Every finding on record at Magnolia Manor Nursing and Rehab Ctr, LLC

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pest and insects. The deficient practice had the potential to affect 89 residents who resided in the facility. Findings:Observation on 04/30/2026 at 8:30 a.m. with S3Housekeeping of Resident #1 and #3's room revealed a live roach crawling on the wall, on the top of Resident #1's refrigerator, and underneath the desk-style phone on top of the refrigerator. During an interview on 04/30/2026 at 8:30 a.m. S3Housekeeping reported she saw one roach yesterday in Resident #1 and #3's room. During an interview on 04/30/2026 at 8:40 a.m. S2Maintenance reported S4Certified Nurse Aide just made him aware yesterday afternoon about a roach on the wall in Resident #1 and #3's room.Observation on 04/30/2026 at 8:45 a.m. with S2Maintenance of Resident #1 and #3's room revealed roach feces and dead roach carcasses on the top of Resident #1's personal refrigerator. Further observation revealed when S2Maintenance picked up the phone and a book laying on top of the refrigerator, live roaches ran out from underneath. During an interview on 04/30/2026 at 8:53 a.m. S4Certified Nurse Aide reported she noticed a roach yesterday in Resident #1 and #3's room. During an interview on 04/30/2026 at 12:45 a.m. S1Administrator reported he went with S1Maintenance to Resident #1 and #3's room and when S1Maintenance picked up the refrigerator, a couple live roaches ran out from underneath it. During an interview on 04/30/2026 at 4:30 p.m. S1Administrator confirmed there were live roaches in Resident #1 and 3's room and should not have been.

Based on record review, observation and interview, the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 1 (#23) of 1 resident reviewed for indwelling catheter.Findings:Review of the facility's Catheter Management undated policy revealed in part:Policy: Catheter management is the routine care administered when an indwelling catheter is in place. This routine care protects the resident from infection, injury, and promotes comfort.b. Watch for kinking in the tubing to can interfere with patency and free flow of urine. Never allow the bag or tubing to touch the floor. Review of Resident #23's medical record revealed an admit date of 04/19/2022 with diagnoses including neurogenic bladder and Type 2 Diabetes Mellitus.Review of Resident #23's current comprehensive care plan revealed Resident #23 had a suprapubic catheter related to a diagnosis of urinary retention.An observation on 03/02/2026 at 9:25 a.m., revealed Resident #23 was self-propelling down the hall in a wheelchair. Further observation revealed Resident #23's indwelling urinary catheter tubing was dragging on the floor beneath the wheelchair.During an interview on 03/02/2026 at 9:30 a.m., S1LPN acknowledged Resident # 23's indwelling catheter tubing was lying on the floor under the wheelchair and should not have been.

Based on record review, observation, and interviews, the provider failed to ensure respiratory care was provided with professional standards of practice for 1 (#84) of 1 resident reviewed for respiratory care. Findings: Review of the provider's undated Oxygen Administration (concentrator or tank) policy included:Humidifier bottles, cannulas, and oxygen tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, cannula or mask should be placed in a plastic bag. Purpose:To administer high-purity oxygen for the treatment of disease or emergency conditions through oxygen concentrator or tank. Review of Resident #84's medical record revealed the following, in part: Resident #84 was admitted to the provider on 02/14/2026 with diagnoses including in part: chronic obstructive pulmonary disease, tobacco use, nonspecific abnormal finding of lung field, centrilobular emphysema, chronic respiratory failure with hypoxia, and shortness of breath. Review of Resident #84's physician orders for March 2026 included:Oxygen three liters per minute as needed every five minutes minimum for chronic obstructive pulmonary disease.Change oxygen tubing, nasal cannula, and humidifier bottle and clean filter every night shift, every Saturday. Observation on 03/02/2026 at 8:30 a.m. revealed Resident #84's humidifier bottle was dated 02/23/2026 and there was no water in the humidifier bottle. During an interview on 03/02/2026 at 8:35 a.m. S4LPN verified Resident #84's humidifier bottle had no water in the humidifier bottle. During an interview on 03/03/2026 at 1:10 p.m. S4LPN reported staff who were working on 02/28/2026 should have changed Resident's #84's humidifier bottle, nasal cannula, and ensure the filter was cleaned.

Based on record review, observations, and interviews, the facility failed to ensure medications were stored properly for 2 (#21 and #68) of 4 residents reviewed for accidents. Findings:Review of the facility's Self-Administration of Medication policy (undated) revealed in part:It is the policy of this facility that each resident has the right to self-administer medications, but is the responsibility of the interdisciplinary team to determine that it is safe prior to the resident exercising that right.If the right is granted, a specific order to self-administer must be obtained which includes how, when and for what reason the medication can be used.Facility personnel must assure safety of bedside storage of medication. A locked box may be necessary in some instances. Resident #21Review of Resident #21's medical record revealed an admit date of 10/02/2025 with diagnoses including in part chronic kidney disease, end stage renal disease and postmenopausal atrophic vaginitis. Review of Resident #21's Quarterly MDS assessment dated [DATE] revealed in part a BIMS score of 15, indicating intact cognition. Review of Resident #21's physician orders revealed in part: 03/06/2025 Estradiol vaginal cream 0.1 mg/gm Insert 1 application vaginally at bedtime every Monday, Wednesday, Friday for itching related to postmenopausal atrophic vaginitis. Further review of Resident #21's physician orders failed to reveal an order for self-administration of estradiol vaginal cream. An observation on 03/02/2026 at 8:45 a.m. revealed a tube of estradiol cream 0.01% in Resident #21's bathroom cabinet labeled with Resident #21's name. During an interview on 03/02/2026 at 8:50 a.m., S2CNA acknowledged Resident #21 had a tube of estradiol cream in the bathroom cabinet. During an interview on 03/02/2026 at 9:30 a.m., S1LPN acknowledged Resident #21 had a tube of estradiol cream in the bathroom cabinet and should not have. S1LPN reported Resident #21 did not have an order to self-administer the vaginal cream. Resident #68Review of Resident #68's medical record revealed an admit date of 09/06/2024 with diagnoses including in part anxiety disorder and major depressive disorder. Review of Resident #68's Quarterly MDS assessment dated [DATE] revealed in part a BIMS score of 14, indicating intact cognition. Review of Resident #68's physician orders failed to reveal an order for self-administration of medication. An observation on 03/02/2026 at 8:20 a.m. revealed two bottles of phenylephrine hydrochloride 1% nasal spray and one bottle of Aspercreme with 4% lidocaine. During an interview on 03/02/2026 at 8:25 a.m., S1LPN acknowledged nasal spray and lidocaine cream were at Resident #68's bedside and should not have been. S1LPN confirmed Resident #68 did not have a physician order to self-administer medications.

Based on record review, observation and interview, the facility failed to maintain professional standards for food service safety by failing to ensure frozen food items were stored in a sealed container. Findings:Review of the facility's Storage of Frozen Food policy with a revision date of 12/2012 revealed in part:Policy: The facility ensures the quality and safety of frozen food through accepted storage practices.Procedure:4. Frozen food is stored in the original package.5. Food taken out of original containers is put in a clean, sanitized container with a tight fitting. No food is left uncovered. An observation of the walk-in freezer on 03/02/2026 at 8:00 a.m. revealed frozen broccoli, frozen egg rolls and frozen waffles stored in unsealed plastic bags and open to air. During an interview on 03/02/2026 at 8:00 a.m., S3Dietary Manager acknowledged the frozen broccoli, frozen egg rolls and frozen waffles should have been stored in a sealed bag in the freezer and were not.

Based on record review, and interview the facility failed to inform a resident's responsible party of a resident's change in condition for 1 (#1) of 3 (#1, #2, #3) sampled residents. The facility failed to notify Resident #1's responsible party of the initiation of a medication. Findings: Review of Resident #1's medical record revealed an admit date of 08/09/2024 and a re-admission date of 01/15/2026 with diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, bipolar II disorder, type 2 diabetes mellitus without complications, schizoaffective disorder bipolar type, generalized anxiety disorder, unspecified convulsions, unspecified conjunctivitis, contracture to left hip, and pressure ulcer sacral region. Review of Resident #1 Minimum Data Set, dated [DATE] revealed a BIMS (Brief Interview Mental Status) score of 9 indicating moderately impaired cognition. Review of Resident #1's June 2025 Physician's Orders revealed and order for Depakote oral tablet delayed release 125 milligrams by mouth two times a day for mood/stabilization related to Schizoaffective Disorder, Bipolar type with a start date of 06/30/2025. Review of Resident #1's June 2025 Medication Administration Record revealed documentation of administration of Depakote 125 milligrams beginning on 06/30/2025. During a telephone interview on 02/10/2026 at 9:00 a.m. Resident #1's Responsible Party reported she had not been notified that Resident #1 was placed on Depakote on 06/30/2025. Resident #1's Responsible Party further reported she found out about Resident #1's order for Depakote on 07/24/2025 when Resident #1 refused to have his blood drawn for a Depakote level. Review of Resident #1's medical record including progress notes, failed to reveal any documentation confirming that Resident #1's responsible party was notified of the start of Depakote in June 2025. During an interview on 02/11/2026 at 3:45 am S1 DON (director of nurses) confirmed Resident #1's responsible party should have been notified of Resident #1's order for Depakote. S1 DON also confirmed she was unable to provide any evidence that Resident #1's responsible party was notified in June 2025.

Based on record review, surveillance video review and interviews, the facility failed to protect the resident's right to be free from physical, verbal abuse and psychosocial harm by a staff member for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The actual harm occurred for Resident #1, who was cognitively impaired, on 02/13/2025 at 8:32 a.m. when S6 CNA (Certified Nurse Assistant) was observed on surveillance video verbally and physically abusing Resident #1 while providing care. Physical abuse occurred when S6 CNA pulled down on Resident #1's left contracted leg, forcefully snatched Resident #1's right arm from the right side rail and pushed Resident #1's right arm towards him, then snatched the diaper off Resident #1. Verbal abuse occurred when S6 CNA cursed at Resident #1 saying, God d-mn it and D-mn. While S6 CNA provided incontinent care, S6 CNA stated, I can't do this anymore, I refuse to do this ever again, you trying to hurt me. It can be determined a reasonable person would not expect that they would be harmed in his own home or a health care facility and would experience psychosocial harm - dehumanization and humiliation as a result of the verbal and physical abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/31/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's Abuse/Neglect Policy with a revision date of 03/20/2025 revealed in part: Purpose: The purpose of the Abuse/neglect policy is to comply with the seven-step approach to abuse and neglect detection and prevention: 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection 7. Reporting and Response Policy: It is the policy of the facility that each resident will be free from abuse. This facility will not condone any form of resident abuse. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect, and misappropriation of property. Physical abuse includes hitting, slapping, pinching, biting, and kicking. It also includes controlling behavior through corporal punishment. Alleged violation - is the terminology used when a verbal allegation of resident abuse, neglect, or misappropriation of resident property has been made either by a resident, family member, visitor or employee. An alleged violation may also be triggered by an observation of an injury of unknown origin (i.e., bruise or skin tear) that the resident or staff member cannot explain. Mistreatment means inappropriate treatment or exploitation of a resident. Review of Resident #1's room surveillance video with audio was viewed on Resident #1's sister cellphone with Resident #1's sister present. The surveillance video clip started on 02/13/2025 at 8:32 a.m. with a duration of about 5 minutes and revealed the following: S6 CNA could be seen pulling down on Resident #1's left contracted leg and Resident #1 could be heard saying, That hurt me. Two voices, male and female, could be heard saying, God d-mn it, God d-mn it and S6 CNA stated, D-mn. Then S6 CNA forcefully snatched Resident #1's right arm from the right side rail and pushed Resident #1's right arm towards him. S7 CNA was holding him over and Resident #1 could be heard saying, You are not going to pull me out, you are not going to pull me out. S6 CNA said, I'm not and snatched diaper off of Resident #1. While S6 CNA provided incontinent care she said, I can't do this anymore. Resident #1 stated, I'm sorry if I hurt your feelings, I'm sorry if I hurt your feelings, I'm sorry if I hurt your feelings. S6 CNA then stated, I refuse to do this ever again, you trying to hurt me. Review of Resident #1's medical record revealed the following diagnoses but not limited to neurological conditions, hemiplegia following cerebral infraction affecting left non-dominant side, non-Alzheimer's dementia, anxiety disorder, bipolar disorder, schizophrenia, metabolic encephalopathy, muscle wasting and atrophy, to the left shoulder, right lower leg, and left thigh, age related cognitive decline, insomnia, and adjustment disorder with anxiety. Review of Resident #1's Quarterly and State Optional MDS (Minimum Data Set) assessment date 01/08/2025 revealed a BIMS (Brief Interview of Mental Status) of 99; indicating resident was unable to complete the interview. Further review revealed Resident #1 required extensive assistance with two person physical assist for bed mobility, transfer and was always incontinent of urine and bowel. Review of Resident #1's March 2025 Physician Orders revealed: 08/09/2024: Turning and repositioning program: Turn and reposition every 2 hours and as needed. 01/16/2025: incontinence care: Check for incontinence at least every two hours. Cleanse Peri area/buttocks with remedy essentials cleanse, Pat dry, apply Remedy prevent silicone cream as a preventative maintenance. Review of Resident #1's Care Plan revealed in part, Resident #1 had impaired physical mobility, had a self-care deficit, and was resistive to care related anxiety - with interventions to use draw sheet only - per family request for turning and repositioning. During an interview on 04/01/2025 at 2:35 p.m., Resident #1's sister reported the surveillance video on 02/13/2025 at 8:32 a.m. revealed S6 CNA manhandled Resident #1 while providing care and she would call that abuse. During a telephone interview on 04/02/2025 at 11:00 a.m., S6 CNA reported she was not Resident #1's primary CNA and she assisted other CNAs with ADL (activities of daily living) care as he was a two person assist with everything except feeding. S6 CNA reported in the video she was assisting S7 CNA with morning care. S6 CNA reported trying to loosen Resident #1 fingers off the rail. S6 CNA reported the video was edited and did not show when he grabbed her hand and she tried to loosen his grip. During a telephone interview on 04/01/2025 at 2:30 p.m., S7 CNA reported Resident #1 was a two person assist with all ADLs, but was able to feed self. S7 CNA reported she received in-service/training on identifying rough handling, yelling, and cursing during patient care was considered abuse and S6 CNA should have been reported immediately to the Administrator. During an interview on 04/02/2025 at 4:40 p.m., S1 Administrator reported on 03/14/2025 Resident #1's sister made an allegation of abuse of her brother (Resident #1) that occurred on 02/13/2025 during morning care and she had a video. S1 Administrator reported an investigation was started for alleged abuse on 03/14/2025. S1Administrator requested the video from Resident #1's sister and on 03/15/2025 about noon (around lunch) Resident #1's s sister provided the video to S3 DON (Director of Nursing). S1 Administrator reported on 03/15/2025 he watched the video from 02/13/2025 of S6 CNA and S7 CNA with Resident #1 and it revealed S6 CNA was rough with Resident #1 while providing care and abuse was substantiated. S1 Administrator reported S6 CNA was suspended on 03/14/2025 and was terminated on 03/17/2025. During an interview on 04/03/2025 at 10:30 a.m., S1 Administrator reported care and monitoring for Resident #1 are reviewed daily in the facility's quality assurance meeting. On 04/03/2025 at 11:00 a.m., S2 Assistant Administrator presented the facility's QA (Quality Assurance) daily meetings from 02/14/2025 through 03/31/2025. Review of facility's QA meeting note revealed Resident #1's care concerns, grievances and issues with nursing and incident on 02/13/2025. During the survey, in-service records and QA monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. Beginning on 03/14/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 03/21/2025: Incident investigation report started on 03/14/2025. Review of Resident #1's incident investigation report folder and corroborated with S9 Corporate Nurse revealed: On 03/14/2025 at 12:10 p.m., Resident #1's sister made an allegation that Resident #1 was abused during care, incident investigation report started within two hours of an allegation of abuse. On 03/14/2025: S6 CNA was suspended from facility and residents on Hall A were assessed and interviewed by administrative nursing team members for injuries. S6 CNA had not provided care for Resident #1 since 02/13/2025. On 03/14/2025: S3 DON notified physician of the allegation of abuse. In-services on 03/14/2025 on Abuse and Neglect-define abuse, verbal abuse, report, baseline staff interviews were initiated regarding abuse and neglect. On 03/17/2025: the Police were notified and police report initiated. On 03/17/2025: S6 CNA was terminated, S7 CNA reviewed video of care on 02/13/2025 and reeducated on abuse. On 03/18/2025: Inservice on removing residents' hands off the assist handles - you cannot pry (forcefully remove) the residents' hands off assist handles. Do not bend fingers back. Do not grab the arm. On 03/20/2025: Revision to Abuse policy #5 Investigation and Protection when there is a witnessed or alleged abuse event. On 03/21/2025: In-service on reporting abuse/investigation and protection/employee interview and workplace violence. On 03/21/2025: Baseline employee questionnaire was implemented regarding the changes to the policy/procedure of resident protection. Plan of action and/or return demonstration by S3 DON revealed after reviewing the video with S7 CNA, retraining on abuse was provided on 03/17/2025. S3 DON and S7 CNA discussed grabbing residents hand off the assist handle was considered physical abuse and if S6 CNA was the person cursing in the video that was considered verbal abuse. This should be reported immediately. S7 CNA verbalized understanding and signed on 03/18/2025. Post Event Sustained Monitoring-alleged/inappropriate physical encounter 03/15/2025 through 03/27/2025. QAPI (Quality Assurance and Performance Improvement) monitoring Staff/resident Interview Post event sustained monitoring-alleged/inappropriate physical encounter from 02/24/2025 through 03/27/2025-3x week for 6 weeks in an effort to sustain facility compliance related to alleged/inappropriate physical abuse encounters at the facility, monthly thereafter. Negative findings will be addressed by facility administration immediately with plan of action in place. Effectiveness of this QAPI will be discussed weekly in QA minutes for 6 weeks as well. Monitoring: Employee interview: protection of the resident with new guidelines 03/21/2025 through 03/27/2025. Date facility asserts the likelihood for serious harm to any resident no longer exists: 03/21/2025.

Based on surveillance video and interviews, the facility failed to treat and care for each resident in a manner that promotes dignity and enhancement of his or her quality of life for 1 (#1) resident of 3 (#1, #2, #3) residents reviewed for abuse. S6 CNA (Certified Nurse Assistant) provided care to Resident #1 in a hurried manner, spoke to Resident #1 in a disrespectful manner and talked to other staff about Resident #1. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/31/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of Resident #1's room surveillance video on 04/01/2025 at 3:00 p.m. provided by Resident #1's family memeber's cellphone with Resident #1's family member who was present revealed: Surveillance video clip started on 02/12/2025 at 2:04 p.m. with a duration of about 5 minutes. At the start of the video S6 CNA walked passed the camera and stated; Just nothing else better to do; Just nothing else better to do. S8 CNA moved the overbed table and attempted to try to remove the cup of juice from Resident #1's right hand. S6 CNA then attempted to remove the cup of juice from Resident #1's right hand. Resident #1 moved hand away with the cup of juice in hand. S6 CNA then told Resident #1 waste it; I don't care; I don't have nothing to do with that. S6 CNA then walked out of the view of the camera. S8 CNA then moved the covers back and Resident #1 gave S8 CNA the cup of juice. S6 CNA removed linens from under Resident #1's right leg forcefully. Resident #1 was hollering you're hurting me. CNA staff was not touching Resident #1. Further review of surveillance video revealed S6 CNA continued to talk and carry on a conversation when S5 ADON (Assistant Director of Nursing) came to the door to check on the care of Resident #1. S6 CNA told S5 ADON that Resident #1 liked to fight; that's why I stopped helping other CNAs with him. While S6 CNA bathed Resident #1, S8 CNA asked for Resident #1's hand and called Resident #1's name. S6 CNA stood back and made hand gestures and all of sudden said I got to go; I got to get out of here. Resident #1's hand was on the side rail and S6 CNA removed Resident #1's hand and turned Resident #1 to the left side to remove the brief. Review of Resident #1's March 2025 Physician Orders revealed: 08/09/2024: Turning and repositioning program: Turn and reposition every 2 hours and as needed. 01/16/2025: incontinence care: Check for incontinence at least every two hours. Cleanse peri area/buttocks with Remedy essentials, cleanse, pat dry, apply Remedy prevent silicone cream as a preventative maintenance. Review of Resident #1's Care Plan revealed in part, Resident #1 had impaired physical mobility, had a self-care deficit, and was resistive to care related to anxiety with interventions to use draw sheet only per family request for turning and repositioning. During a telephone interview on 04/02/2025 at 11:00 a.m., S6 CNA reported becoming overwhelmed with the job. S6 CNA confirmed rushing while providing care for Resident #1, talking about Resident #1 to other staff while providing care, and speaking to Resident #1 in a disrespectful manner was a dignity issue. During an interview on 04/02/2025 at 9:27 a.m., S3 DON (Director of Nursing) reported when CNA staff provided care for Resident #1 they should talk in resident's eye view, should not converse among themselves while giving care, and care should not be provided in a hurried manner. S3 DON confirmed S6 CNA appeared agitated, care was carried out in a hurried manner, the manner in which S6 CNA spoke to Resident #1 and when S6 CNA talked about the resident while providing care was a dignity issue. During an interview on 04/03/2025 at 10:30 a.m., S1 Administrator reported care and monitoring for Resident #1 are reviewed daily in the facility's quality assurance meeting. On 04/03/2025 at 11:00 a.m., S2 Assistant Administrator presented the facility's QA (Quality Assurance) daily meetings from 02/14/2025 through 03/31/2025. Review of facility's QA meeting note revealed Resident #1's care concerns, grievances and issues with nursing and incident on 02/13/2025. During the survey, in-service records and QA monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. Beginning on 02/13/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 02/25/2025: Incident investigation report started on 02/13/2025. Review of Resident #1's incident investigation report folder and corroborated with S9 Corporate Nurse revealed: On 02/13/2025 at 3:25 p.m., Resident #1's family member shared a video clip of CNAs providing care and stated the CNA was rough with his arm. The video was time stamped 02/12/2025. On 02/13/2025: S6 CNA was suspended from facility pending outcome of the investigation and Resident #1 was assessed and all the residents on Hall B were assessed. On 02/13/2025: Inservice on abuse/neglect and burnout initiated and continued on shift to shift for all staff. On 02/14/2025: Baseline interviews were started with all staff members regarding alleged/actual abuse-staff interview to verifiy that the staff knew who to report abuse to and if they were aware of any abuse allegations or actual abuse situations. On 02/14/2025: physician made aware of allegation and body audit of Resident #1. On 02/20/2025: Inservices on how to respond to the aggressive resident during care were initiated to licensed and unlicensed nursing staff and continued throughout all shifts by nursing administration. On 02/25/2025: Personnel action presented to S6 CNA - stated she was rushing while providing care to Resident #1 and did not slow down so he could understand the directions to decrease behaviors. She had been suspended from 02/13/2025 until 02/24/2025 and was moved to another hall because the abuse allegation was not substantiated with the information given in the videoclip provided by the family on 02/13/2025. On 02/25/2025: A care monitor reviewing dignity and privacy was initiated by S3 DON to monitor compliance from previous inservices and baseline interview.

Based on record reviews, surveillance video review and interviews, the facility failed to implement policies and procedures to ensure an allegation of abuse was reported to administration in a timely manner per the facility's policy for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. S7 CNA (Certified Nurse Assistant) failed to recognize and report physical and verbal abuse during incontinent care provided by S6 CNA. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/31/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of facility's Abuse/Neglect Policy with a revision date of 03/20/2025 revealed in part: Purpose: The purpose of the Abuse/Neglect policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Policy: It is the policy of the facility that each resident will be free from abuse. This facility will not condone any form of resident abuse. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse . Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect, and misappropriation of property. Physical abuse includes hitting, slapping, pinching, biting, and kicking. It also includes controlling behavior through corporal punishment. Alleged violation is the terminology used when a verbal allegation of resident abuse, neglect, or misappropriation of resident property has been made either by a resident, family member, visitor or employee. An alleged violation may also be triggered by an observation of an injury of unknown origin (i.e., bruise or skin tear) that the resident or staff member cannot explain. Mistreatment means inappropriate treatment or exploitation of a resident. Immediately means as soon as possible, but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement. *Immediately for purposes of reporting a crime resulting in serious body injury means covered individual shall report immediately, but no more than 2 hours after forming the suspicion. 6. Reporting and Response It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. Internal Reporting: a. Employees must always report any abuse or suspension of abuse immediately to the Administrator or his or her designee of the facility . Review of Resident #1's medical record revealed the following diagnoses but not limited to neurological conditions, hemiplegia following cerebral infraction affecting left non-dominant side, non-Alzheimer's dementia, anxiety disorder, bipolar disorder, schizophrenia, metabolic encephalopathy, muscle wasting and atrophy, to the left shoulder, right lower leg, and left thigh, age related cognitive decline, insomnia, and adjustment disorder with anxiety. Review of Resident #1's Quarterly and State Optional MDS (Minimum Data Set) assessments dated 01/08/2025 revealed a BIMS (Brief Interview of Mental Status) of 99; indicating Resident #1 was unable to complete the interview. Further review of Resident #1's Quarterly and State Optional MDS assessments revealed Resident #1 required extensive assistance with two person physical assist for bed mobility, and transfer and was always incontinent of bladder and bowel. Review of Resident #1's March 2025 Physician Orders revealed: 08/09/2024: Turning and repositioning program: Turn and reposition every 2 hours and as needed. 01/16/2025: incontinence care: Check for incontinence at least every two hours. Cleanse peri area/buttocks with Remedy essentials, cleanse, pat dry, apply Remedy prevent silicone cream as a preventative maintenance. Review of Resident #1's Care Plan revealed in part, Resident #1 had impaired physical mobility, had a self-care deficit, and was resistive to care related to anxiety with interventions to use draw sheet only per family request for turning and repositioning. Review of Resident #1's room surveillance video with audio was viewed on Resident #1's sister cellphone with Resident #1's sister present. The surveillance video clip started on 02/13/2025 at 8:32 a.m. with a duration of about 5 minutes and revealed the following: S6 CNA could be seen pulling down on Resident #1's left contracted leg and Resident #1 could be heard saying, That hurt me. Two voices, male and female, could be heard saying, God d-mn it, God d-mn it and S6 CNA stated, D-mn. Then S6 CNA forcefully snatched Resident #1's right arm from the right side rail and pushed Resident #1's right arm towards him. S7 CNA was holding him over and Resident #1 could be heard saying, You are not going to pull me out, you are not going to pull me out. S6 CNA said, I'm not and snatched diaper off of Resident #1. While S6 CNA provided incontinent care she said, I can't do this anymore. Resident #1 stated, I'm sorry if I hurt your feelings, I'm sorry if I hurt your feelings, I'm sorry if I hurt your feelings. S6 CNA then stated, I refuse to do this ever again, you trying to hurt me. During a telephone interview on 04/01/2025 at 2:30 p.m., S7 CNA reported after receiving an in-service/training on identifying rough handling, yelling and cursing during patient care was considered abuse, S7 CNA should have reported S6 CNA immediately to the Administrator. During an interview on 04/02/2025 at 4:40 p.m., S1 Administrator reported on 03/15/2025 he watched the video from 02/13/2025 of S6 CNA and S7 CNA with Resident #1 and it revealed S6 CNA was rough with Resident #1 while providing care and abuse was substantiated. S1 Administrator reported S6 CNA was suspended on 03/14/2025 and was terminated on 03/17/2025. During an interview on 04/03/2025 at 10:30 a.m., S1 Administrator reported care and monitoring for Resident #1 are reviewed daily in the facility's quality assurance meeting. On 04/03/2025 at 11:00 a.m., S2 Assistant Administrator presented the facility's QA (Quality Assurance) daily meetings from 02/14/2025 through 03/31/2025. Review of facility's QA meeting note revealed Resident #1's care concerns, grievances and issues with nursing and the incident on 02/13/2025. During the survey, in-service records and QA monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. Beginning on 03/14/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 03/21/2025: Incident investigation report started on 03/14/2025. Review of Resident #1's incident investigation report folder and corroborated with S9 Corporate Nurse revealed: On 03/14/2025 at 12:10 p.m., Resident #1's sister made an allegation that Resident #1 was abused during care, incident investigation report started within two hours of an allegation of abuse. On 03/14/2025: S6 CNA was suspended from facility and residents on Hall A were assessed and interviewed by administrative nursing team members for injuries. S6 CNA had not provided care for Resident #1 since 02/13/2025. On 03/14/2025: S3 DON notified physician of the allegation of abuse. In-services on 03/14/2025 on Abuse and Neglect-define abuse, verbal abuse, report, baseline staff interviews were initiated regarding abuse and neglect. On 03/17/2025: the Police were notified and police report initiated. On 03/17/2025: S6 CNA was terminated, S7 CNA reviewed video of care on 02/13/2025 and reeducated on abuse. On 03/18/2025: Inservice on removing residents' hands off the assist handles - you cannot pry (forcefully remove) the residents' hands off assist handles. Do not bend fingers back. Do not grab the arm. On 03/20/2025: Revision to Abuse policy #5 Investigation and Protection when there is a witnessed or alleged abuse event. On 03/21/2025: In-service on reporting abuse/investigation and protection/employee interview and workplace violence. On 03/21/2025: Baseline employee questionnaire was implemented regarding the changes to the policy/procedure of resident protection. Plan of action and/or return demonstration by S3 DON revealed after reviewing the video with S7 CNA, retraining on abuse was provided on 03/17/2025. S3 DON and S7 CNA discussed grabbing residents hand off the assist handle was considered physical abuse and if S6 CNA was the person cursing in the video that was considered verbal abuse. This should be reported immediately. S7 CNA verbalized understanding and signed on 03/18/2025. Post Event Sustained Monitoring-alleged/inappropriate physical encounter 03/15/2025 through 03/27/2025. QAPI (Quality Assurance and Performance Improvement) monitoring Staff/resident Interview Post event sustained monitoring-alleged/inappropriate physical encounter from 02/24/2025 through 03/27/2025-3x week for 6 weeks in an effort to sustain facility compliance related to alleged/inappropriate physical abuse encounters at the facility, monthly thereafter. Negative findings will be addressed by facility administration immediately with plan of action in place. Effectiveness of this QAPI will be discussed weekly in QA minutes for 6 weeks as well. Monitoring: Employee interview: protection of the resident with new guidelines 03/21/2025 through 03/27/2025. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/31/2025. It was determined to be a Past Noncompliance Citation.

Based on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 1 (#52) out of 5 (#15, #20, #26, #52, #88) residents reviewed for unnecessary meds. The facility failed to monitor Resident #52's edema while receiving a diuretic. Findings: Review of Resident #52's medical records revealed admitted [DATE] with the following diagnoses, including in part: chronic pulmonary edema and chronic diastolic (congestive) heart failure. Review of Resident #52's Physician's Orders revealed an order dated 08/01/2024 for Furosemide Tablet 40mg (milligram). Give 1 tablet by mouth two times a day. Review of Resident #52's November 2024 Medication Administration Record (MAR) failed to reveal monitoring for edema. During an interview on 12/04/2024 at 10:32 a.m. S4 LPN (Licensed Practical Nurse) confirmed Resident #52 was receiving a diuretic. S4 LPN further reported she was unable to provide documentation Resident #52's edema was monitored. During an interview on 12/04/2024 at 10:45 a.m. S2 Director of Nursing acknowledged Resident #52 was not monitored for edema and should have been.

Based on record reviews, observations and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#52) out of 1 (#52) resident reviewed for respiratory services. The facility failed to clean Resident #52's oxygen concentrator filter weekly and as needed. Findings: Review of Facility's oxygen Tanks: Administration (concentrator or tank) Policy (no date) revealed: Policy: Humidifier bottles, cannulas and O2 (oxygen) tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well . Review of Resident #52's medical records revealed admitted [DATE] with the following diagnoses, including in part: pneumonia/unspecified organism (onset 11/29/2024), acute respiratory failure with hypoxia, chronic obstructive pulmonary disease/unspecified, chronic pulmonary edema, dependence on supplemental oxygen and chronic diastolic (congestive) heart failure. Review of Resident #52's Physician's Orders revealed an order dated 08/06/2024 for O2 (oxygen) at 2 liters/nasal cannula PRN (as needed) for shortness of breath every 12 hours as needed. Observation on 12/02/2024 at 8:50 a.m. revealed Resident #52 wearing continuous oxygen at 2 liters via nasal cannula. Further observation revealed filter on oxygen concentrator contained a fine gray film. During an interview on 12/02/2024 at 8:50 a.m. Resident #52 reported she wears her oxygen all the time. Observation on 12/02/2024 at 12:00 p.m. revealed Resident #52 wearing continuous oxygen at 2 liters via nasal cannula. Further observation revealed filter on oxygen concentrator contained a fine gray film. Observation on 12/03/2024 at 11:00 a.m. revealed Resident #52 wearing continuous oxygen at 2 liters via nasal cannula. Further observation revealed filter on oxygen concentrator contained a fine gray film. Observation on 12/03/2024 at 1:35 p.m. revealed Resident #52 wearing continuous oxygen at 2 liters via nasal cannula. Further observation revealed filter on oxygen concentrator contained a fine gray film. During an interview on 12/03/2024 at 1:35 p.m. S4 LPN (Licensed Practical Nurse) reported the 11-7 nurse changes the oxygen tubing and humidifier. S4 LPN acknowledged the oxygen concentrator filter was dirty with gray fluffy particles and was unaware it needed to be cleaned.

Based on record review, surveillance video review, and interviews, the facility failed to protect the resident's right to be free from physical abuse and psychosocial harm by staff for 1 (#3) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for Resident #3, who was cognitively impaired, on 07/04/2024 at approximately 7:33 p.m. when S7 Sunshine Aide was observed on surveillance video physically abusing Resident #3. S7 Sunshine Aide was observed hitting Resident #3 on her hands and forearm with a hard plastic kitchenware cup. Because this type of inappropriate, unwanted physical abuse would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in Resident #3's position would have experienced severe psychosocial harm-dehumanization, and humiliation- as a result of the physical abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility's Abuse/Neglect policy statement (revision date 12/11/2018) revealed in part: This facility will not condone any form of resident abuse or neglect. Each resident residing on the facility has the right to be free from verbal, sexual, mental, and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean and humiliate a resident (s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. 1. Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 6. Physical Abuse - includes hitting, slapping, pinching, and kicking. Additionally, it includes acts of corporal punishment to control behavior. Review of Resident #3's medical record revealed an admitted [DATE] with medical diagnoses including, but not limited to Medical Diagnoses: generalized osteoarthritis unspecified diastolic (congestive) heart failure, type 2 DM (Diabetes Mellitus), vascular dementia with behavioral disturbances, chronic pain, long term insulin use, schizoaffective disorder/bipolar type, muscle wasting and atrophy multiple sites, right shoulder/ left shoulder, right lower leg, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, visual hallucinations, restlessness and agitation, schizophrenia. Review of Resident #3's Quarterly MDS (Minimum Data Set) dated 05/29/2024 revealed a BIMS (Brief Interview for Mental Status) of 5 out of 15 indicating severely impaired cognition. Further review of Resident #3's Quarterly MDS revealed no functional limitation in range of motion to upper or lower extremity. Review of Resident #3's Comprehensive Care Plan revealed: Behavior: verbally aggressive toward staff and other residents with interventions to talk calm voice when behavior is disruptive, remove from public area when behavior is disruptive and unacceptable, reinforce unacceptability of verbal abuse, monitor for target behaviors, do not argue with resident, discuss options for appropriate channeling of anger Thought process impaired: Impaired cognition related to diagnosis of dementia with behavioral disturbances. Resident has a history of visual hallucinations. Resident has a history of sun downing in evening times with interventions to administer medications as ordered, anticipate needs, approach in a calm manner, ask simple direct questions, call light within reach, calmly talk with resident and offer reassurance prior to care. Review of Resident #3's July 2024 Physician Orders revealed: 10/18/2021: Namenda 10 mg tablet. Give one tab by mouth twice daily. 10/30/2020: Monitor for behaviors and side effects -is on psychotropic medications Review of facility's incident investigation report revealed an altercation on 07/04/2024 with Resident #3 and S7 Sunshine Aide. Resident #3 in her wheelchair went up to the coffee cart, grabbed two empty coffee cups and threw them at S7 Sunshine Aide when she came out of a room. This occurred when they were approximately 3-4 feet apart. S7 Sunshine Aide reacted, she stated to protect herself. S7 Sunshine Aide said she was trying to knock the other cup out of her hand. They were both swinging their arms in front of them, and S7 Sunshine Aide appeared to make contact with Resident #3's arm 2-3 times. Review of the date and time stamped surveillance video with S1 Administrator revealed on 07/04/2024: 7:33:04: Coffee cart on the hall with hard plastic kitchenware cups on top of the cart. 7:33:08: Resident #3 exited her room in her wheel chair and continued toward the cart with cups and silverware. 7:33:26-30: Resident #3 continued down the hall way, picked up 1 cup with her left hand and 2 cups with her right hand off the coffee cart. 7:33:34: S5 RN (Registered Nurse) came out of another resident room and attempted to redirect Resident #3 to put the cups back on the coffee cart. Attempt was unsuccessful as Resident #3 was moving her mouth appearing to be talking and did not return the cups to the cart. The video did not have sound. 7:33:39: S7 Sunshine Aide exited another room across the hall with a cup in her right hand and walked around the cart to Resident #3. Resident #3 had cups in both her right and left hands with her right hand raised. S7 Sunshine Aide had a cup in her right hand with her right hand raised. 7:33:43: As S7 Sunshine Aide walked closer to Resident #3, Resident #3 begin to swing her right hand holding 2 cups and S7 Sunshine Aide moved to dodge the swing of Resident #3. S7 Sunshine Aide was also swinging at Resident #3 with a cup in her right hand. Both S7 Sunshine Aide and Resident #3 continued to swing at each other as cups fell from Resident #3 hands. S7 Sunshine Aide still had cups in her right hand and made contact with Resident #3's hands and forearm. 7:33:48: S7 Sunshine Aide pushed the other cups on the cart and walked away from Resident #3. Resident #3 attempted to pick up silverware and cups that were on the floor as the video ended. Review of S5 RN (Registered Nurse), nursing note dated 07/09/2024 at 5:59 p.m. (late entry): Resident #3 in wheelchair in hall when she saw S7 Sunshine Aide picking up silverware. Resident #3 rolled over to her cart and picked up silverware and started to throw them at S7 Sunshine Aide; but dropped some. S7 Sunshine Aide picked them up. Resident #3 was cursing and making threats and attempted to throw silverware at S7 Sunshine Aide. S7 Sunshine Aide came out of room with arms raised in order to guard her face. Resident #3 continued to yell at S7 Sunshine Aide as S7 Sunshine Aide was working in another resident room. Writer attempted to calm res down when S7 Sunshine Aide stepped close and begin to attempt to hit resident. Addendum nursing note by S5 RN dated 07/11/2024 at 1:46 p.m. revealed a late entry for 07/04/2024 when the above incident occurred. S8 Physician was notified and attempted to notify responsible party and S7 Sunshine Aide was sent home. A body audit was completed with another nurse and no injuries found. During an interview on 07/23/2024 at 4:21 p.m. S5 RN reported she was in another resident's room on the night of 07/04/2024. Resident #3 was throwing a cup of silverware and S7 Sunshine Aide got upset. S5 RN reported Resident #3 and S7 Sunshine Aide were separated and S7 Sunshine Aide was told to clock out and go home. Resident #3 was assessed with no injuries. During an interview on 07/23/2024 at 4:45 p.m. S6 CNA (Certified Nurse Assistant) reported she did not see the beginning. S6 CNA reported she was in the breakroom when she heard lots of noise and commotion. S6 CNA reported she walked to the end of the hall and witnessed S7 Sunshine Aide swinging at Resident #3 who was in the hallway, in her wheel chair. Resident #3 and S7 Sunshine were swinging at each other. S6 CNA reported S7 Sunshine Aide did hit Resident #3 on the arm. S6 CNA reported she also heard Resident #3 say you hit me. During an interview on 7/23/2024 at 3:50 p.m. S4 Assistant Administrator reported the administrator was out of town when the incident occurred on 07/04/2024. S4 Assistant Administrator reported she started the facility's incident investigation report after being notified on 07/04/2024 around 8:15 p.m. by S2 DON (Director of Nursing) of an altercation and S4 Assistant Administrator needed to come to the facility to view the surveillance video. S4 Assistant Administrator reported she then watched the surveillance video and the footage showed S7 Sunshine Aide did hit Resident #3's arm. S4 Assistant Administrator reported the authorities were notified, Resident #3's responsible party was also notified. S4 Assistant Administrator reported Resident #3 was interviewed. S4 Assistant Administrator reported during the interview with Resident #3, Resident #3 stated the girl hit my arm. S4 Assistant Administrator reported when she arrived to the facility S7 Sunshine Aide had already left and did not answer telephone calls. During an interview on 07/24/2024 at 10:00 a.m. Resident #3 reported staff was nice to her. Resident #3 denied being scared or fearful at the facility. Resident #3 was unable to recall S7 Sunshine Aide. During an interview on 07/25/2024 at 10:00 a.m. S3 ADON (Assistant Director of Nursing) reported on 07/05/2024 S7 Sunshine Aide came straight to the S3ADON's office after clocking in. S3 ADON reported asking S7 Sunshine Aide to provide details of the incident but S7 Sunshine Aide was not able to explain what happened. S3 ADON reported she informed S7 Sunshine Aide that the S1 Administrator and S4 Assistant Administrator would also like to speak to her and walked S7 Sunshine to the front foyer to wait on the S1 Administrator and S4 Assistant Administrator. S3 ADON reported S7 Sunshine Aide left the facility and they have not been able to make contact with her. S3 ADON reported Resident #3 was being seen by a behavioral health nurse practitioner and was care planned for aggressive behaviors. S3 ADON reported at times Resident #3 is not easily redirected and staff should walk away. Attempted telephone interview with S7 Sunshine Aide on 07/25/2024 at 1:00 p.m. telephone call went to voicemail. During an interview on 07/25/2024 at 2:30 p.m. S9 NP (Nurse Practitioner) reported Resident #3 had aggressive behaviors and received a report of an incident on 07/04/2024. Resident #3 was assessed on 07/05/2024 and S9 NP ordered lab, urine and changed her medications. S9 NPs Assessment found no injuries and Resident#3 had not been withdrawn or appeared fearful since incident. S9 NP reported the behavioral health nurse practitioner would have followed up with Resident #3's medications. Attempted telephone interview with S10 Behavioral Health NP on 07/25/2024 at 4:00 p.m Office staff reported S10 Behavioral Health NP was not in the office, message left with office staff. Multiple observations during survey revealed Resident #3 ate lunch in dining room with other residents. Observations during survey revealed Resident #3 was talkative with other residents and staff. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice. Review of facility's Performance Improvement Plan revealed the following with a completion date of 7/11/2024: Topic: Abuse/ Neglect Areas identified as needing improvement: knowing de-escalation tactics and dealing with burnout Plan implementation: 1. Abuse-Neglect monitoring was started on 07/05/2024 and in-service (Abuse and Neglect) with all staff 2. 07/05/2024 census was pulled, care plan nurse ask residents the attached questions. All staff were given test regarding abuse and neglect. 3. 07/10/2024 De-escalation training was done by all staff Implemented changes will be monitored by ADON and DON for 6 weeks beginning 07/04/2024. Plan will be evaluated for effectiveness by review of incidents and review of monitoring. Review of typed facility's incident investigation report time line by S3 ADON dated 07/11/2024 revealed in part, 07/05/2024 S9 NP made rounds and increased Seroquel to 50 mg in the a.m. and 100 mg in the p.m. as well as adding Vistaril 25 mg every evening. New order to collect a urinalysis with culture and sensitivity. S10 Behavioral Health NP notified of resident behavior and medication change. Resident #3's care plan updated to notify staff to only remove dishes etc. from room while Resident #3 is out of the room. Updated the aggression to the care plan to include: (resident becomes angry and physically aggressive with staff when staff attempts to assist or redirect). Resident #3 hoards silverware including coffee cups and utensils in her room. Added to wall care sign in room. 07/05/2024: In-service initiated on abuse-which includes both physical and mental abuse, in-service initiated on burn-out, de-escalation-report abusive patient as soon as it is noted to happen to supervisor or nurse. Communication in-service staff to be in close proximity with communicating patient care. Testing completed for all staff on abuse and neglect. Resident interviews completed to ensure all resident feel safe and have no concerns. 07/08/2024: Abuse and Neglect-Grievance monitor added as a QA (Quality Assurance) tool for administrative staff to complete with all residents and to for six weeks and then weekly which includes a questionnaire for reside to ensure they feel safe and have no other concerns. 07/10/2024: De-escalation in-service with completed by S11 RN, __________ local behavioral hospital with de-escalation testing for all staff. 07/11/2024: Resident #3 does not recall the incident; she has continued her daily activities as usual. Resident #3 remains very social and has a good quality of life.

Based on record reviews and interviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4, #5) residents reviewed for accidents received adequate supervision to prevent accidents/falls. The deficient practice resulted in harm for Resident #1 on 08/08/2023 when the resident fell from bed after S4 CNA (Certified Nursing Assistant) left Resident #1's room during peri care to seek assistance of a second CNA. Resident #1 required two person assistance for bed mobility. On 08/08/2023 S4 CNA was providing peri care, Resident #1 was positioned to her right side with her foot hanging off the bed and S4 CNA realized she could not reposition Resident #1 alone. S4 CNA left Resident #1's room to obtain assistance and when S4 CNA returned, Resident #1 was on the floor with left leg bent at the knee. Resident #1 was transported and admitted to a local hospital on 08/08/2023 with diagnosis of fracture of left femur. Findings: Review of hospital physician progress notes revealed in part: Resident #1 was admitted to hospital on 08/08/2023 with diagnosis of fracture of left femur and orthopedics consulted. On 08/09/2023 Resident #1 had a left open reduction internal fixation (ORIF) performed. Resident #1 was discharged back to nursing home on 08/14/2023 with immobilizer to left lower extremity. Review of Resident #1's medical record revealed an admitted [DATE] and reentry date of 08/14/2023 with diagnoses including, but not limited to, Left Femur Fracture, HIV (Human Immunodeficiency Virus), Latent Syphilis, Multifocal Leukoencephalopathy, Obesity, and Generalized Weakness. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Further review of the MDS dated [DATE] revealed Resident #1's functional status was total dependence requiring two person physical assist with bed mobility. Review of Resident #1's Care Plan revealed, in part, the following: Activities of daily living (ADL) deficits and included approach of two person assistance with all ADLs with start date of 01/27/2023. Review of facility's Incident Report dated 08/08/2023 for Resident #1 revealed in part, S4 CNA was providing peri care for Resident #1, S4 CNA stepped out to seek help, when S4 CNA returned resident was found on floor. Review of documentation of S4 CNA statement for Resident #1's 08/08/2023 fall revealed: On 08/08/2023 S4 CNA was changing Resident #1 in the bed and Resident #1 was turned to her right side with foot was hanging off of the bed. (Resident #1 was still in the bed) S4 CNA went to get another CNA for help and when S4 CNA went back in the room Resident #1 was out of the bed. Review of documentation of S5 CNA statement for Resident #1's 08/08/2023 fall revealed: S5 CNA went to Resident #1's room to assist with her care. S5 CNA noticed Resident #1 was lying on the floor by the refrigerator and Resident #1's knee was bent. Review of documentation of S3 LPN (Licensed Practical Nurse), MDS (Minimum Data Set) Nurse statement for Resident #1's 08/08/2023 fall revealed: After being summoned to Resident #1's room, S3 LPN, MDS Nurse entered room and observed resident lying on floor in supine position with left leg bent at knee back toward resident's head. Resident #1 stated she was lying on the bed positioned on her side, she moved her leg and slid off the bed. S3 LPN, MDS Nurse questioned S4 CNA assigned to resident and S4 CNA stated she was performing peri care, needed help, stepped outside in hallway to get help, returned to room to find resident on floor. Review of documentation of S2 DON (Director of Nursing) statement for Resident #1's 08/08/2023 fall revealed in part: S4 CNA provided one person ADL care per Resident #1's Care Communication sheet. During an interview on 08/30/2023 at 3:05 p.m. S7 Therapy Director reported Resident #1 was receiving occupational therapy prior to her hospitalization on [DATE]. S7 Therapy Director reported she has noticed a decline in Resident #1 over the past couple of years related to progression of Resident #1's Neuro Syphilis and the lesions on Resident #1's brain. S7 Therapy Director confirmed the MDS assessment dated [DATE] reporting resident required assist of two persons with ADLs was an accurate assessment of the assistance Resident #1 required. During an interview on 08/31/2023 at 8:02 a.m. S6 LPN reported Resident #1 required two person assist with ADLs, but on the day of the incident when Resident #1 broke her leg, there was only one CNA helping her. During an interview on 08/31/2023 at 10:35 a.m. Resident #1 confirmed earlier this month when she fell out of bed and broke her leg there was only one CNA in the room helping her and the CNA left the room to get assistance leaving Resident #1 positioned to her right side. Resident #1 also reported she was transported to the hospital and had surgery on her left leg the next day. During an interview on 08/31/2023 at 10:45 a.m. S3 LPN, MDS Nurse reported each resident has a Care Communication sheet hanging in their room which informs staff of the amount of assistance required by the resident. S3 LPN, MDS Nurse reported the Care Communication sheet is based on each Resident's care plan. S3 LPN, MDS Nurse further reported she knows Resident #1's Care Communication sheet stated resident required assistance of one person with ADLs prior to Resident #1 falling and breaking her leg because she was the person who filled the sheet out. During an interview on 08/31/2023 at 11:05 a.m. S2 DON confirmed the resident's care plan and Care Communication sheet should match. S2 DON acknowledged Resident #1's care plan revealed Resident #1 was a 2 person assist with ADLs and the Care Communication Sheet indicated Resident #1 was a 1 person assist for everything except transfers. During an interview on 08/31/2023 at 11:30 a.m. S1 Corporate Nurse reviewed Resident #1's care plan and confirmed Resident #1 was care planned for two person assist with all ADLs since 01/27/2023.

Based on record review, observation and interviews, the facility failed to ensure the plan of care had been revised for 1 (#64) of 1 resident reviewed for [CONDITION(S)] (Urinary Tract Infection). The facility failed to ensure the care plan had been revised for Resident #64 after removal of Foley catheter. Findings: Review of Resident #64's comprehensive care plan revealed -11/8/2021 potential for [CONDITION(S)] and /or complications related to use of indwelling catheter due to urine retention with interventions including catheter care with soap and water every day, catheter leg bag on at all times, change 18 French/10cc (cubic centimeters) catheter every month, monitor intake and output, and monitor color and condition of urine every shift. Review of Resident #64's 11/12/2021 MDS (Minimum Data Set) revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. Bowel/bladder: no appliances, occasionally incontinent of urine. Observation on 12/13/2021 at 8:30 am failed to reveal Resident #64 with an indwelling Foley catheter. During an interview on 12/13/2021 at 11:05 am Resident #64 reported she did not have a catheter. During an interview on 12/14/2021 at 2:45 pm S3 MDS Nurse reported Resident #64's Foley catheter was discontinued 11/16/21 and the care plan should have been updated and was not. During an interview on 12/15/2021 at 9:10 am S4 LPN (Licensed Practical Nurse) reported Resident #64 has not had a catheter since returning from the hospital November 16, 2021.

Based on record review, observations, and interviews the facility failed to provide services to prevent further contractures and potential decline in range of motion for 2 (#58) of 2 (#29, #58) residents reviewed for limitations in range of motion. Findings: Review of Resident #58's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly MDS (Minimum Data Set) dated 11/5/21 revealed Resident #58 was assessed to have a BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. Further review revealed Resident #58 was assessed to have [CONDITION(S)]. Observation on 12/13/21 at 8:55 AM revealed Resident #58 sitting up in bed, without a splint device in place to left hand contracture. During an interview on 12/13/21 at 1:20 PM Resident #58 reported having a splint for his left hand in the past, but was lost when he changed rooms a few months ago. Observation on 12/14/21 at 9:30 AM revealed Resident #58 lying in bed, without a splint device in place on left hand contracture. Observation on 12/15/21 at 7:45 AM revealed Resident #58 lying in bed, without a splint device in place on left hand contracture. During an interview on 12/15/21 at 9:30 AM S5 OT (Occupational Therapist) reported Resident #58 completed therapy on 10/8/21 and should have been utilizing a resting hand splint on contracted left hand. During an interview on 12/15/21 at 9:35 AM S6 CNA (Certified Nursing assistant) reported a splint should have been put on Resident #58 every morning and confirmed Resident #58 did not have splint on left arm/hand. S6 CNA was unable to locate splint in Resident #58's room. During an interview on 12/15/21 at 9:38 AM S7, RN (Registered Nurse) assigned to Resident #58 reported she was not aware Resident #58 should have had a resting hand splint in place.

Based on record reviews and interview, the facility failed to ensure an alleged violation of abuse was reported immediately, but not later than 24 hours to the State Survey Agency for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sample residents. Findings: Review of the facility's Abuse/Neglect Investigation, Protection and reporting policy presented to the surveyor by S3 ADON (Assistant Director of Nursing) revealed - #5 The Administrator will submit the initial SIMS according to state reporting guidelines within 24 hours of his/her the discovery of the alleged violation. Review of the facility's SIMS (Statewide Incident Management System) report revealed the incident occurred 11/20/2021. Review of the SIMS reported revealed it was not entered within the required time and was not entered until 11/22/2021. Review of the facility's Incident Log revealed resident #1 on 11/22/2021 at 3:45 PM had localized tissue [CONDITION(S)]. Incident level marked as high. Location of occurrence, other. Resident transferred to the emergency room . Review of the facility's Incident Report completed by the facility's nurse dated 11/22/2021 for resident #1. The facility's nurse documentation revealed the type of incident as other. Reported to supervisor 11/22/2021 at 3:45 PM. Types of injuries localized tissue [CONDITION(S)]. Property involved, other. Activity at this time, other. Incident reported by CNA (certified nurse's assistant). Incident was non-witnessed. Narrative of incident and description of injuries revealed a CNA observed the left hand and fingers swollen and reported it to the nurse. Left hand and fingers swollen, warm to touch. Immediate action taken, assessed left hand and fingers. Notified NP (nurse practitioner) and orders given for x-ray. Physician notified 11/22/2021 at 3:45 PM. Resident transfer to a local hospital ER (emergency room ) via of medical transport 11/22/2021 at 10:00 PM. Disposition resident returned to the facility after ER visit. Review of resident #1's Progress Notes dated 11/22/2021 at 3:45 PM the facility nurse documented resident #1's left hand and fingers noted to be swollen, warm to touch and resident verbalized painful. 3:51 PM NP notified, new order's x-ray, and labs. 4:20 PM RP (responsible party) notified, 4:30 PM X-ray Company notified, lab request placed in lab book. Resident #1 alert, verbal with clear speech propelling self around (via of using arms, hands and feet). Review of the x-ray results dated 11/22/2021 revealed, 2 views of the left hand. Impression, spiral fracture of the (left hand) fourth metacarpal bones. During an interview on 12/7/2021 at 2:55 PM the Director of Nursing confirmed during the investigation of verbal abuse it was determined resident #1 was pushed via wheelchair into her room by S4 CNA. As S4 CNA was pushing resident #1 into her room resident #1 was swing her arms about and S4 CNA did not stop and let resident #1 calm down. Instead S4 CNA kept pushing resident #1 into her room and resident #1 hit her hand on the door of the room resulting in a fracture to her finger. During an interview on 12/7/2021 at 3:00 PM S1 Administrator reported he or S2 Director of Nursing are the ones that would enter a SIMS report of abuse or alleged violation of abuse. S1 Administrator did confirm that S4 CNA continued pushing resident #1 into her room while the resident was agitated and this caused resident #1 to hit her hand on the door and fracture her finger.

Based on interviews and record reviews the facility failed to provide services that met professional standards for 1 (#1) of 5 sample residents. The facility failed to follow their policies and procedures to ensure a resident was assessed for injuries after an allegation of abuse which resulted in a delay of care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: Review of the facility's Abuse/Neglect Investigation, Protection and Reporting policy presented to the surveyor by S3 ADON (Assistant Director of Nursing) revealed - #8 The Administrator shall investigate the alleged violation by interviewing all parties having knowledge or information about the occurrence, including residents. The Administrator will review the clinical record and a physical assessment of the alleged victim will be conducted by two facility nurses. During an interview on 12/3/2021 at 2:50 PM S2 DON (Director of Nursing) reported after she and S1 Administrator reviewed the facility's video of the incident that occurred 11/20/2021 it was clear, the one hard push of resident #1's wheelchair by S4 CNA (Certified Nursing Assistant) while resident #1 had her arm up, resisting going in her room, causing the injury to her left hand. S2 DON reported S4 CNA did not follow company policy and did not follow in-service training that she had been given on how to handle residents with dementia and agitation. S2 DON reported resident #1 should have been physically assessed by the weekend RN (Registered Nurse) after the alleged abuse. Review of the facility's In-Service Training Report dated 6/11/2021 given by S2 DON revealed S4 CNA signature that she had attended. Subject covered, How to respond to an aggressive resident. How you react may escalate or diffuse the situation. Try to stay calm, do not yell or holler at the resident. Leave the resident in a safe position and get the nurse. Do not bring a crowd to stand around. Do not try and handle the situation alone. Do not try and man handle the resident. Review of the facility's In-Service Training Report dated 8/25/2021 given by S2 DON revealed S4 CNA signature that she had attended. Subject covered, Abuse/Neglect. Report to DON/Administrator immediately. In the case of resident to resident suspected abuse separate them from one another until the investigation is completed. Staff will check on the resident more frequently to ensure the safety and protection of the resident. Discussed definitions of abuse and neglect. Possible indicators of potential abuse and neglect. Reporting of accidents/incidents, assisting accident victim investigation action, abuse/neglect investigations, protection and reporting. During an interview on 12/8/2021 at 9:30 AM S3 ADON (Assistant Director of Nursing) reported there is a 24 Hour Nursing Report form (in the jot book) used to provide continuity of care, there is one at each nurse's station. S3 ADON reported walking rounds are to be done at the beginning of each shift. S3 ADON reported the swelling of resident #1's left hand was documented on the 24 hour Nursing Report form and the nurses did not review the 24 Hour Nursing Report form on the jot book. S3 ADON reported this resulted in a delay of treatment and care for resident #1. S3 ADON reported this is a Personnel Action form (write up) was done for each nurse working with resident #1 the day of the incident. Review of the facility's Personnel Action forms revealed the following write ups for their staff nurses that failed to assess resident #1's injured left hand. 1. S5 LPN (License Practical Nurse) Willful or careless disregard. CNA (certified nursing assistant) notified nurse of resident #1 left hand swelling on Sunday 11-7 shift 11/21/2021. Never took initiative to communicate. However failing to notify provider, MD or family which prolonged care for an injured resident. Walking rounds needed to be completed at shift change to improve hand off of residents. 2. S6 LPN, Inattention to work - notification of resident #1 left hand swelling reported on jot book sheet on 11/21/2021. Nurse fell to recognize Jot sheet by signing to ensure continuity of care for our resident. To further improve on information received or reported during shift change walking rounds needed to be completed with off going nurse to improve hand off of care. 3. S7 LPN, Inattention, willful or careless disregard to work CNA notified of resident #1's left hand swelling on 11/22/2021 around lunch time. The nurse failed to review or recognize the jot book sheet by signing the form, walking rounds needed to be completed to improve hand off of care.

Based on interviews and record review the facility failed to notify 1 (#1) of 5 (#1, #2, #3, #4 and #5) resident's RP (responsible party) of a change in their plan of care and/or treatment. The facility did not notify resident #1's RP after the consultation with the Orthopedic Specialist. Findings: During an interview 12/7/2021 at 11:21 AM with resident #1's RP (responsible party), her daughter-in-law, reported she was notified resident #1 had an x-ray at the facility and was being sent out to the emergency room . She reported she never got a clear picture of what was going on. She reported the facility told her resident #1 had a bone spur or something. She reported she was aware resident #1 was being sent to see an Orthopedic Specialist, she gave consent. She reported no one from the facility notified her about the outcome of the orthopedic visit. She reported the facility does not keep her informed about resident #1's condition. She reported when she didn't hear back from the facility she assumed everything was alright. Resident #1's RP reported she is the one to be notified in case of an emergency or any changes in condition. Review of resident #1's clinical records failed to reveal any documentation resident #1's RP (daughter-in-law) had been notified with the results of the Orthopedic Specialist consult for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/7/2021 at 12:15 PM S2 DON reported resident #1's RP was aware her left hand was fractured. She reported she was not aware resident #1's RP was not notified after the Orthopedic consult and she should have been. Review of the facility's Policy and Procedures and Nurse Orientation-Annual Skills - Resident and family Notification Guidelines revealed the following: Notification of resident and the resident representative of changes in the resident's condition is the primary responsibility of the nurse assigned to the resident. Any order change, addition or discontinuance. Any significant change in the resident's condition etc.

Based on record reviews and interviews, the facility failed to ensure resident care plans were implemented for 1 (#51) out of 35 total sampled residents reviewed. Resident # 51's blood pressure was not monitored as ordered. Findings: Review of Resident # 51's active physician's orders [REDACTED]. Hold if systolic <100 (less than) and diastolic <60. Review of Resident # 51's Vital Signs failed to reveal blood pressures documented with [MEDICATION NAME] dosing at 8:00 AM and 5:00 PM for (MONTH) 2019 and (MONTH) 1-6/2020. Review of Resident # 51's (MONTH) 2019 and (MONTH) 2020 MAR's (Medication Administration Record) failed to reveal blood pressures documented with [MEDICATION NAME] administration for (MONTH) 2019 and (MONTH) 1-6/2020. During an interview on 1/9/2020 at 1:45 PM S2 DON (Director of Nursing) and S3 ADON (Assistant Director of Nursing) acknowledged Resident # 51's MAR and Vital Signs failed to reveal blood pressure documentation with administration of [MEDICATION NAME] 25 mg BID (twice a day) was completed for (MONTH) 2019 and (MONTH) 2020 as ordered and should have been.

Based on record reviews, observations and interviews, the facility failed to ensure accommodation of needs were met for 2 (#1, #25) out of 7 residents who were independent of toilet use according to the Resident Census and Conditions Form. Resident #1 and #25 were missing pull cords on the call lights by the toilet. Findings: Review of Facility List of residents independent with toileting provided by S4 Corporate Nurse included Resident # 1 and Resident # 25. Resident #1 Review of Resident # 1's MDS (Minimum Data Set) dated 12/30/19 revealed BIMS (Brief Interview Mental Status) of 10; toilet use independent no set-up. Observations on 1/6 - 1/9/2020 revealed Resident # 1's call light next to toilet was missing a cord. During an interview on 1/6/19 at 9:40 AM Resident # 1 confirmed that she is able to use the bathroom on her own without assistance. During an interview on 1/6/19 at 1:00 PM S6 LPN (Licensed Practical Nurse) reported Resident #1 is able to do for themself and use the bathroom independently. During an observation on 1/9/20 at 10:30 AM accompanied by S2 DON (Director of Nursing). S2 DON acknowledge Resident # 1's call light next to the toilet was missing a pull cord and indicated there should be one. Resident #25 Review of Resident # 25's MDS dated [DATE] revealed a BIMS of 14. Observations on 1/6 - 1/9/2020 revealed Resident # 25's call light next to toilet was missing a cord. During an interview on 1/6/19 at 1:00 PM S6 LPN (Licensed Practical Nurse) reported Resident # 25 is able to do for themself and use the bathroom independently. During an observation on 1/9/20 at 10:31 AM accompanied by S2 DON (Director of Nursing). S2 DON acknowledge Resident #25's call light next to the toilet was missing pull cord and indicated there should be one.