door open which resulted in actual psychosocial Harm for Resident #1. The findings include: Review of the facility policy titled, Reporting and Investigation of Resident Abuse, Mistreatment and Neglect, dated 3/2019, showed .It is the policy of this facility that each resident has the right to be free from .verbal .and mental abuse .Definitions .Abuse .the willful or deliberate infliction of .intimidation .with resulting .mental anguish .Mental abuse .includes .humiliation, harassment, threats of punishment . Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Polyneuropathy, Osteomyelitis of Vertebrae, Intraspinal Abscess, Pneumonia, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, Type 2 Diabetes Mellitus, and Dependence on Renal Dialysis. The resident was discharged on [DATE]. Review of Resident #1's baseline care plan dated 3/17/2023, showed he was alert and oriented. Review of Resident #1's 5-day Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental status (BIMS) assessment score of 15, indicating he was cognitively intact. He had no behaviors. He required limited assistance of 1 staff member for bed mobility, transfers, walking, dressing, toileting, and hygiene. He was independent with set up for eating. Review of Resident #1's nursing progress note dated 3/28/2023, showed .propelled self to 1st floor to wait on ride with family to transfer to [name of hospital] for PICC [Peripherally Inserted Central Catheter] placement . Review of the facility's investigation dated 3/28/2023, showed at approximately 6:00 AM, Resident #1 reported to the Assistant Director of Nursing (ADON) he had a complaint about CNA #2. The resident stated to the ADON he asked for a cup of coffee and CNA #2 refused to get the resident the coffee. Resident #1 reported to the ADON he and CNA #2 engaged in a verbal altercation, both using foul language. The resident reported he was on the phone and the person on the phone overheard the incident. The resident reported to the ADON he did not want CNA #2 back in his room and .didn't feel safe staying in the facility . The ADON spoke to CNA #2 who reported the resident asked for a cup of coffee and he did not get it for the resident because the nurse told him the resident's blood pressure was too high. CNA #2 told the ADON the resident then asked the CNA to check with the nurse to see if she had given his medications and the CNA told the resident he did get his medications. The CNA reported to the ADON the resident then began to use foul language and the CNA told the resident he was not going to be disrespected. The CNA reported to the ADON the resident aggressively shut the door onto the CNA's left ankle .in which he responded by pushing the door back open . Further review showed the Director of Nursing (DON) received a report from the ADON regarding a .disagreement between the resident and a CNA [CNA #2] . CNA #2 reported to the DON he answered Resident #1's call light and he had requested coffee. The CNA told the resident he could not get the coffee for him. The CNA reported to the DON the resident turned his call light on for a second time and asked for his medications. The CNA reported the nurse told him the resident had already had his medications. The CNA reported when he went back to Resident #1's room and told the resident he had already taken his medications, the resident began cursing the CNA and told him to get out of his room. CNA #2 reported to the DON the resident then grabbed the door and slammed it before the CNA could back out of the room. The CNA reported the door .struck him on the ankle causing severe pain and at that point [CNA #2] kicked the door open forcefully. [CNA #2] stated he was angry and told the resident not to talk to him that way, that he wasn't going to be disrespectful to him like that . Further review showed the CNA reported .some of these resident [residents] think they can treat the staff any way they want to and that [the facility] does nothing about it. [CNA #2] stated he had been struck by residents many times over the years but those residents don't know or understand what they are doing and that this resident does know exactly what he is doing and is mean on purpose . Further review showed the DON spoke to Resident #1 while he was outside waiting on his ride to the hospital .He told me he had relayed the incident to [the ADON] and did make the statement he would not feel safe here. I assured him the employee would not be here and he would not be allowed to work and that he would be safe . Further review showed the DON spoke to Resident #1's Family Member regarding the incident. The Family Member reported .she heard everything said .[CNA #2] answered his call light she heard [Resident #1] say tell her I need my medicine .[CNA #2] told him he already had his medicine and an argument started . Continued review of the investigation showed witness statements were obtained. Review of CNA #2's witness statement, undated, showed, .Resident call light was on, so I answered it .Resident stated he was ready for his meds .I stated that you've already taken your meds, and that's when the resident started yelling .He continued yelling and cursing and telling me to get out of his Got [God] D_ _ _ room and slams the door on my foot/ankle and that's when I kicked the door back and let the resident know that I will not tolerated [tolerate] being talked to or disrespected. I wasn't cussing and only became upset when the resident slammed the door on me . Review of Licensed Practical Nurse (LPN) #1's witness statement, dated 3/29/2023, showed .as I was leaving [Resident #1] was on elevator and I rode down with him He started talking about what happened earlier that [CNA #2] stated he would .kick his ass .no witness to this and he heard [CNA #2] in the hallway with 2 other people and [CNA #2] was describing what happened out loud so he could hear . Review of CNA #1's witness statement, dated 3/29/2023, showed .Yesterday morning [Resident #1] and [CNA #2] got into an altercation, I wasn't in the area during their disagreement but [CNA #2] explained that [Resident #1] was being disrespectful & [and] rude to him & closed the door on him before he could exit the room, things got heated, words were exchanged and he [CNA #2] left the room . Review of Resident #1's nursing progress note dated 3/28/2023, showed .Plans to transfer to [name of rehabilitation facility] tomorrow . Review of Resident #1's nursing progress note dated 3/29/2023, showed .Resident seen by .NP [Nurse Practitioner] for eval [evaluation] for discharge. To transfer to [name of rehabilitation facility] today after dialysis .Discharge Summary Completed . Review of Resident #1's Nurse Practitioner's (NP) Discharge Summary dated 3/29/2023, showed .He was admitted to [name of facility] for continuation of his IV [Intravenous] antibiotics as well as rehabilitation postsurgery [post-surgery]. Resident has done well with his therapy and it is felt that he would benefit transfer to [name of rehabilitation facility] for more intensive therapy . During an interview on 4/25/2023 at 10:48 AM, the Receptionist stated she works at the front desk of the facility on Mondays through Fridays and did remember seeing Resident #1 frequently because he would come downstairs to get coffee and to leave for his dialysis appointments. She stated Resident #1 was .very nice but edgy .if you don't tell him something [information he asked for] quickly, he would get upset/argumentative . If he thought his ride [to dialysis] wasn't coming, he would get upset . She stated she could normally explain things and he would .calm right down . During an interview on 4/25/2023 at 2:07 PM, the DON stated she spoke to Resident #1's Family Member. She stated the Family Member called her to report Resident #1 had an argument with a CNA, the Family Member had been on the phone with the resident during the argument and had heard the incident. The DON stated the Family Member had not told her what she had heard. The DON stated the resident came downstairs that morning (3/28/2023) and talked to the Assistant Director of Nursing (ADON) about what had happened. The DON said when she went to talk to Resident #1 outside while he was waiting on transportation to the hospital, Resident #1 stated .I cursed .I wanted to get some coffee .I had a question about my medicine . The DON stated .the resident was really angry and said 'I don't think I can be safe here' .said 'I don't want him taking care of me anymore' . The DON confirmed the resident identified CNA #2 who worked on the 11:00 PM- 7:00 AM shift. The DON stated .he [Resident #1] said he didn't want him [CNA #2] taking care of him. He said ' .I [Resident #1] was cursing at him [CNA #2] and he was cursing at me .' .I [the DON] was not able to establish that it [abuse] occurred [abuse had occurred] . The DON stated .We did talk to [CNA #2] and he said he never cursed him [Resident #1] .he [CNA #2] went into the room and he [Resident #1] wanted coffee .his blood pressure had been elevated and the nurse told him [CNA #2] not to give him the coffee right then and he [Resident #1] became angry . he [Resident #1] told him [CNA #2] to get out of the room .the second time his call light came on [CNA #2] went in and he [Resident #1] said the nurse hadn't gave him his medication and the nurse said she had given it and [CNA #2] went back and told him [Resident #1] that he already had it and the resident slammed the door on [CNA #2's] ankle and he [CNA #2] did open the door back up .[CNA #2] denied cursing him . During an interview on 4/25/2023 at 2:24 PM, the ADON stated she had worked the 11:00 PM- 7:00 AM shift on 3/28/2023. She stated she went downstairs to her office and Resident #1 was in the coffee area getting some coffee. The ADON said Resident #1 asked her who did he need to talk to complain about one of the CNAS. She stated .he [Resident #1] said that guy that's taking care of me is lazy, and he wouldn't come down here and get my cup of coffee and wouldn't do a thing for me and we did get into an argument, and I used some foul language, and he did too The ADON stated the resident reported he and the CNA were cursing each other. She stated .he [Resident #1] didn't say specifics, he felt like he [Resident #1] shouldn't have cussed and didn't want the CNA [CNA #2] taking care of him anymore .he [Resident #1] said he was on the phone with someone who had overheard .he [Resident #1] said I don't feel safe here . The ADON stated after the resident reported he did not feel safe at the facility she reported the incident to the DON. She stated the resident then went outside and she had CNA #2 come to her office. She stated .he [CNA #2] said he answered the call light but told him [Resident #1 he couldn't get the coffee because of his blood pressure per the nurse and [Resident #1] asked about his medicine and said he [CNA #2] would ask the nurse and .he told [Resident #1] he had gotten his meds and he [Resident #1] got more upset .he [CNA #2] said as he was leaving the room the resident slammed the door on his ankle and hurt his ankle .I told [CNA #2] he could not work until the investigation was finished .he did say the resident cussed him, but he did not say he cussed the resident. He said the resident cussed all the time . The ADON stated the resident did have .a tendency to get upset . The ADON stated .[CNA #2] was very upset about his ankle hurting and said he shouldn't be treated that way . and stated the facility had to call Human Resources (HR) to talk to him. During an interview on 4/25/2023 at 2:37 PM, the Social Service Director (SSD) stated .I did go and talk to him [Resident #1] and what he told me was they got in a verbal argument over coffee .they were both [Resident #1 and CNA #2] yelling at each other .he said something about pushing a door open .[CNA #2] pushed the door open I believe .said it was about bringing him coffee .he was on blood pressure medicine and had some blood pressure issues and they were worried about him drinking the coffee and [CNA #2] didn't want to get it for him because of his blood pressure . During a telephone interview on 4/25/2023 at 2:48 PM, Resident #1 stated CNA #2 came into his room and asked if there was anything he could do for him. The resident stated he asked the CNA to get him some coffee and the CNA said 'no'. The resident stated he then told the CNA he would go downstairs and get the coffee himself and the CNA told him to .do whatever you want .and I [Resident #1] said 'just go on .get on out [get out of the room]' .and the [CNA] pushed the door back on me and said you don't talk to me like that .and then I said a cuss word .then the [CNA] was outside the door saying 'I'm gonna stomp you' . The resident stated when he left his room, he saw the CNA talking to other staff and .he [CNA #2] said 'he doesn't know who he is talking to' . The resident stated as he walked by the nurse's station the CNA called him a 'bitch'. The resident stated he then went downstairs and told a lady downstairs about the incident. The resident stated he had never seen the CNA before that day. The resident stated .once he kept threatening me, I thought what would he do when I was asleep .I felt scared something might happen during the night . The resident stated he did not feel safe at the facility after the incident. During an interview on 4/25/2023 at 3:30 PM, LPN #2 stated Resident #1 did like to drink coffee frequently and she had brought a coffee maker to the facility that she had let him use. She stated .he would get upset if the CNAs wouldn't make him coffee . She stated the resident did have high blood pressure. She stated on the day of the incident .the night shift nurse [LPN #1] said she wasn't gonna give him coffee because he had blood pressure problems . She stated Resident #1 had stated to her .[Resident #1] had shut the door and [CNA #2] kicked the door open .[Resident #1] said they were both cussing each other . The LPN stated .that evening they said he was going to [name of rehabilitation facility] . During an interview on 4/25/2023 at 3:48 PM, Registered Nurse (RN) #1 stated .he was always wanting coffee .he would be frustrated if he had to wait . During a telephone interview on 4/25/2023 at 8:26 PM, LPN #1 stated .he was always complaining because we wouldn't go get him coffee .that morning [3/28/2023] .I didn't have any problems but [CNA #2] told me he [Resident #1] said he hadn't taken his medicine but he had took it . She stated she went to talk to Resident #1, and he told her to go away. She stated she later rode down the elevator with Resident #1 and he told her CNA #2 had .threatened him and he said he was gonna kick his ass .it was probably because we [the staff] wouldn't go get him any coffee . The LPN stated the reason the staff could not get the resident coffee was .it was my 5 o'clock [5:00 AM] med [medication] pass and I [LPN #1] was passing meds [medications] .[CNA #2] was making his last round [checking residents for incontinence] .he [Resident #1] was able to go get the coffee himself . LPN #1 stated the resident was able to go downstairs and get his coffee himself but would always ask someone to go get the coffee for him. During a telephone interview on 4/25/2023 at 11:12 PM, CNA #2 stated that morning [3/28/2023] I went in [into Resident #1's room] because his call light was on .he stated he hadn't had his medicine and I told the nurse but she said he did get them .I went back to the room and told him he already took his medicine . and he got upset and was cussing .when I tried to exit the room he slammed the door on my ankle and it was such pain .I wear low top shoes .and I kicked the door open and said I won't be treated like that . CNA #2 stated he continued doing his rounds after the incident occurred. He denied cursing the resident, denied talking about the incident to other employees, and denied stating he would whip/stomp the resident's ass. CNA #2 stated he did go back to the nurse's station but denied seeing Resident #1 after the incident until after he (CNA #2) had been in the ADON's office. He stated his supervisor told him the ADON wanted to see him in her office. He stated the ADON asked him about the incident. The CNA confirmed he had been upset because his ankle was hurting. He stated he gets mistreated frequently by residents and stated .I come here to take care of people and should not be disrespected by residents . During a telephone interview on 4/25/2023 at 11:21 PM, CNA #1 stated Resident #1 .wanted things done a certain way .If you were not doing it how he liked it he would tell you how he wanted it done .wanted it his way or no way at all . She stated .mostly he [Resident #1] would ask for coffee in the mornings .I used to would call the kitchen and get him coffee, but he didn't like it [coffee from the kitchen] .some mornings he would go downstairs and get his own coffee . CNA #1 stated on the day of the incident (3/28/2023) she heard CNA #2 talking about the incident. She stated CNA #2 said Resident #1 had .pushed the door on him [CNA #2] .he [CNA #2] was telling how they [CNA #2 and Resident #1] had got into it [a verbal altercation] .[Resident #1] was angry and slammed the door on him [CNA #2] .[CNA #2] said he told [Resident #1] if you're gonna be that way I won't take care of you . During an interview on 4/26/2023 at 9:27 AM, CNA #3 stated on the day of the incident (3/28/2023) Resident #1 told her he had a bad morning and was upset but he did not tell her why he was upset or what happened to cause him to have a bad morning. During an interview on 4/26/2023 at 9:35 AM, the Human Resources Director (HRD) stated she had spoken to CNA #2 on the morning of the incident (3/28/2023). She stated the CNA was in the ADON's office and he was asking to file a workers compensation claim due to his ankle injury. She stated CNA #2's ankle was very tender to touch and swollen at the time she spoke to him. She stated CNA #2 was upset .he [CNA #2] said the resident [Resident #1] was alert and oriented and he felt he had done it on purpose .said he [CNA #2] was exiting the room and the resident was following him out of the room and the resident was cussing and slammed the door on his ankle .he [CNA #2] stated he gets mistreated from residents but this one [Resident #1] did it on purpose .he [CNA #2] was slightly angry and frustrated and felt disrespected. He felt he had been intentionally injured .he [CNA #2] got the door off his ankle and told the resident I will not be disrespected . She stated the CNA was suspended from work during the investigation. She stated the DON and ADON completed the investigation and then .we all came together and made a determination .there was absolutely no abuse . and the CNA was allowed to return to work. During an interview on 4/26/2023 at 9:51 AM, the NP stated he was made aware of the incident between Resident #1 and CNA #2. He stated .I don't remember if we [the NP and Resident #1] talked about it [the incident] .I talked to him about going to [name of rehabilitation facility] to get a different setting . the facility's way to be proactive to change the environment . He stated the incident was .something about a door slamming on somebody's foot and a verbal altercation between the CNA and the resident . The NP stated he had not been aware of Resident #1 making statements of not feeing safe at the facility after the incident. The NP confirmed the incident probably caused Resident #1 psychological harm if he did not feel safe at the facility and stated .I can't say it didn't . He stated the facility had not consulted for the resident to receive psychological services after this incident and stated .it wouldn't have hurt to have . The NP stated he had not seen the resident after he transferred to the rehabilitation facility. He stated it was not his expectation for the CNA to kick the door back open even if it did hurt his ankle and stated .in healthcare you can't react like that . During a telephone interview on 4/26/2023 at 11:57 AM, Resident #1's Family Member stated on 3/28/2023 . it was about 6 [6:00 AM] in the morning .we [the Family Member and Resident #1] were on the phone .we were talking about the electricity bill at his house when I heard a big bang .the guy [CNA #2] had slammed the room door into the bathroom door . She stated the resident asked CNA #2 for a cup of coffee. She stated she could not make out what the CNA was saying but the resident told her the CNA stated .I'm not your damn waiter . She stated she could hear both the resident and the CNA yelling and the phone went dead. She stated the resident told her when she called back, he asked the CNA to check with the nurse because he did not think he had taken his medications. The Family Member stated the resident told her the CNA told Resident #1 .he was gonna stomp him . The Family Member stated .I called and talked to the head nurse [DON] and she said ' .we don't do that kind of stuff here . we don't treat people like that' . when she reported to the DON what had happened. The Family Member stated the resident was scared to stay at the facility and stated to her .I think you need to get me out of here . The Family Member stated the DON called back and said the facility received permission from the resident's insurance to move him to the rehabilitation facility. The Family Member stated the DON stated to her .he [Resident #1] would be safe at [the rehabilitation facility] . During an interview on 4/26/2023 at 12:16 PM, the DON stated she did not feel the incident between Resident #1 and CNA #2 was abuse and stated .it was more of a disagreement with an employee . The DON confirmed the resident stated he did not feel safe at the facility after the incident. She stated the resident originally wanted to go to the rehabilitation facility upon admission and they moved him to the other facility on 3/29/2023 (the day after the incident). The DON confirmed she did tell the resident she felt he would feel safer at the other facility. The DON stated the facility had not consulted psychological services for the resident after he stated he did not feel safe and stated .at first he was extremely angry but later calmed down . She stated she did not feel she should have consulted psychological services. The DON confirmed CNA #2 stated to her and in his witness statement, he kicked the door to Resident #1's room back open when the door hit his ankle. The DON stated it was not her expectation for staff to react that way .you would hope that nobody would respond that way .it's not my expectation for them to do that .If you knew the resident, he was angry and cursing a blue streak, he didn't appear to be scared, he appeared to be angry . During an interview on 4/26/2023 at 1:38 PM, the Administrator stated he did not feel the resident was scared to stay at the facility but confirmed he had not spoken to the resident about the incident. The Administrator confirmed the incident between Resident #1 and CNA #2 was .definitely a disagreement and it was a reaction to a disagreement, and I do not expect the staff to react that way [by kicking the door open] .

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to revise their abuse policy to meet federally required standards for reporting abuse to the State Survey Agency, resulting in the facility failing to report an allegation of abuse within the federally required time frame for 1 resident (Resident #1) of 6 residents reviewed for abuse, when a Certified Nursing Assistant (CNA) had a verbal argument with Resident #1 and then kicked the resident's room door open which resulted in actual psychosocial Harm for Resident #1 . The findings include: Review of the facility policy titled, Reporting and Investigation of Resident Abuse, Mistreatment and Neglect, dated 3/2019, showed .It is the policy of this facility that each resident has the right to be free from .verbal .and mental abuse .[Name of facility] seeks to promote the well-being of our residents by proper training of our employees .The Nursing Supervisor will report all reasonable suspicions of abuse/crime against a resident .to Administrator/DON within 2 hours, who will then report to the local law enforcement if suspicion found to be reasonable or serious bodily injury has occurred .The Administrator, Director of Nursing or designated staff member will complete an investigation of the incident including a written summary of the findings no later than (5) working days of the reported occurrence .All substantiated incidents will be reported by the administrator or his/her designee to the following person and/or agencies .Bureau of Quality Assurance of Health Care Facilities . Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Polyneuropathy, Osteomyelitis of Vertebrae, Intraspinal Abscess, Pneumonia, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, Type 2 Diabetes Mellitus, and Dependence on Renal Dialysis. The resident was discharged on [DATE]. Review of Resident #1's baseline care plan dated 3/17/2023, showed he was alert and oriented. Review of Resident #1's 5-day Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental status (BIMS) assessment score of 15, indicating he was cognitively intact. Review of the facility's investigation dated 3/28/2023, showed Resident #1 reported to the Assistant Director of Nursing (ADON) he had a complaint about Certified Nursing Assistant (CNA) #2. Resident #1 reported to the ADON he did not want CNA #2 back in his room and he did not feel safe in the facility. Review of the facility's investigation showed the ADON spoke to CNA #2 who reported Resident #1 began to use foul language and the CNA told the resident he was not going to be disrespected. CNA #2 reported to the ADON the resident aggressively shut the door onto the CNA's left ankle .in which he responded by pushing the door back open . Further review showed the Director of Nursing (DON) received a report from the ADON regarding the incident between Resident #1 and CNA #2. CNA #2 reported to the DON he answered Resident #1's call light, the resident and the CNA argued, and the resident then grabbed the door and slammed it before the CNA could back out of the room. CNA #2 reported the door .struck him on the ankle causing severe pain and at that point [CNA #2] kicked the door open forcefully. [CNA #2] stated he was angry and told the resident not to talk to him that way, that he wasn't going to be disrespectful to him like that . Review of the facility investigation showed the DON spoke to Resident #1 and Resident #1 reported to the DON due to the incident with CNA #2, Resident #1 did not feel safe in the facility. During an interview on 4/25/2023 at 2:07 PM, the DON stated .he [Resident #1] said he didn't want him [CNA #2] taking care of him. He said ' .I [Resident #1] was cursing at him [CNA #2] and he was cursing at me .' .I [the DON] was not able to establish that it occurred [abuse had occurred] . The DON confirmed she had not reported the allegation to the State Survey Agency because she did not feel it was abuse. She stated the facility did complete an investigation and determined no abuse had occurred. During a telephone interview on 4/25/2023 at 2:48 PM, Resident #1 confirmed there was a disagreement between him and CNA #2 when Resident #1 asked CNA #2 to get him a cup of coffee on 3/28/2023. Resident #1 stated CNA #2 pushed the door back open on the resident when the resident had closed the door on CNA #2. Resident #1 stated he overhead CNA #2 talking to other staff after the incident and stated he did not feel safe at the facility .I felt scared something might happen during the night . During an interview on 4/26/2023 at 12:16 PM, the DON stated she did not feel the incident between Resident #1 and CNA #2 was abuse and stated .it was more of a disagreement with an employee . The DON confirmed the facility had not reported the incident to the State Survey Agency because they had not substantiated abuse had occurred. Further interview and review of the facility's abuse policy, the DON confirmed the facility policy's reporting requirements were not in accordance with the federal regulations to report any allegation of abuse to the State Survey Agency within 2 hours of the allegation and to report the results of the investigation within 5 business days.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency within the federally required time frame for 1 resident (Resident #1) of 6 residents reviewed for abuse, when a Certified Nursing Assistant (CNA) had a verbal argument with Resident #1 and then kicked the resident's room door open which resulted in actual psychosocial Harm for Resident #1. The findings include: Review of the facility policy titled, Reporting and Investigation of Resident Abuse, Mistreatment and Neglect, dated 3/2019, showed .It is the policy of this facility that each resident has the right to be free from .verbal .and mental abuse .Definitions .Abuse- the willful or deliberate infliction of .intimidation .Verbal- the use of oral .disparaging or derogatory terms to the resident .Mental Abuse .threats of punishment or deprivation .The Nursing Supervisor will report all reasonable suspicions of abuse/crime against a resident .to Administrator/DON within 2 hours, who will then report to the local law enforcement if suspicion found to be reasonable or serious bodily injury has occurred .The Administrator, Director of Nursing or designated staff member will complete an investigation of the incident including a written summary of the findings no later than (5) working days of the reported occurrence . Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Polyneuropathy, Osteomyelitis of Vertebrae, Intraspinal Abscess, Pneumonia, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, Type 2 Diabetes Mellitus, and Dependence on Renal Dialysis. The resident was discharged on [DATE]. Review of Resident #1's baseline care plan dated 3/17/2023, showed he was alert and oriented. Review of Resident #1's 5-day Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental status (BIMS) assessment score of 15, indicating he was cognitively intact. Review of the facility's investigation dated 3/28/2023, showed at approximately 6:00 AM, Resident #1 reported to the Assistant Director of Nursing (ADON) he did not want CNA #2 back in his room and .didn't feel safe staying in the facility . The ADON spoke to CNA #2 who reported to the ADON Resident #1 aggressively shut the door onto the CNA's left ankle .in which he [CNA #2] responded by pushing the door back open . Further review showed the Director of Nursing (DON) received a report from the ADON regarding an incident between Resident #1 and CNA #2. Review of the facility investigation showed the DON spoke to Resident #1 and Resident #1 reported to the DON due to the incident with CNA #2, Resident #1 did not feel safe in the facility. Review showed the DON also spoke to Resident #1's family member who had overheard the incident while on the phone with Resident #1 and the family member confirmed she overheard an argument between the resident and the CNA. Continued review of the investigation showed a witness statement from CNA #2 which stated .Resident [#1] call light was on, so I answered it .Resident stated he was ready for his meds .I stated that you've already taken your meds, and that's when the resident started yelling .He continued yelling and cursing and telling me to get out of his Got [God] D_ _ _ room and slams the door on my foot/ankle and that's when I kicked the door back and let the resident know that I will not tolerated [tolerate] being talked to or disrespected. I wasn't cussing and only became upset when the resident slammed the door on me . During an interview on 4/25/2023 at 2:07 PM, the DON confirmed .[Resident #1] was really angry and said 'I don't think I can be safe here' .said 'I don't want him taking care of me anymore' . The DON confirmed the CNA the resident was talking about was CNA #2 who works on the 11:00 PM- 7:00 AM shift. The DON confirmed she had not reported the allegation to the State Survey Agency because she did not feel it was abuse. She stated the facility did complete an investigation and determined no abuse had occurred. During a telephone interview on 4/25/2023 at 2:48 PM, Resident #1 stated CNA #2 came into his room and asked if there was anything he could do for him. The resident stated he asked the CNA to get him some coffee and the CNA said no. The resident stated he then told the CNA he would go downstairs and get the coffee himself and the CNA told him to .do whatever you want .and I [Resident #1] said 'just go on .get on out [get out of the room]' .and the [CNA] pushed the door back on me and said 'you don't talk to me like that' .and then I said a cuss word .then the [CNA] was outside the door saying 'I'm gonna stomp you' . Resident #1 stated when CNA #2 left his room, he saw CNA #2 talking to other staff and .he [CNA #2] said 'he doesn't know who he is talking to' . The resident stated as he walked by the nurse's station the CNA called him a bitch. The resident stated he then went downstairs and reported the incident to a staff member. Resident #1 stated .once he kept threatening me, I thought what would he do when I was asleep .I felt scared something might happen during the night . During an interview on 4/26/2023 at 9:35 AM, the Human Resources Director (HRD) confirmed CNA #2 was suspended from work during the investigation. She stated that the DON and ADON had completed the investigation and then .we all came together and made a determination .there was absolutely no abuse . and CNA #2 was allowed to return to work. During an interview on 4/26/2023 at 12:16 PM, the DON stated she did not feel the incident between Resident #1 and CNA #2 was abuse and confirmed the facility had not reported the incident to the State Survey Agency because they had not substantiated abuse occurred.