Every finding on record at Maryland Gardens Post Acute

Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 7 of 15 residents sampled (#6, #19, #22, #65, #66, #76, and #77) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.Findings include:Regarding Resident #66 and Resident #65:-Resident #66, the alleged victim, was re-admitted [DATE] with diagnoses that included major depressive disorder, mood disorder, cerebral infarction, aphasia, vascular dementia with behavioral disturbances, Schizoaffective disorder depressive type, and bipolar II disorder. The care plan revised on February 12, 2019 revealed that Resident #66 had a communication problem related to expressive aphasia secondary to cerebral vascular accident (CVA). The care plan also revealed that Resident #66 was able to make his needs known through few words and gestures and had a communication book but gets frustrated when asked to use it. Interventions included anticipating and meeting his needs, monitoring and documenting physical nonverbal indicators of discomfort or distress. The care plan initiated on February 31, 2023 revealed that Resident #66 had a mood problem related to psychological diagnoses. The care plan also revealed that Resident #66 exhibited demanding and aggressive behavior, verbal aggression towards staff and show signs in addition to physical aggression. Interventions included administering medications as ordered, monitor and record mood to determine if problems seem to be related to external causes.A quarterly minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 9, indicating that the resident had moderate cognitive impairment. A Change of Condition progress note dated June 2, 2024 revealed that at approximately 8:05 a.m. the patio monitor and Certified Nursing Assistants (CNA) alerted the nurse and other day nurse of an incident on the patio smoking area. The note further documented that Resident #66 was involved in a physical altercation with Resident #65 who hit Resident #66 in the mouth with Resident #65's closed fist. The Change of Condition noted documented that Resident #65 was upset that Resident #66 had his finger in his face and yelling at him. The note also revealed that Resident #65 stated to the nurse that he punched Resident #66.A Change in Condition Evaluation form dated June 2, 2024 revealed that Resident #66 was involved in a physical altercation with a peer in which Resident #66 was hit in the mouth by Resident #65 due to Resident #66 yelling at Resident #65. Further review of the evaluation form revealed no injuries to Resident #66. A Change of Condition progress note dated June 2, 2024 documented that nurse was monitoring resident due to physical altercation. The note documented that resident was hit in the right side of the jaw with closed fist and was now complaining of right sided jaw pain rating it a 6 out of 10. The progress note revealed that Resident #66 was given Tylenol and continued to be monitored. A Medication Administration (MAR) note for Resident #66, dated June 3, 2024 documented that that the administration of the Tylenol was effective and the pain was now a 0 out of 10. -Resident #65, the alleged perpetrator, was admitted [DATE] with diagnoses that included Schizophrenia, unspecified bipolar disorder, and unspecified intracranial injury without loss of consciousness. A care plan initiated on February 17, 2021 revealed that Resident #65 was that physical aggressor towards another resident. Interventions included assessing and anticipating resident's needs and giving Resident #65 as many choices as possible about care and activities. A care plan initiated July 19, 2021 revealed that Resident #65 had a behavior problem related to psychological diagnoses. The care plan revealed that Resident #65 exhibited behaviors including sexual inappropriateness at times with staff and peers, resistive to care when he doesn't get his way, and incites peers. Interventions included anticipating resident's needs and administering medications as ordered. A quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 indicating sever cognitive impairment. The MDS also documented that Resident #65 exhibited delusions, verbal behavior, and rejection of cares. A health status note dated June 2, 2024, revealed that Resident #65 was involved in a physical altercation with Resident #66 at 8:05 a.m. The health status note documented that the writer observed Resident #65 fighting with Resident #66 and were immediately separated. The note also revealed that Resident #65 admitted that he punched Resident #66 in the face. The note documented that Resident #65 stated that Resident #66 was yelling at him from the patio and he told Resident #66 to come closer. Resident #66 left the patio and approached Resident #65 pointing a finger at Resident #65. Resident #65 told the writer 'I did not like that so I punched him, he was up in my face I didn't know if he was going to hit me. I have the right to defend myself so I punched him.'A Change in Condition Evaluation form dated June 2, 2024 revealed that Resident #65 was involved in a physical altercation with a male peer in which Resident #65 punched Resident #66 in the face. The facility follow-up investigation report dated June 2, 2024 revealed that that the facility concluded that the allegations of abuse were inconclusive due to not getting a complete history from the individuals involved and witnesses could not corroborate the alleged event. An interview was conducted on July 2, 2026 at 8:17 a.m. with CNA (Staff #6) who stated that she remembered Resident #66 who liked to keep to himself and had a very hard time communicating with others. Staff #6 stated that he would at times get frustrated with staff or other residents if they could not understand him. An interview was conducted on July 2, 2026 at 9:23 a.m. with CNA (Staff #30) who stated that he remembered Resident #65 as being very aggressive especially when he got angry. Staff #30 stated that he was never physically aggressive with staff but they did have to watch him to make sure he did not get angry at other residents as he was known to get into altercations with residents. An interview was conducted on July 2, 2026 at 10:11 a.m., via telephone, with Hospitality Aid (Staff # 23) who stated that she was watching over the smokers and witnessed Resident #66 go over to Resident #65 yelling at him with his finger pointing at Resident #65. Staff #23 stated that she saw Resident #65 punch Resident #66 in the jaw and they started fighting. Staff #23 stated that they separated the residents and assessed Resident #66 but did not see any injuries. Regarding Resident #76, #77, and #19:-Resident #76, the alleged victim, was admitted on [DATE] with diagnoses that included bipolar disorder, neuromuscular dysfunction of bladder, major depressive disorder, post traumatic stress disorder (PTSD), and suicidal ideations.A care plan initiated on February 19, 2024 revealed that Resident #76 had a behavior problem related to psychological diagnoses monitoring for verbal aggression, panic attacks/terrors, the inability to sleep, and refusal of cares. Interventions included administering medications as ordered and intervening as necessary to protect the rights and safety of others. An annual MDS assessment dated [DATE] revealed a BIMS score of 15 indicating cognition is completely intact. The MDS further documented verbal behaviors and other behaviors not directed at others significantly interfering with the resident's participation in activities or social interactions. A summery for providers note dated July 19, 2024 documented a change of condition marked as other. Further review of the note provided no description of the incident but indicated that no injuries were noted, no pain, and no signs of distress. The note revealed that the primary care provider was contacted with recommendations of no new orders and to continue monitoring. A health status note dated July 20, 2024 documented that Resident #76 was on change of condition for status post physical altercation received. The health status note revealed that Resident #76 received no injuries and did not complain of pain.-Resident #77, the alleged perpetrator and victim, was admitted on [DATE] with diagnoses of dehydration and Schizoaffective disorder.An admission MDS assessment dated [DATE] revealed a BIMS score of 8 indicating moderate cognitive impairment. The admission MDS documented that Resident #77 exhibited delusions and other behavior symptoms not directed at others. A health status note dated July 19, 2024 documented that the writer was summoned to dining room by staff reporting that Resident #77 punched Resident #76 in the arm.A change of condition evaluation form dated July 19, 2024 documented that Resident #77 was involved in physical aggression on Resident #76 punching her in the arm.A health status note dated July 20, 2024 revealed that Resident #77 was on change of condition for physical aggression as the aggressor. The note revealed the resident was compliant with medications and no current behaviors.A care plan initiated on July 22, 2024 revealed that Resident #77 had behavior problems related to psychological diagnoses. The care plan documented that Resident #77 flicks his nipples in public and places himself on the floor crawling around. Interventions included anticipating the needs of the resident and intervening as necessary to protect the rights and safety of others.-Resident #19, the alleged perpetrator, was re-admitted on [DATE] with diagnoses of adjustment disorder with depressed mood, unspecified dementia with other behavioral disturbances. An admission MDS dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS assessment documented that the resident exhibited verbal behaviors which interferes with resident's participation in activities or social interactions. The assessment revealed that current behaviors are worse compared to previous assessments.A health status note dated July 5, 2024 revealed that Resident #19 was observed visiting with other residents in the common area when Resident #19 became upset with roommate and became verbally aggressive turning aggression towards staff.A behavior note dated July 11, 2024 revealed the writer witness Resident #19 be verbally aggressive with another resident and was redirected immediately. A Change of condition note dated July 19, 2024 revealed that Resident #19 was involved in a resident to resident altercation. The change of condition note documented that Resident #19 was the aggressor and pushed Resident #77. The note revealed that Resident #19 stated that she was defending her friend (Resident #76) because she is wheelchair bound and unable to defend herself.A change of condition evaluation form dated July 19, 2024 documented that Resident #19 was involved in physical aggression as the aggressor on Resident #77.A follow-up investigation report submitted July 25, 2024 revealed that on July 19, 2024 at approximately 5:10 p.m. Resident #76 was was sitting in the dining room when Resident #77 started 'flicking his own nipples outside of the dining room. The report revealed that Resident #76 went out and told Resident #77 to 'knock it off'. The report documented that Resident #77 followed Resident #76 back into the dining room calling her vulgar names and hit Resident #76 on the right arm. The report documented that as staff were separating the residents, Resident #19 came over and pushed Resident #77 away from Resident #76. The investigation report verified the incident based on Resident #76's reporting of the incident. An interview was conducted on July 2, 2026 at 8:17 a.m. with CNA (Staff #6) who stated that she remembered the incident and had to separate all the residents from each other. Staff #6 said she did not witness the initial altercation however she remembered the incident because after the incident took place they had to change staffing in the dining room to have one staff member have eyes on the residents while the other staff members prepare for the meal. Staff #6 stated that prior to the incident all staff would be busy getting residents and prepping food so there were no real eyes on the residents during this time which she indicated why it escalated because there were no eyes on the residents prior to the actual altercation.Regarding Resident #22 and Resident #6-Resident #22, the alleged victim, was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), major depressive disorder, and unspecified dementia without behavioral disturbances.A care plan revised on February 5, 2026 revealed that the Resident had behavior problems related to psychological diagnoses, exhibiting non-compliance with care plan, self-isolation, false accusations, and exit seeking. Interventions included anticipating Resident's needs and intervening as necessary to protect the rights and safety of others.A quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. The quarterly MDS revealed behaviors including rejection of cares and wandering. A struck out health status note dated June 27, 2026 at 2:11 p.m. from Licensed Practical Nurse (LPN/Staff #32) revealed that Resident #22 was found with Resident #6 standing over him. The note revealed that Resident #22 stated that Resident #9 walked up to him and began hitting him. The note also documented that the residents were found by staff hitting each other and Resident #22 was requesting Resident #6 to be moved from his room. The health status note revealed that the strike out reason listed was correction on June 27, 2026 at 2:13 p.m.A late entry health status note dated June 27, 2026 at 2:13 p.m. written by Staff #32 revealed that Resident #22 was present in his room while his roommate Resident #6 was standing in his room yelling, screaming and cursing at another CNA calling them names threatening to hit them. The health status note revealed that residents were separated and placed on 1:1 until Resident #6 was moved.A Change of Condition Evaluation form dated June 27, 2026 at 5:26 p.m. conducted by Staff #32, revealed that Resident #22 had received verbal aggression from Resident #6. The change of condition evaluation form revealed no new skin conditions to Resident #22. A health status note dated June 28, 2026 from staff #32 revealed the patient on change of condition for receiving physical aggression from Resident #6. The note revealed all vitals were in normal range and patient had no complaints of pain or discomfort. An electronic MAR note dated June 28, 2026 at 9:22 p.m. documented change of condition for receiving physical aggression. The MAR note revealed that the provider and responsible party were notified. The MAR note documented that the Receiver of physical aggression (Resident #22) is to be monitored every shift for 3 days. An interview was conducted on June 29, 2026 at 9:34 a.m. with Resident #22 who stated that on Saturday June 27, 2026 his roommate at the time Resident #6 came over to him and started hitting him in the bed. Resident #22 said they he fought back to protect himself until staff came in and separated us. Resident #22 stated that he bruised his left hand. They moved Resident #6 to another room and he stated he feels safe now. An observation of Resident #22 was conducted at 9:34 a.m. revealing a large bruise on Resident #22's left hand covered with a bandage reading '6/28' and initials. Notification was given to the Administrator (Staff #43) on June 29, 2026 at 10:54 a.m. advising the administrator the report of resident to resident altercation made by Resident #22. A Nursing note dated June 29, 2026 at 11:00 a.m. revealed skin check was completed on Resident #22 indicating a skin tear and discoloration on the left hand. -Resident #6, the alleged perpetrator, was admitted on [DATE] with diagnoses that included anoxic brain damage, communicating hydrocephalus, PTSD, major depressive disorder, unspecified dementia, and unspecified mood disorder. A care plan initiated on May 18, 2026 revealed that Resident #6 had a behavior problem related to psychological diagnosis monitoring for delusions, inability to sleep, labile moods, restlessness, and visual hallucinations exhibiting physical aggression with staff, verbally aggressive using vulgar language towards staff. The care plan documented that on May 15, 2026 Resident #6 was the initiator of verbal aggression and was placed on a 1:1 with no indication on time frame or indication of conclusion date.An admission MDS assessment dated [DATE] revealed a BIMS score of 1 indicating severe cognitive impairment. The MDS assessment documented that resident exhibited physical behaviors and other behaviors which significantly interferes with the resident's care and puts others at risk of physical injury. The MDS did not indicate the resident exhibiting verbal behaviors. The assessment documented that Resident #6 significantly intrudes on the privacy or activity of others. A behavior note dated June 22, 2026 at 1:00 p.m. revealed Resident #6 observed crying intermittently appearing visibly distressed. The behavior note documented that resident displayed rapid mood changes shifting from tearful to angry. The note revealed resident angrily paced around the room and unit repeatedly stating he wanted to leave, demonstrating exit-seeking behavior. Resident #6 remained agitated with the staff unable to redirect. A health status note dated June 22, 2026 at 4:14 p.m. revealed that 911 was called due to the inability for staff to calm and redirect Resident #6. The health status note revealed the police were not willing to take the resident despite the staffs wishes. An order dated June 22, 2026 revealed a change of condition for physical aggression with provider and responsible party notified. The order revealed monitoring of the resident every shift for physical aggression for three days with end date of June 26, 2026. An electronic MAR note dated June 24, 2026 revealed that during administration of Ativan resident was observed sitting in bed ripping his brief mumbling to self while punching the bed covers. An electronic MAR note dated June 25, 2026 revealed patient was awake, crying, removing brief and showing aggression towards staff. An electronic MAR note dated June 25, 2026 that resident attempted to hit CNA during one instance of agitation. A Physician Assistant (PA) Note dated June 26, 2026 revealed that staff reported to the PA ongoing episodes of physical aggression. The PA note documented that these episodes of physical aggression seem to be triggered in the afternoon. The PA note recommended a gradual dose reduction of quetiapine. to 25 mg by mouth twice daily. The PA note documented that staff are to monitor closely for behavioral changes, increased agitation, or worsening aggression during the step reduction. A draft note dated June 27, 2026 at 1:44 p.m. by Staff #32 revealed resident #6 was witnessed standing over his roommate Resident #22 hitting him. Residents were separated and Resident #6 was placed on 1:1. The draft note was observed in the medical record on June 29, 2026 at 10:00 a.m. A late entry health status note dated June 27, 2026 at 1:44 p.m. by staff #32 revealed Resident #6 standing in his own room yelling, screaming and cursing at CNA threatening to hit them while Resident #22 was present. This note was observed in the medical record on June 30, 2026 at 8:30 a.m. replacing the previous draft note. A physician's order dated June 27, 2026 by the PA revealed a change of condition for physical aggression. The order revealed to monitor resident for physical aggression for three days. This order was discontinued on June 29, 2026 at 11:12 a.m., by the medical director, after notification by surveyor of the allegations of abuse. The physician order revealed the reason for discontinuing order had incorrect indication. A Change of Condition Note dated June 29, 2026 at 1:47 p.m. by Staff #43 revealed resident involved in verbal aggression with staff while in the room with his roommate. A physician's order dated June 29, 2026 revealed change of condition for verbal aggression provider notified and family notified to be monitored for 3 days. A physician's order dated June 29, 2026 revealed change of condition order for 3 days to monitor for physical aggression monitoring resident every shift until July 2, 2026. A Follow-up Investigation Report signed July 2, 2026 revealed the facility concluded that the allegation was inconclusive even though the facility acknowledged witnessed contact was made by the residents as Resident #6 was attempting to climb into Resident #22's bed resulting in skin tear of Resident #22.An interview was conducted with Licensed Practical Nurse (LPN/Staff #32) on July 1, 2026 at 10:19 a.m. who stated that she did not witness the incident but was called to the incident, when she arrived there were three CNAs trying to separate both Resident #22 and Resident #6. Staff #32 stated she heard a CNA calling for nurse on the walkie when she got to the room the patients were separated. Staff # 32 stated that she struck out the initial progress reports regarding the physical altercation because she was told not to document what was reported to her by staff just what she observed. Staff #37 stated that the CNAs reported that the Residents were together fighting when they arrived on scene. Staff #37 stated that while she was talking to Resident #22 she noticed there was blood and the hand was assessed and bandaged. Staff #32 stated that resident to resident abuse is when a resident harms another resident. An interview was conducted with CNA (Staff # 50) on July 2, 2026 at 8:51 a.m. who stated that Resident #6 can get physically aggressive with staff especially if the Resident does not want to do the task. Staff #50 stated on June 27, 2026 she was on the patio when she heard the call from another CNA, Staff # 50 stated when she went in there Resident #6 was over Resident #22 while Resident #22 was on the ground in a sitting position next to the bed. Staff #50 stated that they moved Resident #6 to the foot of the bed and helped Resident #22 up from the ground that is when she noticed the blood on Resident #22's hand. Staff #6 stated that the nurses came in and helped bandage Resident #22. An interview was conducted with CNA (Staff # 30) on July 2, 2026 at 9:23 a.m. who stated that he arrived after the other CNAs had separated the residents and Resident #22 was back in his bed being tended to by the nurses. Staff #30 stated he took Resident #6 out of the room and stayed with Resident #6 as his 1:1 for the rest of the shift. Staff #30 stated that when resident to resident abuse occurs they first try and deescalate the situation, then provide care for any injuries, and then notify his superior of the incident right away within 2 hours. An interview was conducted with Assistant Director of Nursing (ADON/Staff #56) on July 2, 2026 at 12:12 p.m. who stated that she was the on call nurse on June 27, 2026 when Staff #32 had contacted her regarding an incident with Resident #22 and Resident #6. Staff #56 stated that Resident #6 was over the top of Resident #22 in his side of the bed they think because Resident #6 was trying to get into the bed. She stated that Residents were separated and the Director of Nursing decided to place Resident #6 on 1:1 care as he had shown increase aggression over the past two weeks. Staff #56 stated that physicians have been working on Resident #6's medications but he still shows signs of physical aggression in the afternoons. Staff #56 stated she called the Director of Nursing who had conversations with the Administrator afterwards. Staff #56 stated that family on both sides were called immediately but the police were not called.An interview was conducted with the Director of Nursing (DON/Staff #40) on July 2, 2026 at 1:12 p.m. stated that she was called on Saturday June 27, 2026 with notification that Resident #6 was trying to get into Resident #22's bed and that Resident #6 was getting physically and verbally aggressive with the staff while be separated off of Resident #22. Staff #40 stated that she instructed Staff #56 to place Resident #6 on 1:1 for physical aggression over the weekend. Staff #40 stated that physical abuse can be hitting grabbing slapping other residents and if there is an allegation or a concern that resident to resident happened then we would initiate the notification process followed by the investigation process. An interview was conducted with Administrator (Staff # 43) on July 2, 2026 at 1:37 p.m. stated that he was notified that Resident #6 was trying to get into Resident 22's bed and staff had to separate them. Staff #43 stated that he did not feel this was abuse because Resident #22 just wanted him out of the room. Staff #43 stated that they removed Resident #6 from the room and placed him in his own room with a 1:1 sitter as added precaution because of Resident #43's history with verbal & physical aggression. Staff #43 stated that he did not feel this was resident to resident abuse because there was not willful intent, even though Resident #6 was trying to get into Resident #22's bed.A Policy and Procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Revised April 2021, revealed that residents have the right to be free from abuse including freedom from verbal and physical abuse. The policy revealed that the objective of the policy is to protect residents from abuse or misappropriation of property by anyone including other residents.

Based on clinical record review, resident and staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#27) received pain medication per physician ordered parameters. The deficient practice placed the resident at risk for receiving medication outside physician-prescribed parameters, which could result in unnecessary medication exposure and adverse drug reactions. The universe was 18 and the sample size was 6.Findings include:Resident #27 was admitted on [DATE], with diagnoses including rheumatoid arthritis, extrapyramidal and movement disorder, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility.A physician order dated June 18, 2025, revealed an order for Sulindac Tablet 200 mg, one tablet by mouth two times a day at 0800 and 2000 for pain related to rheumatoid arthritis. The order specified administration for pain rated 1-10. Additional physician orders included routine pain monitoring utilizing a 0-10 pain scale every shift beginning November 1, 2023, and post-pain level monitoring three times daily beginning February 28, 2025. A black box warning was associated with the order, stating cardiovascular and thrombotic risks were associated with this medication.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment further revealed the resident experienced pain, received a pain medication regimen within the previous five days, received non-pharmacological pain interventions, reported occasional pain that rarely affected sleep, did not interfere with therapy, occasionally interfered with day-to-day activities, and had a documented pain intensity score of 2.Clinical record review of the June 2026 Medication Administration Record (MAR) revealed Sulindac was administered at 0800 and 2000 outside of parameters for 27 out of the 30 days in the month of June 2026. Review of corresponding pain monitoring documentation revealed the resident's pain score was documented as 0 (no pain) for the majority of June 2026, with documented pain scores of 5, 8, and 3 only on June 25, June 29, and June 30, respectively. Further review revealed Sulindac was administered only five times within the physician-ordered pain parameter of 1-10 during the previous 60 days between May 1, 2026 and June 30, 2026, while the medication continued to be administered despite documented pain scores of 0 on numerous occasions.An interview was conducted with Resident #27 on July 1, 2026, at 9:07 AM. The resident stated she experienced pain in both hands, particularly her left hand, reported difficulty opening bags and pulling down her pants due to hand pain, and stated the bilateral hand splints had been helpful.An interview was conducted on July 1, 2026, at 2:29 PM with Certified Nursing Assistant (CNA/Staff #4) Staff #4 stated she generally became aware of the residents' pain when the resident requested pain medications or tylenol for her hand pain. She further stated that she reports these requests to the nurse and the nurse should follow up with the resident's needs.An interview was conducted on July 1, 2026, at 2:35 PM with Registered Nurse (RN/Staff #19) Staff #19 stated nurses rely on physician orders for resident treatments and medications. During review of the resident's electronic health record (EHR) and medication orders, he confirmed the Sulindac order specified administration for pain rated 1-10. He further stated that based on the way the order was written, he would want to call the physician and ask whether the medication should be administered when the resident's pain score was documented as 0. He stated he administered the Sulindac this morning and that the medication administration record shows Sulindac was administered outside of parameters in the month of June. He stated the risks of administration outside the physician's ordered parameters could expose the resident to adverse effects, including cardiovascular and thrombotic risks associated with non-steroidal anti-inflammatory medications.An interview was conducted on July 1, 2026, at 3:09 PM with the Director of Nursing (DON), Staff #13. The DON confirmed the resident had an active physician order for Sulindac to be administered for pain rated 1-10 and acknowledged the medication had been administered despite documented pain scores of 0. The DON stated a pain score of 0 indicates the resident has no pain and confirmed the medication should not have been administered outside the physician's ordered parameters. The DON further stated administering medication contrary to the physician's order could result in adverse drug reactions and constituted a failure to follow physician orders.A progress note by a Family Nurse Practitioner (FNP) dated July 1, 2026 at 6:55 PM, revealed, A pain scale was entered incorrectly for scheduled medication for pain (Sulindac). The pain scale was not needed and will not be needed going forward. The previous order for Sulindac was modified to Sulindac Tablet 200 MG Give 1 tablet by mouth two times a day for Pain. On July 2, 2026, the facility provided MedlinePlus drug information on Sulindac. The information revealed People who take nonsteroidal anti-inflammatory medications (NSAIDs) (other than aspirin) such as sulindac may have a higher risk of having a heart attack or a stroke than people who do not take these medications. These events may happen without warning and may cause death. This risk may be higher for people who take NSAIDs for a long time. Do not take an NSAID such as sulindac if you have recently had a heart attack, unless directed to do so by your doctor. Tell your doctor if you or anyone in your family has or has ever had heart disease, a heart attack, or a stroke, if you smoke, and if you have or have ever had high cholesterol, high blood pressure, or diabetes. Get emergency medical help right away if you experience any of the following symptoms: chest pain, shortness of breath, weakness in one part or side of the body, or slurred speech. If you will be undergoing a coronary artery bypass graft (CABG; a type of heart surgery), you should not take sulindac right before or right after the surgery. NSAIDs such as sulindac may cause ulcers, bleeding, or holes in the stomach or intestine. These problems may develop at any time during treatment, may happen without warning symptoms, and may cause death. The risk may be higher for people who take NSAIDs for a long time, are older in age, have poor health, or drink large amounts of alcohol while you are taking sulindac.On July 2, 2026, the facility provided documentation and in-service records of staff education on medication administration and parameters. The subjects included Proper Medication Administration, dated July 1, 2026 for 15 minutes and Reviewing the 'Order Line Listing' daily and clarifying orders if needed with the provider(s), dated July 1, 2026 for 30 minutes.Review of the facility policy titled Pain Assessment and Management, revised October 2022, stated the purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.Recognizing pain3. Review the medication administration record to determine how often the individual requests and receives PRN pain medication, and to what extent the administered medications relieve the resident's pain.Implementing Pain Management Strategies5. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications.

Based on observations, staff interviews, and facility policy, the facility failed to ensure multiple food items were stored, labeled, and dated in accordance with professional standards, and failed to wash, rinse, and sanitize dishware in accordance with the manufacturer's instructions. The deficient practice places residents at risk for complications from foodborne illness. The universe was 79. Findings include:An initial observation of the kitchen was conducted on June 29, 2026, at 8:11 A.M with the Dietary Manager (Staff #57). Observations were made of the large walk-in refrigerator, freezer, and dry storage area revealing the following deficiencies: -2 pound bag of mixed vegetables open and exposed to air with no open or use-by date-One 5 pound bag of corn open and exposed to air with no open or use-by date-One 6 pound bag of corn open and exposed to air with no open or use-by date-Approximately 4 pounds of [NAME] Dean sausage patties open and exposed to air with no open or use-by date-One package of cheese slices with no open or use-by date-One half full 30 ounce cup of McDonald's tea observed in the freezer. The dietary manager confirmed that it belonged to an employee.-Approximately 2 pounds of smoked ham with no open or use-by date-Approximately 1/2 pounds of sliced turkey with no open or use-by date-One open package of turkey slices with no open or use-by date-One expired Branched-Chain Amino Acids (BCAA) recovery protein supplement. The dietary manager confirmed that it belonged to an employee.-Half-and-half creamers stored with cucumbers and zucchini in the same box-Approximately 2 pounds of romaine lettuce open and exposed to air with an expiration date of June 25, 2026-One orange stored on the floor-One molded zucchini with fuzzy white spots-One food container observed on the floor-Approximately 15 green bell peppers with black discoloration and signs of spoilage-18 salsa and dessert containers with no lids open and exposed to air- One box of tomatoes with no use-by date- One box of onions with no use-by date-one unsealed package of bacon opened and exposed to air -Five gallons of milk with an expiration date of June 25, 2026-Sediment and dirt observed around refrigerator fan units-One package of hamburger buns with no open or use-by date-Debris, dust, and dirt observed on the ceiling of the kitchen-Sugar spilled on the floor in the dry storage area -One opened 50 pound bag of sugar exposed to air- One opened 50 pound bag of brown sugar exposed to air- One opened bag of oats exposed to air with no use-by date-Three opened bags of cornbread mix open and exposed to air with no use-by date-Two containers of rice with rice spillage, dust and debris on the handles, and rice debris on the floor-One 3 pound bag of macaroni open with no use-by date-Air filters and light fixtures with visible gray dust and debris on them-Ice scoop holder containing liquid and sediment at the bottom-Brown sediment and buildup observed around the interior and exterior of the ice machine- Two dead cockroaches were observed, one in the dishwasher drain and the other underneath the stove.An interview was conducted on June 29, 2026 at 8:11 A.M. with the Dietary Director (Staff #57). He stated that all food items are required to be labeled with both the date opened and the use-by date upon opening. He stated that food maintained beyond its use-by date or left uncovered could result in contamination. Staff #57 stated he provides in-service training to dietary staff regarding proper food labeling, dating, storage, first-in, first-out (FIFO) practices, and sanitation, and stated that kitchen staff possess food handler's cards and are expected to follow these procedures. A second observation of the kitchen was conducted on June 30, 2026, at 8:53 A.M., which revealed the following deficiencies:-Approximately 30 pieces of garlic toast were stored open to air in a box with the bag untied.-An employee's Coca-Cola bottle was observed stored in the kitchen- A package of turkey slices was observed open and exposed to the air.-Spillage, debris, and sediment were observed along the edges of the refrigerator.-Dust and sediment were observed above the stove, creating a risk of contamination to food and a potential fire hazard.-Grime and debris were observed on the floor beneath kitchen tables-One container of cereal had no expiration date.-Dirt and debris were observed in the corners of the kitchen counters, and dirt, hair, and food debris were observed in a floor drain.An observation was conducted on June 30, 2026, at 8:53 A.M of the low-temperature chemical dishwasher which revealed a final rinse temperature of 135 degrees Fahrenheit. A sanitizer test strip (litmus test) indicated no detectable sanitizing chemical was being dispensed while the dishwasher was operating. At the time of the observation, approximately 32 bowls, 16 plates, 12 cups, and 7 trays had been washed through the dishwasher without detectable sanitizer.A poster containing the manufacturer's operating instructions for the low-temperature dishwasher, produced by [NAME] Chemical, was observed posted on the wall above the dishwasher. The posted instructions directed staff to check chemical levels to make sure products are available. Refill or replace as necessary and to check low temp sanitizer level minimum once per day. Range = 50-100 PPM. After the observation, an interview was conducted with staff #61. He stated he did not verify if sanitizer is being dispensed today, but sometimes he does. He further stated that the risk of not verifying sanitizer concentration was residents becoming sick.An observation was conducted on June 30, 2026 at 9:15 A.M. Staff #57 tested three quaternary ammonium (QAC) sanitizer buckets used for food preparation surfaces. All three sanitizer buckets measured 50 parts per million (ppm). An interview was conducted on July 2, 2026, at 9:39 A.M. with the Dietary Director (Staff #57). Staff #57 stated he has served as the Dietary Director, Housekeeping Director, and Laundry Director for the past three years. He stated he has over 20 years of dietary experience and is responsible for training staff on food storage, labeling, date marking, and proper washing procedures. He stated he conducts in-service training and acknowledged that staff had been under the impression that placing only one date on opened food items was sufficient. He stated he is responsible for providing the training and following up with staff to ensure food items are properly labeled with both open and use-by dates. He stated the Administrator also conducts periodic kitchen visits and has previously identified food items that were opened without use-by dates. He stated it is his responsibility to verify food products are properly labeled and dated and that he performs a walkthrough of the kitchen each morning. He further stated he expects cooks to assist in identifying improperly labeled food items and to ensure dietary aides and activity staff properly date any food items they access. He stated all dietary staff possess food handler cards. He stated that he assists with receiving food deliveries, oversees FIFO rotation, and guides dietary aides and cooks during storage. He stated he did not look but should have at the numerous unlabeled and improperly stored food items identified during the survey. He stated kitchen vents are typically cleaned every Wednesday to reduce the potential for fire and cross-contamination from accumulated debris. He stated staff are now responsible for cleaning the vents weekly. He stated the risks of not properly storing and rotating food is foodborne illness.An interview was conducted on July 2, 2026, at 12:00 P.M. with the Maintenance Director (Staff #106). Staff#106 stated he has worked at the facility for almost four years. He further stated the facility replaces HVAC filters approximately every three months and changes them sooner if they become excessively dirty. He stated maintenance changes the water filters for the ice machine and performs routine oil cleaning on the ice machine. He stated the hood filters are cleaned by running them through the dishwasher monthly, while the hood exhaust system receives professional servicing every six months. He further stated kitchen staff are responsible for cleaning the hood and vents between scheduled maintenance, including wiping down the exterior surfaces. He stated he has not personally cleaned the kitchen hood, but maintenance recently replaced the silicone around the hood. Staff #106 stated the dishwasher machine is leased and he was unsure whether the vendor performs routine inspections. He further stated maintenance does not routinely inspect the refrigerators beyond verifying that the units are maintaining appropriate temperatures.An interview was conducted on July 02, 2026 at 2:11 P.M. with the Administrator (staff #43). He stated it is the responsibility of the kitchen staff to inspect the food and that per the facility's policy, food must be dated. A review of the facility policy titled Food Receiving and Storage with a revision date of November 2022 states foods shall be received and stored in a manner that complies with safe food handling practices. Dry foods that are stored in bins are removed from original packaging, labeled and dated. Such foods are rotated using a first in - first out system. Food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents. All foods stored in the refrigerator or freezer are covered, labeled and dated. Refrigerated foods are labeled, dated and monitored so they are used following appropriate state/food guidelines.

Based on dining observations and interviews, the facility failed to have sufficient space to accommodate all dining activities. The deficient practice resulted in residents not having a dining area that accommodates residents' physical needs. The census was 79.Findings include:An observation was conducted on June 29, 2026 between 11:52 A.M. and 12:25 P.M. The facility had one dining room for residents residing in the long-term care unit. The dining area had one small area to accommodate six residents who needed assistance with their eating. Within this small space, there was one large dining table to accommodate the six residents sitting across from each other and one on each end. The table sat approximately 2 feet from the kitchen counter where staff picked up resident meals. Within this space, there were three large metal meal carts, two blue coolers on stands, and one coffee stand. Observed staff picking up trays from the kitchen counter, bumping against the residents' wheelchairs to get to the other dining section area. These residents were also observed to be moved to accommodate other residents coming to their dining tables. In the other area of the dining room, observations of multiple residents were observed with limited room to accommodate leg rests, bariatric wheelchairs, and electric wheelchairs. Many of these residents were unable to sit up close to their tables due to their leg rest budding against the other residents leg rest. There was one resident observed directly beneath the speakers and television which was at a very loud level. Resident #49 was observed leaning to his left side. CNA was observed repositioning this resident. At 11:56 A.M., 20 residents were present in the dining room with approximately five to six staff members assisting. Resident #50 was observed in a large electric wheelchair where he had to sit with his back against the wall of the dining room, having to sit sideways to eat his meal. Due to the limited space, the resident spilled his juice on his pants and shirt. He was observed having difficulty trying to reach over to his plate to feed himself. Additional residents continued entering the dining room. Residents were seated three to four per square table. At 11:59 A.M., 33 residents were observed seated in the dining room. The dining room was observed to have limited space for residents being brought into the dining room for lunch. At 12:12 P.M., 37 residents were observed eating lunch in the main dining room. At 12:25 p.m., half of the residents had received their meal while others were still waiting to be served.An interview was conducted on July 1, 2026 at 10:00 A.M. with resident #50. He stated that he dislikes eating in the dining room due to the noise and limited space. He further stated there were too many people in the dining room, that it's so loud where you can't hear your neighbors speak, and it's too crowded for his wheelchair. He stated sometimes he has to be moved out of the way by staff members to make room for more people. He also stated that residents usually eat outside in the open courtyard where pigeons gather and fly around while eating their meals. An interview was conducted on July 1, 2026 at 8:24 A.M. with Certified Nursing Assistant (CNA/Staff #7). She stated there is not enough room for residents in the dining room and it gets really crowded so sometimes they use the patio as an overflow to accommodate the residents. An observation was conducted on July 2, 2026, at 7:58 A.M. Residents were observed eating breakfast on the outdoor patio due to limited indoor dining space. A resident was observed seated at a cement patio table while receiving breakfast assistance from the Social Services Director (Staff #91). Bird droppings were observed around the perimeter of the table and smeared on the tabletop directly in front of the resident while the resident was eating. Staff stated she had wiped the table with a disinfectant wipe but had not noticed the bird droppings on the sides of the table.An interview was conducted on July 2, 2026, at 8:00 A.M. with the Assistant Director of Nursing (ADON/Staff #56). She stated the patio is cleaned every Friday and acknowledged pigeons have been an ongoing problem because residents feed them. She further stated bird droppings frequently fall on staff clothing.An interview was conducted on July 2, 2026, at 9:39 A.M. with the Dietary, Housekeeping, and Laundry Director (Staff #57). Staff #57 stated he has been discussing two meal services because it is pretty tight in the dining hall. He further stated the facility had recently admitted more residents, and that the activities staff had also discussed implementing two meal services. He stated he did not know the maximum dining room capacity or applicable safety code occupancy.A request was placed on July 2, 2026 at 10:21 A.M. for the facility's policy on accommodations for dining. An interview was conducted with the resident #64 on July 2, 2026 at approximately 10:30 A.M., She stated residents are routinely required to eat outside and reported birds frequently fly overhead, dropping feathers and feces on residents and their meal trays. The resident stated, I hate eating outside. We are only eating inside because you guys are here now. She further stated that she hurries while eating in the dining hall to get out of there because it's too much for me. Another resident, resident #3, confirmed the concern, stating, Half the time you don't know if it's raining or birds are pooping on you. They try to steal your food when we are eating. Both residents stated they usually eat meals on the outdoor patio.An interview was conducted on July 2, 2026 at 11:26 A.M. with the administrator (Staff #43). He stated that the facility does not have an official policy for accommodations for dining. A request was placed on July 2, 2026 at 2:21 P.M for the state code for number of residents allowed in the dining hall, and the standard occupancy for dining hall as issued by a government or code organization. The administrator stated that the facility has the facility's minimum egress requirements under the 1997 Uniform Building Code, which revealed only the occupant load factor of 15 square feet per person, which converts to 1.39 square meters per person. He further stated that he did not see a maximum occupancy sign in the dining hall. Review of the facility policy titled Resident Rights, revised February 2021, stated that Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to:B. be treated with respect, kindness, and dignity

Based on observations, staff interviews, clinical record review, facility documentation, and policies and procedures, the facility failed to ensure medical records remained confidential for one resident (#7). The deficient practice could result in unauthorized visibility to residents' personal and medical records that compromise residents' right to privacy and confidentiality. The universe was 17, and the sample was 1.Findings include:An observation was conducted on July 01, 2026, at 11:54 AM of Licensed Practical Nurse (LPN/staff #28). Staff #28 completed medication administration for resident #7 and returned to the medication cart, located in the patio walkway outside the resident's room. At 11:55 AM, staff #28 locked the medication cart and walked away to return medication to the medication room, leaving the laptop powered on and unlocked. The unattended laptop screen displayed resident #7's name, date of birth , and medications. While the laptop remained unattended and unlocked, surveyors and facility staff walked through the patio walkway and around the location of the medication cart. At 11:56 AM, Staff #28 returned to the medication cart while speaking on a cellphone and resumed use of the laptop.An interview was conducted with Staff #28 on July 01, 2026 at 11:57 AM. Staff #28 was asked to identify the risks associated with leaving an unlocked laptop displaying resident information unattended. Staff #28 stated the risk was to HIPAA (Health Insurance Portability and Accountability Act) and the importance of maintaining HIPAA is to protect residents. Staff #28 stated resident #7's information had been visibly displayed while the laptop was unattended.An interview was conducted on July 02, 2026, with the Director of Nursing (DON/staff #40). Staff #40 stated the facility's expectations for protecting residents' confidentiality are to abide by HIPAA. She further stated staff are expected to protect resident confidentiality by locking or fully closing laptops and turning over paperwork containing resident information whenever leaving a workstation unattended. Staff #40 stated leaving resident information visible on an unlocked laptop does not meet facility expectations and further stated the risk of not maintaining HIPAA compliance is that the facility is giving people access to protected information, which is a violation of state and federal law.Review of the facility policy titled Resident Rights, with a revision date of February 2021, states employees shall treat all residents with kindness, respect, and dignity.4. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer.Review of the facility policy titled HIPAA Policy & Procedure, with a revision date of February 2026, revealed a policy statement to protect patient privacy and confidentiality and safeguard Protected Health Information (PHI) in all forms (verbal, written, electronic) and a procedure to:8. log out of EHR systems after use.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to implement their abuse policy involving an allegation of abuse with 3 of 15 residents (#6, #22, and #80). The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated. -Regarding Resident #80 Resident #80 was admitted on [DATE] with diagnoses that included unspecified mood disorder, suicidal ideations, anxiety disorder, and depression. A Nurses Note dated May 15, 2026 7:08 a.m. revealed that the writer was alerted by Resident #80 that she had been in a physical altercation with a Certified Nursing Assistant (CNA #12). The nurses note goes on to reveal that prior to this incident Resident #80 was resistant to having CNAs helping her with a shower. The note documents that Resident #80 came out yelling stating she was in a fight with the CNA. The note also documented that there were some visible scratches to her arms but refused treatment to said areas. The note revealed that the Director of Nursing and Nurse Practitioner were notified of the allegation. A follow up nurses note by the Director of Nursing (DON/Staff #40) dated May 15, 2026 at 7:09 a.m. revealed that Resident #80 reported that the scratches were self inflicted as she hit her arms on the bed while grabbing the CNA. A Change of Condition evaluation dated May 15, 2026 at 7:15 p.m. revealed that Resident #80 came out of the room yelling that she didn't want CNA #12 in her room because they got into a fight. The change of condition note revealed that Resident #80 said she slapped and choked CNA #12. Review of physician orders revealed no change of condition orders or monitoring orders regarding the allegations made on May 15, 2026. A Medicare 5-day Minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 14, indicating the resident is cognitively intact. The MDS assessment revealed that Resident #80 suffers from delusions, physical and verbal behavior, and rejection of care and wandering. A care plan dated May 18, 2026 revealed that Resident #80 had behavior problems related to primary diagnosis of mood disorder and other psychological diagnoses. The care plan revealed that resident # 80 exhibited impatience with staff and exhibits false allegations, physical aggressive towards staff, and harms self when upset. Interventions include administer medications as ordered, and anticipate and meet the Resident's needs. A physicians order dated May 18, 2026 for cares in pairs. Three days after the first initial allegation of abuse. A Social Service Note dated May 19, 2026 revealed that Resident #80 had made statements indicative of suicidal ideation and requested to leave the facility. The social services note revealed that the Crisis team was called out to meet with Resident #80, who told the Crisis team that she has been beaten up by CNA #12 in a fight. The social services note documented per facility protocol regarding the allegation initially reported on 5/14/2026, the identified CNA was removed from assignment with the resident pending reviewing and the resident was put on cares in pairs.Review of CNA Staff #12 Time Report sheet revealed that Staff #12 worked the following shifts; May 14, 2026 2:04 p.m.-10:12 p.m. May 17, 2026 2:02 p.m.-10:06 p.m.May 18, 2026 1:58 p.m.-10:03 p.m. Further review of the the Time Report Sheets revealed that Staff #12 was pulled from the schedule on administrative paid leave on May 19 and May 20, 2026. An interview was conducted with CNA (Staff #6) on July 2, 2026 at 8:17 a.m. who stated that she had worked a lot with Resident #80 and had described Resident #80 as having a lot of anxiety. Staff #6 stated she had a good bond with Resident #80 and would light up and be happy when they interreacted but Staff #6 stated that it quickly changed a few days before the Crisis when she reported the altercation with another CNA. Staff #6 stated she did not who it was and Resident # 80 would not tell Staff #6 who it was or what they did. Staff #6 stated that she made her nurses aware but Resident #80 was known for making false accusations so not sure what was investigated. An interview was conducted with CNA (Staff #30) on July 2, 2026 at 9:23 a.m. who stated that he remembered Resident #80 because she was always sexually inappropriate with the men and it was hard to redirect her. Staff #30 stated that he was not there at the time but he heard the next day May 15, 2026 that Resident #80 had alleged abuse against Staff #12 and had bruises on her arms. An interview was conducted with Social Services Director (Staff # 91) on July 2, 2026 at 12:21 p.m. stated that Resident #80 was very combative with all the staff. Staff # 91 stated that she knew that Staff #12 had scratches on her from taking care of her. Staff #91 stated that she heard about the allegations made on May 15, 2026 but she stated that she was not given a name of who the CNA was until she made the second allegation on May 19, 2026. Staff #91 stated that is when they pulled her off the schedule. An interview was conducted with the Director of Nursing (DON/Staff #40) on July 2, 2026 at 1:12 p.m. stated that if there is an allegation staff to resident abuse notification would be made immediately to the abuse coordinator (Staff #43). Staff #40 stated that was notified by the agency nurse of the allegation that Resident #80 was involved in a fight with CNA #12. Staff #40 stated she conducted interview with Resident #80 and determined that Resident #80 was the only aggressor in the fight with Staff #12. Staff #40 did state that she reported to Staff #43 that same day of the allegations. Staff #40 stated that Staff #43 is responsible to report to the state agencies any allegations unless he is unavailable then Staff #40 state that it would be her responsibility. An interview was conducted with Administrator (Staff # 43) on July 2, 2026 at 1:37 p.m. stated that if there is an allegation of abuse then he reports to all reporting state agencies within two hours and then they conduct their investigation. Staff #43 stated that the allegation Resident #80 made of fighting CNA #12 was not considered reportable because during an interview of the resident Resident #80 stated she was the aggressor. Regarding Resident #22 and Resident #6:-Resident #22, the alleged victim, was admitted on [DATE] with diagnoses that included COPD, major depressive disorder, and unspecified dementia without behavioral disturbances.A care plan revised on February 5, 2026 revealed that the Resident has behavior problem related to psychological diagnoses, exhibiting non-compliance with care plan, self-isolation, false accusations, and exit seeking. Interventions include anticipating Resident's needs and intervening as necessary to protect the rights and safety of others.A quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. The quarterly MDS revealed behaviors including rejection of cares and wandering. A struck out health status note dated June 27, 2026 at 2:11 p.m. from Licensed Practical Nurse (LPN/Staff #32) revealed that Resident #22 was found with Resident #6 standing over him. The note revealed that Resident #22 stated that Resident #9 walked up to him and began hitting him. The note also documented that the residents were found by staff hitting each other and Resident #22 was requesting Resident #9 to be moved from his room. The health status note revealed that the strike out reason listed was correction on June 27, 2026 at 2:13 p.m.A late entry health status note dated June 27, 2026 at 2:13 p.m. written by Staff #32 revealed that Resident #22 was present in his room while his roommate Resident #6 was standing in his room yelling, screaming and cursing at another CNA calling them names threatening to hit them. The health status note revealed that residents were separated and placed on 1:1 until Resident #6 was moved.A Change of Condition Evaluation form dated June 27, 2026 at 5:26 p.m. conducted by Staff #32, revealed that Resident #22 had received verbal aggression from Resident #6. The change of condition evaluation form revealed no new skin conditions to Resident #22. A health status note dated June 28, 2026 from staff #32 revealed the patient on change of condition for receiving physical aggression from Resident #6. The note revealed all vitals were in normal range and patient had no complaints of pain or discomfort. An electronic MAR note dated June 28, 2026 at 9:22 p.m. documented change of condition for receiving physical aggression. The MAR note revealed that the provider and responsible party were notified. The MAR not documented that the Receiver of physical aggression (Resident #22) is to be monitored every shift for 3 days. An interview was conducted on June 29, 2026 at 9:34 a.m. with Resident #22 who stated that on Saturday June 27, 2026 his roommate at the time Resident #6 came over to him and started hitting him in the bed. Resident #22 said they he fought back to protect himself until staff came in and separated us. Resident #22 stated that he bruised his left hand. They moved Resident #6 to another room and he stated he feels safe now. An observation of Resident #22 was conducted at 9:34 a.m. revealing a large bruise on Resident #22's left hand covered with a bandage reading 6/28 and initials. Notification was given to the Administrator (Staff #43) on June 29, 2026 at 10:54 a.m. advising the administrator the report of resident to resident altercation made by Resident #22. A Nursing note dated June 29, 2026 at 11:00 a.m. revealed skin check was completed on Resident #22 indicating a skin tear and discoloration on the left hand. Resident #6, the alleged perpetrator, was admitted on [DATE] with diagnoses that included anoxic brain damage, communicating hydrocephalus, PTSD, major depressive disorder, unspecified dementia, and unspecified mood disorder. A care plan initiated on May 18, 2026 revealed that Resident #6 had a behavior problem related to psychological diagnosis monitoring for delusions, inability to sleep, labile moods, restlessness, and visual hallucinations exhibiting physical aggression with staff, verbally aggressive using vulgar language towards staff. The care plan documented that on May 15, 2026 Resident #6 was the initiator of verbal aggression and was placed on a 1:1 with no indication on time frame or indication of conclusion date.An admission MDS assessment dated [DATE] revealed a BIMS score of 1 indicating severe cognitive impairment. The MDS assessment documented that resident exhibited physical behaviors and other behaviors which significantly interferes with the resident's care and puts others at risk of physical injury. The MDS did not indicate the resident exhibiting verbal behaviors. The assessment documented that Resident #6 significantly intrudes on the privacy or activity of others. A behavior note dated June 22, 2026 at 1:00 p.m. revealed Resident #6 observed crying intermittently appearing visibly distressed. The behavior note documented that resident displayed rapid mood changes shifting from tearful to angry. The note revealed resident angrily paced around the room and unit repeatedly stating he wanted to leave, demonstrating exit-seeking behavior. Resident #6 remained agitated with the staff unable to redirect. A health status note dated June 22, 2026 at 4:14 p.m. revealed that 911 was called due to the inability for staff to calm and redirect Resident #6. The health status note revealed the police were not willing to take the resident despite the staffs wishes. An order dated June 22, 2026 revealed a change of condition for physical aggression with provider and responsible party notified. The order revealed monitoring of the resident every shift for physical aggression for three days with end date of June 26, 2026. An electronic MAR note dated June 24, 2026 revealed that during administration of Ativan resident was observed sitting in bed ripping his brief mumbling to self while punching the bed covers. An electronic MAR note dated June 25, 2026 revealed patient was awake, crying, removing brief and showing aggression towards staff. Another electronic MAR note dated June 25, 2026 that resident attempted to his CNA during one instance of agitation. A Physician Assistant (PA) Note dated June 26, 2026 revealed that staff reported to the PA ongoing episodes of physical aggression. The PA note documented that these episodes of physical aggression seem to be triggered in the afternoon. The PA note recommended a gradual dose reduction of quetiapine. to 25 mg by mouth twice daily. The PA note documented that staff are to monitor closely for behavioral changes, increased agitation, or worsening aggression during the step reduction. A draft note dated June 27, 2026 at 1:44 p.m. by Staff #32 revealed resident #6 was witnessed standing over his roommate Resident #22 hitting him. Residents were separated and Resident #6 was placed on 1:1. The draft note was observed in the medical record on June 29, 2026 at 10:00 a.m. A late entry health status note dated June 27, 2026 at 1:44 p.m. by staff #32 revealed Resident #6 standing in his own room yelling, screaming and cursing at CNA threatening to hit them while Resident #22 was present. This not was observed in the medical record on June 30, 2026 at 8:30 a.m. replacing the previous draft note. A physician's order dated June 27, 2026 by the PA revealed a change of condition for physical aggression. The order revealed to monitor resident for physical aggression for three days. This order was discontinued on June 29, 2026 at 11:12 a.m., by the medical director, after notification by surveyor of the allegations of abuse. The physician order revealed the reason for discontinuing order had incorrect indication. A Change of Condition Note dated June 29, 2026 at 1:47 p.m. by Staff #43 revealed resident involved in verbal aggression with staff while in the room with his roommate. A physician's order dated June 29, 2026 revealed change of condition for verbal aggression provider notified and family notified to be monitored for 3 days. A physician's order dated June 29, 2026 revealed change of condition order for 3 days to monitor for physical aggression monitoring resident every shift until July 2, 2026. A Follow-up Investigation Report signed July 2, 2026 revealed the facility reported the allegation of abuse only after the state agency brought it to their attention. The facility concluded that the allegation was inconclusive even though the facility acknowledged witnessed contact was made by the residents as Resident #6 was attempting to climb into Resident #22's bed resulting in skin tear of Resident #22.An interview was conducted with Licensed Practical Nurse (LPN/Staff #32) on July 1, 2026 at 10:19 a.m. who stated that she did not witness the incident but was called to the incident, when she arrived there were three CNAs trying to separate both Resident #22 and Resident #6. Staff #32 stated she heard a CNA calling for nurse on the walkie when she got to the room the patients were separated. Staff # 32 stated that she struck out the initial progress reports regarding the physical altercation because she was told not to document what was reported to her by staff just what she observed. Staff #37 stated that the CNAs reported that the Residents were together fighting when they arrived on scene. Staff #37 stated that while she was talking to Resident #22 she noticed there was blood and the hand was assessed and bandaged. Staff #32 stated that resident to resident abuse is when a resident harms another resident. An interview was conducted with CNA (Staff # 50) on July 2, 2026 at 8:51 a.m. who stated that Resident #6 can get physically aggressive with staff especially if the Resident does not want to do the task. Staff #50 stated on June 27, 2026 she was on the patio when she heard the call from another CNA, Staff # 50 stated when she went in there Resident #6 was over Resident #22 while Resident #22 was on the ground in a sitting position next to the bed. Staff #50 stated that they moved Resident #6 to the foot of the bed and helped Resident #22 up from the ground that is when she noticed the blood on Resident #22's hand. Staff #6 stated that the nurses came in and helped bandage Resident #22. An interview was conducted with CNA (Staff # 30) on July 2, 2026 at 9:23 a.m. who stated that he arrived after the other CNAs had separated the residents and Resident #22 was back in his bed being tended to by the nurses. Staff #30 stated he took Resident #6 out of the room and stayed with Resident #6 as his 1:1 for the rest of the shift. Staff #30 stated that when resident to resident abuse occurs they first try and deescalate the situation, then provide care for any injuries, and then notify his superior of the incident right away within 2 hours. An interview was conducted with Assistant Director of Nursing (ADON/Staff #56) on July 2, 2026 at 12:12 p.m. who stated that if there is an allegation of any kind of abuse especially resident to resident we would notify to the DON or the administrator immediately due to the time frame of reporting. Staff #56 state she was the on call nurse on June 27, 2026 when Staff #32 had contacted her regarding an incident with Resident #22 and Resident #6. Staff #56 stated that Resident #6 was over the top of Resident #22 in his side of the bed they think because Resident #6 was trying to get into the bed. She stated that Residents had to be separated and the Director of Nursing decided to place Resident #6 on 1:1 care as he had shown increase aggression over the past two weeks. Staff #56 stated that family on both sides were called immediately but the police were not called they did not think it was necessary as they had the situation under control. An interview was conducted with the Director of Nursing (DON/Staff #40) on July 2, 2026 at 1:12 p.m. stated that physical abuse can be hitting grabbing slapping other residents and if there is an allegation or a concern that resident to resident happened then we would initiate the notification process followed by the investigation process. Staff #40 stated was called on Saturday June 27, 2026 with notification that Resident #6 was trying to get into Resident #22's bed and that Resident #6 was getting physically and verbally aggressive with the staff while be separated off of Resident #22. Staff #40 stated that she instructed Staff #56 to place Resident #6 on 1:1 for physical aggression over the weekend. Staff #40 stated that she did contact the abuse coordinator Staff #43 and discussed the incident. An interview was conducted with Administrator (Staff # 43) on July 2, 2026 at 1:37 p.m. stated that if there is an allegation of abuse then he reports to all reporting state agencies within two hours and then they conduct their investigation. Staff #43 that he was notified that Resident #6 was trying to get into Resident 22's bed and staff had to separate them. Staff #43 stated that he did not feel this was abuse because Resident #22 just wanted him out of the room. Staff #43 stated that they removed Resident #6 from the room and placed him in his own room with a 1:1 sitter as added precaution because of Resident #43's history with verbal & physical aggression. Staff #43 stated that he did not feel this was resident to resident abuse because there was not willful intent and therefore was not reported. A policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, Revised April 2021, documented that if resident abuse is suspected the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy documented that 'immediately' is defined as within 2 hours of an allegation involving abuse resulting in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility to ensure that an allegation of abuse for 3 out of 15 residents (#6, #22, and #80) was reported to all applicable state agencies within the required timeframe. The deficient practice could result in a delay in the proper investigation of abuse allegations. Findings include:Regarding Resident #80:Resident #80 was admitted on [DATE] with diagnoses that included unspecified mood disorder, suicidal ideations, anxiety disorder, and depression. A Nurses Note dated May 15, 2026 7:08 a.m. revealed that the writer was alerted by Resident #80 that she had been in a physical altercation with a Certified Nursing Assistant (CNA #12). The nurses note goes on to reveal that prior to this incident Resident #80 was resistant to having CNAs helping her with a shower. The note documents that Resident #80 came out yelling stating she was in a fight with the CNA. The note also documented that there were some visible scratches to her arms but refused treatment to said areas. The note revealed that the Director of Nursing and Nurse Practitioner were notified. A follow up nurses note by the Director of Nursing (DON/Staff #40) dated May 15, 2026 at 7:09 a.m. revealed that Resident #80 reported that the scratches were self inflicted as she hit her arms on the bed while grabbing the CNA. A Change of Condition evaluation dated May 15, 2026 at 7:15 p.m. revealed that Resident #80 came out of the room yelling that she didn't want CNA #12 in her room because they got into a fight. The change of condition note revealed that Resident #80 said she slapped and choked CNA #12. Review of physician orders revealed no change of condition orders or monitoring orders regarding the allegations made on May 15, 2026. A Medicare 5-day Minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 14, indicating the resident is cognitively intact. The MDS assessment revealed that Resident #80 suffers from delusions, physical and verbal behavior, and rejection of care and wandering. A care plan dated May 18, 2026 revealed that Resident #80 had behavior problems related to primary diagnosis of mood disorder and other psychological diagnoses. The care plan revealed that resident # 80 exhibited impatience with staff and exhibits false allegations, physical aggressive towards staff, and harms self when upset. Interventions include administer medications as ordered, and anticipate and meet the Resident's needs. A physicians order dated May 18, 2026 for cares in pairs. Three days after the first initial allegation of abuse. A Social Service Note dated May 19, 2026 revealed that Resident #80 had made statements indicative of suicidal ideation and requested to leave the facility. The social services note revealed that the Crisis team was called out to meet with Resident #80, who told the Crisis team that she has been beaten up by CNA #12 in a fight. The social services note documented per facility protocol regarding the allegation initially reported on 5/14/2026, the identified CNA was removed from assignment with the resident pending reviewing and the resident was put on cares in pairs.Review of CNA Staff #12 Time Report sheet revealed that Staff #12 worked the following shifts; May 14, 2026 2:04 p.m.-10:12 p.m. May 17, 2026 2:02 p.m.-10:06 p.m.May 18, 2026 1:58 p.m.-10:03 p.m. Further review of the the Time Report Sheets revealed that Staff #12 was pulled from the schedule on administrative paid leave on May 19 and May 20, 2026. An interview was conducted with CNA (Staff #6) on July 2, 2026 at 8:17 a.m. who stated that she had worked a lot with Resident #80 and had described Resident #80 as having a lot of anxiety. Staff #6 stated she had a good bond with Resident #80 and would light up and be happy when they interreacted but Staff #6 stated that it quickly changed a few days before the Crisis when she reported the altercation with another CNA. Staff #6 stated she did not who it was and Resident # 80 would not tell Staff #6 who it was or what they did. Staff #6 stated that she made her nurses aware but Resident #80 was known for making false accusations so not sure what was investigated. An interview was conducted with CNA (Staff #30) on July 2, 2026 at 9:23 a.m. who stated that he remembered Resident #80 because she was always sexually inappropriate with the men and it was hard to redirect her. Staff #30 stated that he was not there at the time but he heard the next day May 15, 2026 that Resident #80 had alleged abuse against Staff #12 and had bruises on her arms. An interview was conducted with Social Services Director (Staff # 91) on July 2, 2026 at 12:21 p.m. stated that Resident #80 was very combative with all the staff. Staff # 91 stated that she knew that Staff #12 had scratches on her from taking care of her. Staff #91 stated that she heard about the allegations made on May 15, 2026 but she stated that she was not given a name of who the CNA was until she made the second allegation on May 19, 2026. Staff #91 stated that is when they pulled her off the schedule. An interview was conducted with the Director of Nursing (DON/Staff #40) on July 2, 2026 at 1:12 p.m. stated that if there is an allegation staff to resident abuse notification would be made immediately to the abuse coordinator (Staff #43). Staff #40 stated that was notified by the agency nurse of the allegation that Resident #80 was involved in a fight with CNA #12. Staff #40 stated she conducted interview with Resident #80 and determined that Resident #80 was the only aggressor in the fight with Staff #12. Staff #40 did state that she reported to Staff #43 that same day of the allegations. Staff #40 stated that Staff #43 is responsible to report to the state agencies any allegations unless he is unavailable then Staff #40 state that it would be her responsibility. An interview was conducted with Administrator (Staff # 43) on July 2, 2026 at 1:37 p.m. stated that if there is an allegation of abuse then he reports to all reporting state agencies within two hours and then they conduct their investigation. Staff #43 stated that the allegation Resident #80 made of fighting CNA #12 was not considered reportable because during an interview of the resident Resident #80 stated she was the aggressor. Regarding Resident #22 and Resident #6:-Resident #22, the alleged victim, was admitted on [DATE] with diagnoses that included COPD, major depressive disorder, and unspecified dementia without behavioral disturbances.A care plan revised on February 5, 2026 revealed that the Resident has behavior problem related to psychological diagnoses, exhibiting non-compliance with care plan, self-isolation, false accusations, and exit seeking. Interventions include anticipating Resident's needs and intervening as necessary to protect the rights and safety of others.A quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. The quarterly MDS revealed behaviors including rejection of cares and wandering. A struck out health status note dated June 27, 2026 at 2:11 p.m. from Licensed Practical Nurse (LPN/Staff #32) revealed that Resident #22 was found with Resident #6 standing over him. The note revealed that Resident #22 stated that Resident #9 walked up to him and began hitting him. The note also documented that the residents were found by staff hitting each other and Resident #22 was requesting Resident #9 to be moved from his room. The health status note revealed that the strike out reason listed was correction on June 27, 2026 at 2:13 p.m.A late entry health status note dated June 27, 2026 at 2:13 p.m. written by Staff #32 revealed that Resident #22 was present in his room while his roommate Resident #6 was standing in his room yelling, screaming and cursing at another CNA calling them names threatening to hit them. The health status note revealed that residents were separated and placed on 1:1 until Resident #6 was moved.A Change of Condition Evaluation form dated June 27, 2026 at 5:26 p.m. conducted by Staff #32, revealed that Resident #22 had received verbal aggression from Resident #6. The change of condition evaluation form revealed no new skin conditions to Resident #22. A health status note dated June 28, 2026 from staff #32 revealed the patient on change of condition for receiving physical aggression from Resident #6. The note revealed all vitals were in normal range and patient had no complaints of pain or discomfort. An electronic MAR note dated June 28, 2026 at 9:22 p.m. documented change of condition for receiving physical aggression. The MAR note revealed that the provider and responsible party were notified. The MAR not documented that the Receiver of physical aggression (Resident #22) is to be monitored every shift for 3 days. An interview was conducted on June 29, 2026 at 9:34 a.m. with Resident #22 who stated that on Saturday June 27, 2026 his roommate at the time Resident #6 came over to him and started hitting him in the bed. Resident #22 said they he fought back to protect himself until staff came in and separated us. Resident #22 stated that he bruised his left hand. They moved Resident #6 to another room and he stated he feels safe now. An observation of Resident #22 was conducted at 9:34 a.m. revealing a large bruise on Resident #22's left hand covered with a bandage reading 6/28 and initials. Notification was given to the Administrator (Staff #43) on June 29, 2026 at 10:54 a.m. advising the administrator the report of resident to resident altercation made by Resident #22. A Nursing note dated June 29, 2026 at 11:00 a.m. revealed skin check was completed on Resident #22 indicating a skin tear and discoloration on the left hand. Resident #6, the alleged perpetrator, was admitted on [DATE] with diagnoses that included anoxic brain damage, communicating hydrocephalus, PTSD, major depressive disorder, unspecified dementia, and unspecified mood disorder. A care plan initiated on May 18, 2026 revealed that Resident #6 had a behavior problem related to psychological diagnosis monitoring for delusions, inability to sleep, labile moods, restlessness, and visual hallucinations exhibiting physical aggression with staff, verbally aggressive using vulgar language towards staff. The care plan documented that on May 15, 2026 Resident #6 was the initiator of verbal aggression and was placed on a 1:1 with no indication on time frame or indication of conclusion date.An admission MDS assessment dated [DATE] revealed a BIMS score of 1 indicating severe cognitive impairment. The MDS assessment documented that resident exhibited physical behaviors and other behaviors which significantly interferes with the resident's care and puts others at risk of physical injury. The MDS did not indicate the resident exhibiting verbal behaviors. The assessment documented that Resident #6 significantly intrudes on the privacy or activity of others. A behavior note dated June 22, 2026 at 1:00 p.m. revealed Resident #6 observed crying intermittently appearing visibly distressed. The behavior note documented that resident displayed rapid mood changes shifting from tearful to angry. The note revealed resident angrily paced around the room and unit repeatedly stating he wanted to leave, demonstrating exit-seeking behavior. Resident #6 remained agitated with the staff unable to redirect. A health status note dated June 22, 2026 at 4:14 p.m. revealed that 911 was called due to the inability for staff to calm and redirect Resident #6. The health status note revealed the police were not willing to take the resident despite the staffs wishes. An order dated June 22, 2026 revealed a change of condition for physical aggression with provider and responsible party notified. The order revealed monitoring of the resident every shift for physical aggression for three days with end date of June 26, 2026. An electronic MAR note dated June 24, 2026 revealed that during administration of Ativan resident was observed sitting in bed ripping his brief mumbling to self while punching the bed covers. An electronic MAR note dated June 25, 2026 revealed patient was awake, crying, removing brief and showing aggression towards staff. Another electronic MAR note dated June 25, 2026 that resident attempted to his CNA during one instance of agitation. A Physician Assistant (PA) Note dated June 26, 2026 revealed that staff reported to the PA ongoing episodes of physical aggression. The PA note documented that these episodes of physical aggression seem to be triggered in the afternoon. The PA note recommended a gradual dose reduction of quetiapine. to 25 mg by mouth twice daily. The PA note documented that staff are to monitor closely for behavioral changes, increased agitation, or worsening aggression during the step reduction. A draft note dated June 27, 2026 at 1:44 p.m. by Staff #32 revealed resident #6 was witnessed standing over his roommate Resident #22 hitting him. Residents were separated and Resident #6 was placed on 1:1. The draft note was observed in the medical record on June 29, 2026 at 10:00 a.m. A late entry health status note dated June 27, 2026 at 1:44 p.m. by staff #32 revealed Resident #6 standing in his own room yelling, screaming and cursing at CNA threatening to hit them while Resident #22 was present. This not was observed in the medical record on June 30, 2026 at 8:30 a.m. replacing the previous draft note. A physician's order dated June 27, 2026 by the PA revealed a change of condition for physical aggression. The order revealed to monitor resident for physical aggression for three days. This order was discontinued on June 29, 2026 at 11:12 a.m., by the medical director, after notification by surveyor of the allegations of abuse. The physician order revealed the reason for discontinuing order had incorrect indication. A Change of Condition Note dated June 29, 2026 at 1:47 p.m. by Staff #43 revealed resident involved in verbal aggression with staff while in the room with his roommate. A physician's order dated June 29, 2026 revealed change of condition for verbal aggression provider notified and family notified to be monitored for 3 days. A physician's order dated June 29, 2026 revealed change of condition order for 3 days to monitor for physical aggression monitoring resident every shift until July 2, 2026. A Follow-up Investigation Report signed July 2, 2026 revealed the facility reported the allegation of abuse only after the state agency brought it to their attention. The facility concluded that the allegation was inconclusive even though the facility acknowledged witnessed contact was made by the residents as Resident #6 was attempting to climb into Resident #22's bed resulting in skin tear of Resident #22.An interview was conducted with Licensed Practical Nurse (LPN/Staff #32) on July 1, 2026 at 10:19 a.m. who stated that she did not witness the incident but was called to the incident, when she arrived there were three CNAs trying to separate both Resident #22 and Resident #6. Staff #32 stated she heard a CNA calling for nurse on the walkie when she got to the room the patients were separated. Staff # 32 stated that she struck out the initial progress reports regarding the physical altercation because she was told not to document what was reported to her by staff just what she observed. Staff #37 stated that the CNAs reported that the Residents were together fighting when they arrived on scene. Staff #37 stated that while she was talking to Resident #22 she noticed there was blood and the hand was assessed and bandaged. Staff #32 stated that resident to resident abuse is when a resident harms another resident. An interview was conducted with CNA (Staff # 50) on July 2, 2026 at 8:51 a.m. who stated that Resident #6 can get physically aggressive with staff especially if the Resident does not want to do the task. Staff #50 stated on June 27, 2026 she was on the patio when she heard the call from another CNA, Staff # 50 stated when she went in there Resident #6 was over Resident #22 while Resident #22 was on the ground in a sitting position next to the bed. Staff #50 stated that they moved Resident #6 to the foot of the bed and helped Resident #22 up from the ground that is when she noticed the blood on Resident #22's hand. Staff #6 stated that the nurses came in and helped bandage Resident #22. An interview was conducted with CNA (Staff # 30) on July 2, 2026 at 9:23 a.m. who stated that he arrived after the other CNAs had separated the residents and Resident #22 was back in his bed being tended to by the nurses. Staff #30 stated he took Resident #6 out of the room and stayed with Resident #6 as his 1:1 for the rest of the shift. Staff #30 stated that when resident to resident abuse occurs they first try and deescalate the situation, then provide care for any injuries, and then notify his superior of the incident right away within 2 hours. An interview was conducted with Assistant Director of Nursing (ADON/Staff #56) on July 2, 2026 at 12:12 p.m. who stated that if there is an allegation of any kind of abuse especially resident to resident we would notify to the DON or the administrator immediately due to the time frame of reporting. Staff #56 state she was the on call nurse on June 27, 2026 when Staff #32 had contacted her regarding an incident with Resident #22 and Resident #6. Staff #56 stated that Resident #6 was over the top of Resident #22 in his side of the bed they think because Resident #6 was trying to get into the bed. She stated that Residents had to be separated and the Director of Nursing decided to place Resident #6 on 1:1 care as he had shown increase aggression over the past two weeks. Staff #56 stated that family on both sides were called immediately but the police were not called they did not think it was necessary as they had the situation under control. An interview was conducted with the Director of Nursing (DON/Staff #40) on July 2, 2026 at 1:12 p.m. stated that physical abuse can be hitting grabbing slapping other residents and if there is an allegation or a concern that resident to resident happened then we would initiate the notification process followed by the investigation process. Staff #40 stated was called on Saturday June 27, 2026 with notification that Resident #6 was trying to get into Resident #22's bed and that Resident #6 was getting physically and verbally aggressive with the staff while be separated off of Resident #22. Staff #40 stated that she instructed Staff #56 to place Resident #6 on 1:1 for physical aggression over the weekend. Staff #40 stated that she did contact the abuse coordinator Staff #43 and discussed the incident. An interview was conducted with Administrator (Staff # 43) on July 2, 2026 at 1:37 p.m. stated that if there is an allegation of abuse then he reports to all reporting state agencies within two hours and then they conduct their investigation. Staff #43 that he was notified that Resident #6 was trying to get into Resident 22's bed and staff had to separate them. Staff #43 stated that he did not feel this was abuse because Resident #22 just wanted him out of the room. Staff #43 stated that they removed Resident #6 from the room and placed him in his own room with a 1:1 sitter as added precaution because of Resident #43's history with verbal & physical aggression. Staff #43 stated that he did not feel this was resident to resident abuse because there was not willful intent and therefore was not reported. A policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, Revised April 2021, documented that if resident abuse is suspected the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy documented that the administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility, local/state ombudsman, resident's representative, Adult Protective Services, Law enforcement officials, and the resident's attending physician. The policy revealed that 'immediately' is defined as within 2 hours of an allegation involving abuse resulting in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure the care plan was revised for one resident (#27) regarding bilateral hand splints. The deficient practice could result in inaccuracies regarding resident care and omission of required interventions related to range of motion (ROM) and splint use. The sample size was 1 and the universe was 79.Findings include:Resident #27 was admitted to the facility on [DATE], with diagnoses including rheumatoid arthritis, unspecified movement disorder, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility.A review of the resident's care plan, dated January 17, 2023, revealed a focus for pain related to rheumatoid arthritis and limited mobility. Interventions included pain meds as ordered. Further review of the care plan revealed a focus for limited mobility. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction.A physician order dated March 29, 2025 revealed Patient to wear bilateral hand splints daily as tolerated in order to maintain ROM.A review of the most recent quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Further review revealed the resident had rheumatoid arthritis, pain, occasional interference with day-to-day activities, and no current therapy services.A review of the resident's care plan, dated June 16, 2026, revealed no focus for the physician's order for bilateral hand splints or interventions addressing daily splint use, monitoring, or maintenance of range of motion.During initial screening, an observation was conducted on June 29, 2026 at 9:10 a.m. of the resident's hands. The fingers were observed bent and drifting sideways toward the pinky finger. During an interview with resident #27, she stated that she had rheumatoid arthritis.An interview was conducted on July 1, 2026, at 9:07 a.m with the resident. The resident stated the hand splints had helped with her hands and that she applied them herself. The resident reported pain in her hands, particularly the left hand, had difficulty moving her hand at times due to pain, difficulty opening items such as a bag of chips, and difficulty completing some dressing tasks. The resident also stated she did not recall being asked about her care plan. Further observation revealed the resident was not wearing the ordered bilateral hand splints.An interview was conducted on July 1, 2026, at 2:29 p.m. with Certified Nursing Assistant (CNA/Staff #4). Staff #4 stated staff generally become aware of residents' ROM needs and devices by asking the nurse or observing residents with equipment. She stated she was not aware whether Resident #27's bilateral hand splints were part of the resident's daily care routine.An interview was conducted on July 1, 2026, at 2:35 p.m. with Registered Nurse (RN/Staff #19). While reviewing the resident's electronic health record (EHR), Staff #19 stated there was a physician's order for bilateral hand splints. After reviewing the resident's care plan, the RN stated he did not find any reference to the bilateral hand splints and stated the intervention should have been included in the care plan. He further stated that if a resident has an order for a splint or brace, it should be reflected in the care plan. He stated the risk of not including the order in the care plan could result in the intervention being missed.An interview was conducted on July 1, 2026, at 3:09 p.m. with the Director of Nursing (DON/Staff #40). The DON stated therapy typically evaluates residents and communicates recommendations to nursing. During a review of the resident's EHR, she further stated there was an order for bilateral hand splints dated March 29, 2025, and stated the intervention should have been included in the resident's care plan. The DON stated staff, including nursing, social services, dietary, and CNAs, have access to the care plan. She stated the risks of omission of the splint intervention could result in missed ROM interventions and failure to monitor the resident's skin while using the splints.On July 2, 2026, the facility provided documentation and in-service records of staff education on revising care plans. The subject was Care planning adaptive devices, all medical equipment, other DME accurately by reviewing order listing daily, dated July 1, 2026 for 35 minutes.A review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, states that the policy outlines a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on record review, observation, and staff interview,The facility failed to implement infection prevention and environmental cleaning practices consistent with facility policy and accepted infection control standards by reusing contaminated environmental cleaning equipment between resident care areas, storing reusable cleaning tools submerged in disinfectant solution, using contaminated equipment after cleaning areas contaminated with feces, and allowing contaminated equipment to contact resident environments and personal belongings for 2 residents (#14 and #22) out of 5 sampled residents. The facility census was 58. The deficient practice had the potential to contribute to environmental cross-contamination and transmission of infectious organisms, including MDROs, among residents.Findings Include:Record review revealed Resident #14 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses including cellulitis of the left lower extremity, chronic systolic congestive heart failure, type 2 diabetes mellitus, extended-spectrum beta-lactamase (ESBL) multidrug-resistant organism (MDRO), stage 2 chronic kidney disease, and an open wound of the right lower leg. Physician orders dated January 14, 2026, directed staff to implement Enhanced Barrier Precautions (EBP) during high-contact resident care activities due to chronic wounds.Record review revealed Resident #22 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, stage 3A chronic kidney disease, and orthostatic hypotension. Physician orders dated June 29, 2026, directed staff to provide wound care for a wound located on the dorsum (top) of the left hand. Record review further revealed Resident #22 had an active physician order dated June 29, 2026, for treatment of a wound to the left hand.On July 1, 2026, at approximately 1:37 p.m., a room cleaning observation was conducted with Housekeeping Manager (Staff #88) and Housekeeper (Staff #80) in the shared bathroom and resident rooms occupied by Residents #14 and #22. An EBP sign was posted outside the shared entrance.During the observation, Staff #80 discovered extensive fecal contamination on the shower walls and floor and soiled linens in the bathroom. Nursing staff removed the soiled linens and the bulk of the fecal matter; however, visible fecal residue remained on the shower floor before environmental cleaning began.Staff #80 sprayed the contaminated shower with a cleaning solution identified as Apple [NAME] and used a broom to scrub the shower floor. The same broom was later used to sweep Resident #14's room, Resident #22's room, and the shared hallway without cleaning or replacing the broom head. During sweeping, the broom contacted Resident #14's personal belongings, including a belt and chess pieces located on the floor.During the same observation, Staff #80 used a gallon container labeled Apple [NAME] that contained cleaning solution in which a reusable toilet brush and multiple reusable scrub pads were stored submerged together. Visible debris was present in the solution. Staff #80 removed a scrub pad from the container, cleaned the shower walls, returned the used scrub pad to the solution, then removed the toilet brush from the same container to clean the toilet before placing the contaminated brush back into the solution.Staff #88 subsequently mopped Resident #14's room, Resident #22's room, the shared bathroom, and the hallway using the same mop before removing the mop head at the completion of cleaning.On July 2, 2026, at approximately 10:04 a.m., Staff #80 was again observed with the same style container of Apple [NAME] cleaning solution containing a reusable toilet brush and reusable scrub pads submerged in the solution with visible debris. During the observation, Dietary Director (Staff #57) instructed Staff #80 to discard the solution, which was poured onto the gravel outside the building.The facility administrator (Staff #43) was notified on July 2, 2026, at approximately 10:07 a.m., of the infection control concerns identified during the observation. He stated the affected rooms would be re-cleaned.During an interview on July 1, 2026, Staff #80 stated she routinely stored the reusable toilet brush and scrub pads submerged in the Apple [NAME] solution since beginning employment at the facility, reused the toilet brush and scrub pads between resident rooms, believed the practice complied with facility policy, and did not believe it posed an infection control risk because the cleaning solution was strong.During an interview on July 2, 2026, the facility administrator (Staff #43) stated storing cleaning tools in disinfectant solution was not consistent with facility policy because it could contaminate the cleaning solution and contribute to cross-contamination and transmission of infection.During an interview on July 2, 2026, Dietary Director (Staff #57) and Housekeeping Manager (Staff #88) confirmed facility policy required cleaning tools to be stored separately from cleaning chemicals, that disinfectant solutions were to remain uncontaminated, and that using a broom to agitate cleaning solution and then clean multiple resident care areas without changing the broom head was not consistent with facility expectations or policy because it increased the risk of cross-contamination.Review of the facility policy, Enhanced Barrier Precaution (Revised December 2024), stated Enhanced Barrier Precautions are intended to reduce transmission of multidrug-resistant organisms during high-contact resident care activities and identified wound drainage and fecal contamination as conditions that increase the potential for environmental contamination and pathogen transmission.Review of the facility policy, Cleaning and Disinfection of Environmental Surfaces (Revised August 2019), required environmental surfaces to be cleaned and disinfected according to CDC recommendations, visible blood and body fluids to be removed using disposable materials, contaminated materials to be discarded appropriately, cleaning solutions to be replaced with fresh solution frequently, and manufacturer instructions to be followed when using disinfectants.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#1) was free from abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Regarding resident #1: Resident was admitted to the facility on [DATE] with diagnosis that included intracerebral hemorrhage, unspecified, flaccid hemiplegia affecting left dominant side, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, unspecified mood [affective] disorder. A review of the quarterly MDS (minimum data set) dated December 23, 2024 revealed a BIMS (brief interview of mental status) score of 14, indicating resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. A review of the resident's care plan, initiated on December 23, 2024 revealed a focus for impaired cognitive function/impaired thought processes related to impaired decision making, neurological symptoms. Interventions included to administer medications as ordered. Further review of the care plan revealed a focus for psychosocial behaviors related to physically and verbally sexual inappropriateness. Interventions included intervening as necessary to protect the rights and safety of others and to monitor behaviors episodes and attempt to determine underlying cause. A review of the progress notes revealed an alert charting entry dated January 19, 2025 that at approximately 04:30am Certified Nursing Assistant (CNA) called nurse to room to find patient with hematoma to left above eye about golf size. According to resident, roommate had beam rummaging through his closet and taking his clothes. When approached about leaving his clothing alone resident was allegedly hit with a water pitcher by the roommate who allegedly threw it at him. Nurses assisted with wound dressing to bleeding hematoma at the time. The progress note stated notifications to administration, Director of Nursing (DON), case worker, and family all completed. The note stated police were also called and resident was sent to emergency room . Review of the progress notes revealed an entry dated January 19, 2025 that stated resident #1 returned from the hospital with no new orders. The resident was observed to have knots around the left side of forehead that had two steri-strips. The progress note stated the report from emergency room nurse from the hospital stated the CT scan was negative. -Regarding resident #2: Resident #2 was admitted on [DATE] with diagnosis that included other acute osteomyelitis, left ankle and foot, major depressive disorder, recurrent, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the Medicare 5-day MDS dated [DATE] revealed a BIMS (brief interview of mental status) score of 7 indicating severe cognitive impairment. Further review of the MDS revealed a severity score of 7 for mood and delusional behaviors. A review of the resident's care plan, date-initiated on January 15, 2025 revealed a focus for psychosocial behaviors; related to psych diagnosis; monitoring for agitation and sad mood. Interventions included to intervene as necessary to protect the rights and safety of others and approach/speak in a calm manner, divert attention and remove from the situation and take to an alternate location as needed. Review of the progress notes revealed an alert note entry dated January 19, 2025 that resident was allegedly involved in an altercation with his roommate. The progress note stated resident #2 threw a water pitcher at his roommate. Review of the progress notes revealed a health status note dated January 21, 2025 that resident is on change of condition for resident to resident altercation. The progress noted stated no increased agitation noted or reported. It further stated no physical or verbal aggression or roommate conflict. A request was made for the facility self-report or any documentation from the investigation on January 23, 2025 at 11:50 a.m. Staff #320 replied in writing on January 23, 2025 at 12:35 p.m. Our investigation is still in progress, report currently not available. An interview was conducted on January 23, 2025 at 2:03p.m. with resident #1. During the interview it was observed that resident #1 had a hematoma with a small cut in the center on the left side of the resident forehead. Also noted a laceration approximately one inch in length on the left top of the resident's head and purple and blue bruising to the left corner of the resident's eye. During the interview with Resident #1, resident #1 stated the incident occurred between 2:00a.m and 5:00a.m. Resident #1 stated resident #2 was removing clothing from resident #1's closet. Resident #1 stated he got out of bed and went to the bathroom and when he returned resident #2 had put resident #1's pants on and was also attempting to put on one his shirts. Resident #1 stated he tried to grab his shirt and this is when resident #2 grabbed a plastic water pitcher filled with water and clonked me on the head 2-4 times. Resident #1 stated he yelled for his roommate, resident #4 to call for the nurse. Resident #1 stated a nurse came in and asked what was going on. Resident #1 stated he told the nurse resident #2 was taking his clothing from his closet and she turned around and left. Resident #1 could not recall the name of the nurse or provide any identifiers. Resident #1 stated CNA #5 entered the room because the call light was still on and saw the bleeding from his forehead and went for a nurse who treated the wound and sent the resident to the hospital for a CT scan. Resident #1 stated nursing staff were aware of prior incidents of resident #2 taking his clothing. An attempt to interview resident #2 was conducted on January 23, 2025 at 2: 03 p.m. resident was observed on sitting on the patio talking to himself and grasping at the air. Due to the resident's cognition the interview was unable to be completed. An interview was conducted on January 23, 2025 at 2: 15p.m with resident #4. Resident #4 stated resident #2 would often take his food and water from his bedside table. Resident #4 stated he observed the altercation between resident #1 and #2. Resident #4 stated he observed resident #2 swing the cup that holds the water, raising it above his head swinging at resident #1 head. Resident #4 stated Resident #2 hit resident #1 in the head and then swung again hitting him on the head again. Resident #4 stated resident #1 called for him stating help me. Resident #4 stated he was too slow to help as he was in bed before he was able to get to him. Resident #4 stated as he was walking toward resident #1 he observed resident #2 jab resident #1 with his walker. Resident #4 stated I saw a hole on resident #1 head and blood streaming down his head and neck. Resident #4 stated he turned on the call light and two nursing staff came in. Resident #4 stated he informed the nursing staff what had happened. Resident #4 stated his bed is located directly in front of resident #1. Resident #4 stated every night it was something with resident #2 and resident #2 was always in resident #1 closet going through his clothing and trying to wear them. Attempt to contact CNA/Staff #5 was conducted on January 23, 2025 at 2:12 p.m. Message left for a return phone call. An interview was conducted on January 23, 2025 at 2:21 p.m. with CNA/Staff #9. Staff # 9 stated she has worked with both resident #1 and #2. Staff #9 stated resident #2 had a recent room change due to an incident with resident #1. Staff #9 stated she had heard that resident #2 had went up to resident #1 and hit him with a cup. Staff #9 stated she has not observed any aggressive behaviors from resident #2, but that he can be non-compliant with care. Staff #9 stated when there is an incident involving residents that the expectation is that the residents are placed on 1:1 supervision with an immediate room change. Staff #9 stated she has received abuse training and has been trained that staff are to separate the residents involved, report immediately, monitor the situation and take the victim away and out of the situation. An interview was conducted on January 23, 2025 at 2: 03p.m with Licensed Practical Nurse LPN/Staff #7. Staff #7 stated if staff are made aware of an altercation between residents they are to immediately separate, look for injuries, follow the reporting process, notifying the administrator. Staff #7 stated she was informed through report that resident #1 had injuries from an altercation with resident #2 Staff #7 stated there were no reported injuries with resident #2. Staff #7 stated resident #1 is on behavior monitoring for medications and has not received any reports for non-compliance with care. Staff #7 stated there have been no prior incidents with residents #1 or #2. An interview was conducted on January 23, 2025 at 2:55 p.m. with Director of Nursing DON/Staff #30. The DON stated she received a call from Assistant Director of Nursing/ADON/Staff #42 the morning of January 20 at 4:42am informing her that there was an alleged resident to resident altercation and that resident # 2 had thrown a water pitcher at resident #1. Staff #30 stated when she interviewed resident #1 he had informed her that resident #2 was in his closet and when he had told him to get out of his closet that resident #2 had thrown the water pitcher at him. Staff #30 stated the process for reporting alleged abuse is to contact the abuse coordinator, the DON, ADON, other state agencies, family and provider. Staff #30 stated resident both residents were assessed for potential injuries with a skin check and that resident #1 was sent to the hospital due to a hematoma on his head it was bleeding at the time. Staff #30 stated a CT was conducted at the hospital revealing no findings or new orders. A review was conducted of Point Click Care (PCC) , the facility data base for residents by staff #30 revealing no skin assessment completed at the time of injury or following. Further review by Staff #30 revealed no documentation of the laceration on the top L side of resident #1 head. Staff #30 stated she was unaware of the laceration. Staff #30 stated it is her expectation that a skin evaluation and change of condition be completed. Staff #30 stated the risks of not completing the skin assessment can lead to reports of injuries of unknown origin, leading to a delay in treatment and care of the resident. Staff #30 further stated the progress notes of the resident to resident incident is not detailed or thorough and the risks associated with this is missing key information in how to treat or care for the resident when you don't provide accurate documentation. Staff # 30 stated the facility did not have a final hospital report, but would request one. Further review of PCC by staff #30 revealed no documentation for the 1:1 provided for resident #2 or the room change. An interview was conducted on January 23, 2025 at 3:59 p.m. with CNA /Staff #5. Sattf #5 stated she was working the night shift on January 20, 2025 when she noticed the call light on in residents #1, #4 and #2 room. Staff #5 stated when she entered the room she noticed water and shaving cream on the floor. Staff # 5 stated resident #1 was in the bathroom and when he came out she noticed his head and forehead were bleeding. Staff #5 stated resident #2 was sitting on his bed dressed head to toe in resident #1's clothing. Staff #5 stated she immediately went to get the nurse. Staff #5 resident #1 was found to have a knot to the left side of his forehead near his eye and a cut on left top of his head. Staff #5 stated resident #1 informed her and the registry nurse that resident #2 had hit him on top of the head with the water pitcher. Staff #5 stated the nurse addressed resident #1's injuries and that she helped change resident #2 clothing which was wet with water and shaving cream. Staff #5 stated she took resident #2 to the dining room, providing him 1:1 supervision until the day shift arrived. Staff #5 stated resident #1 was sent to the hospital. Staff #5 stated resident #1 had previously informed her that resident #2 would go into other residents' closets and wander around, but no prior incidents of abuse. Staff #5 stated she did not report the information. An interview was conducted on January 23, 2025 at 4:39 p.m. with Abuse Coordinator/ Administrator /Staff # 20. Staff #20 stated he was notified of the alleged abuse at approximately 4:30 am on January 20, 2025. It was reported that resident #2 was confused and had gone through resident #1's things and when asked to stop, resident #2 tossed the cup or mug at him. Staff #20 stated the residents were immediately separated and contacted the provider. The provider asked that resident #1 be sent to the hospital to be evaluated. Staff had reported resident #1 had a cut above his eye. Staff #20 stated resident #2 was separated from all residents and monitored by staff. Staff #20 stated resident #2 was moved to anther room once resident #1 was sent to the hospital. Staff #20 stated interviews were conducted with the other roommates who were available. Staff #20 stated the investigation is ongoing, but does not feel that there was malicious intent. Staff #20 stated resident #2 was moved to another room the same morning. The request for hospital records were provided on January 23, 2025 at 4:42 p.m. The admission physical assessment revealed resident #1 had 2 small hematomas on the frontal aspect and parietal aspect with overlying small lacerations that were closed with steri-strips. Further review of the hospital report revealed resident #1 informed hospital staff that he wanted to press charges and that security was notified to have a police report made. A review of the facility policy titled Abuse Prevention Program revised August 2006 states our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.

Based on observation, staff interviews, clinical record review and facility documentation and policy review, the facility failed to ensure accurate documentation for one resident's injuries (#1 ). This deficient practice could result in residents not receiving the necessary treatment to address their medical issues/problems. Findings include: -Regarding resident #1: Resident was admitted to the facility on [DATE] with diagnosis that included intracerebral hemorrhage, unspecified, flaccid hemiplegia affecting left dominant side, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, unspecified mood [affective] disorder. A review of the quarterly MDS (minimum data set) dated December 23, 2024 revealed a BIMS (brief interview of mental status) score of 14, indicating resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. A review of the resident's care plan, initiated on December 23, 2024 revealed a focus for impaired cognitive function/impaired thought processes related to impaired decision making, neurological symptoms. Interventions included to administer medications as ordered. Further review of the care plan revealed a focus for psychosocial behaviors related to physically and verbally sexual inappropriateness. Interventions included intervening as necessary to protect the rights and safety of others and to monitor behaviors episodes and attempt to determine underlying cause. A review of the progress notes revealed an alert charting entry dated January 19, 2025 that at approximately 04:30am Certified Nursing Assistant (CNA) called nurse to room to find patient with hematoma to left above eye about golf size. According to resident, roommate had beam rummaging through his closet and taking his clothes. When approached about leaving his clothing alone resident was allegedly hit with a water pitcher by the roommate who allegedly threw it at him. Nurses assisted with wound dressing to bleeding hematoma at the time. The progress note stated notifications to administration, Director of Nursing (DON), case worker, and family all completed. The note stated police were also called and resident was sent to emergency room . Review of the progress notes revealed an entry dated January 19, 2025 that stated resident #1 returned from the hospital with no new orders. The resident was observed to have knots around the left side of forehead that had two steri-strips. The progress note stated the report from emergency room nurse from the hospital stated the CT scan was negative. -Regarding resident #2: Resident #2 was admitted on [DATE] with diagnosis that included other acute osteomyelitis, left ankle and foot, major depressive disorder, recurrent, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the Medicare 5-day MDS dated [DATE] revealed a BIMS (brief interview of mental status) score of 7 indicating severe cognitive impairment. Further review of the MDS revealed a severity score of 7 for mood and delusional behaviors. A review of the resident's care plan, date-initiated on January 15, 2025 revealed a focus for psychosocial behaviors; related to psych diagnosis; monitoring for agitation and sad mood. Interventions included to intervene as necessary to protect the rights and safety of others and approach/speak in a calm manner, divert attention and remove from the situation and take to an alternate location as needed. Review of the progress notes revealed an alert note entry dated January 19, 2025 that resident was allegedly involved in an altercation with his roommate. The progress note stated resident #2 threw a water pitcher at his roommate. Review of the progress notes revealed a health status note dated January 21, 2025 that resident is on change of condition for resident to resident altercation. The progress noted stated no increased agitation noted or reported. It further stated no physical or verbal aggression or roommate conflict. A request was made for the facility self-report or any documentation from the investigation on January 23, 2025 at 11:50 a.m. Staff #320 replied in writing on January 23, 2025 at 12:35 p.m. Our investigation is still in progress, report currently not available. An interview was conducted on January 23, 2025 at 2:03p.m. with resident #1. During the interview it was observed that resident #1 had a hematoma with a small cut in the center on the left side of the resident forehead. Also noted a laceration approximately one inch in length on the left top of the resident's head and purple and blue bruising to the left corner of the resident's eye. During the interview with Resident #1, resident #1 stated the incident occurred between 2:00a.m and 5:00a.m. Resident #1 stated resident #2 was removing clothing from resident #1's closet. Resident #1 stated he got out of bed and went to the bathroom and when he returned resident #2 had put resident #1's pants on and was also attempting to put on one his shirts. Resident #1 stated he tried to grab his shirt and this is when resident #2 grabbed a plastic water pitcher filled with water and clonked me on the head 2-4 times. Resident #1 stated he yelled for his roommate, resident #4 to call for the nurse. Resident #1 stated a nurse came in and asked what was going on. Resident #1 stated he told the nurse resident #2 was taking his clothing from his closet and she turned around and left. Resident #1 could not recall the name of the nurse or provide any identifiers. Resident #1 stated CNA #5 entered the room because the call light was still on and saw the bleeding from his forehead and went for a nurse who treated the wound and sent the resident to the hospital for a CT scan. Resident #1 stated nursing staff were aware of prior incidents of resident #2 taking his clothing. An attempt to interview resident #2 was conducted on January 23, 2025 at 2: 03 p.m. resident was observed on sitting on the patio talking to himself and grasping at the air. Due to the resident's cognition the interview was unable to be completed. An interview was conducted on January 23, 2025 at 2: 15p.m with resident #4. Resident #4 stated resident #2 would often take his food and water from his bedside table. Resident #4 stated he observed the altercation between resident #1 and #2. Resident #4 stated he observed resident #2 swing the cup that holds the water, raising it above his head swinging at resident #1 head. Resident #4 stated Resident #2 hit resident #1 in the head and then swung again hitting him on the head again. Resident #4 stated resident #1 called for him stating help me. Resident #4 stated he was too slow to help as he was in bed before he was able to get to him. Resident #4 stated as he was walking toward resident #1 he observed resident #2 jab resident #1 with his walker. Resident #4 stated I saw a hole on resident #1 head and blood streaming down his head and neck. Resident #4 stated he turned on the call light and two nursing staff came in. Resident #4 stated he informed the nursing staff what had happened. Resident #4 stated his bed is located directly in front of resident #1. Resident #4 stated every night it was something with resident #2 and resident #2 was always in resident #1 closet going through his clothing and trying to wear them. Attempt to contact CNA/Staff #5 was conducted on January 23, 2025 at 2:12 p.m. Message left for a return phone call. An interview was conducted on January 23, 2025 at 2:21 p.m. with CNA/Staff #9. Staff # 9 stated she has worked with both resident #1 and #2. Staff #9 stated resident #2 had a recent room change due to an incident with resident #1. Staff #9 stated she had heard that resident #2 had went up to resident #1 and hit him with a cup. Staff #9 stated she has not observed any aggressive behaviors from resident #2, but said that he can be non-compliant with care. Staff #9 stated when there is an incident involving residents that the expectation is that the residents are placed on 1:1 supervision with an immediate room change. Staff #9 stated she has received abuse training and has been trained that staff are to separate the residents involved, report immediately, monitor the situation and take the victim away and out of the situation. An interview was conducted on January 23, 2025 at 2: 03p.m with Licensed Practical Nurse LPN/Staff #7. Staff #7 stated if staff are made aware of an altercation between residents they are to immediately separate, look for injuries, follow the reporting process, notifying the administrator. Staff #7 stated she was informed through report that resident #1 had injuries from an altercation with resident #2. Staff #7 stated there were no reported injuries with resident #2. Staff #7 stated resident #1 is on behavior monitoring for medications and has not received any reports for non-compliance with care. Staff #7 stated there have been no prior incidents with residents #1 or #2. An interview was conducted on January 23, 2025 at 2:55 p.m. with Director of Nursing DON/Staff #30. The DON stated she received a call from Assistant Director of Nursing/ADON/Staff #42 the morning of January 20 at 4:42am informing her that there was an alleged resident to resident altercation and that resident # 2 had thrown a water pitcher at resident #1. Staff #30 stated when she interviewed resident #1 he had informed her that resident #2 was in his closet and when he had told him to get out of his closet that resident #2 had thrown the water pitcher at him. Staff #30 stated the process for reporting alleged abuse is to contact the abuse coordinator, the DON, ADON, other state agencies, family and provider. Staff #30 stated both residents were assessed for potential injuries with a skin check and that resident #1 was sent to the hospital due to a hematoma on his head it was bleeding at the time. Staff #30 stated a CT was conducted at the hospital revealing no findings or new orders. A review was conducted of Point Click Care (PCC) , the facility data base for residents by staff #30 revealing no skin assessment completed at the time of injury or following. Further review by Staff #30 revealed no documentation of the laceration on the top L side of resident #1's head. Staff #30 stated she was unaware of the laceration. Staff #30 stated it is her expectation that a skin evaluation and change of condition be completed. Staff #30 stated the risks of not completing the skin assessment can lead to reports of injuries of unknown origin, leading to a delay in treatment and care of the resident. Staff #30 further stated the progress notes of the resident to resident incident is not detailed or thorough and the risks associated with this is missing key information in how to treat or care for the resident when you don't provide accurate documentation. Staff # 30 stated the facility did not have a final hospital report, but would request one. Further review of PCC by staff 30 revealed no documentation for the 1:1 provided for resident #2 or the room change. An interview was conducted on January 23, 2025 at 3:59 p.m. with CNA /Staff #5. Sattf #5 stated she was working the night shift on January 20, 2025 when she noticed the call light on in residents #1, #4 and #2 room. Staff #5 stated when she entered the room she noticed water and shaving cream on the floor. Staff # 5 stated resident #1 was in the bathroom and when he came out she noticed his head and forehead were bleeding. Staff #5 stated resident #2 was sitting on his bed dressed head to toe in resident #1's clothing. Staff #5 stated she immediately went to get the nurse. Staff #5 resident #1 was found to have a knot to the left side of his forehead near his eye and a cut on left top of his head. Staff #5 stated resident #1 informed her and the registry nurse that resident #2 had hit him on top of the head with the water pitcher. Staff #5 stated the nurse addressed resident #1's injuries and that she helped change resident #2 clothing which was wet with water and shaving cream. Staff #5 stated she took resident #2 to the dining room, providing him 1:1 supervision until the day shift arrived. Staff #5 stated resident #1 was sent to the hospital. Staff #5 stated resident #1 had previously informed her that resident #2 would go into other residents' closets and wander around, but no prior incidents of abuse. Staff #5 stated she did not report the information. An interview was conducted on January 23, 2025 at 4:39 p.m. with Abuse Coordinator/ Administrator /Staff # 20. Staff #20 stated he was notified of the alleged abuse at approximately 4:30 am on January 20, 2025. It was reported that resident #2 was confused and had gone through resident #1's things and when asked to stop, resident #2 tossed the cup or mug at him. Staff #20 stated the residents were immediately separated and contacted the provider. The provider asked that resident #1 be sent to the hospital to be evaluated. Staff had reported resident #1 had a cut above his eye. Staff #20 stated resident #2 was separated from all residents and monitored by staff. Staff #20 stated resident #2 was moved to anther room once resident #1 was sent to the hospital. Staff #20 stated interviews were conducted with the other roommates who were available. Staff #20 stated the investigation is ongoing, but does not feel that there was malicious intent. Staff #20 stated resident #2 was moved to another room the same morning. The request for hospital records were provided on January 23, 2025 at 4:42 p.m. The admission physical assessment revealed resident #1 had 2 small hematomas on the frontal aspect and parietal aspect with overlying small lacerations that were closed with steri-strips. Further review of the hospital report revealed resident #1 informed hospital staff that he wanted to press charges and that security was notified to have a police report made. A review of the facility policy titled Charting and Documentation states all services provided to the resident, progress toward the care plan goals, or nay changes in the residents medical, physical, functional or psychosocial condition, shall be documented in the residents medical record. The medical record should facillitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that a resident was not abused by another resident for 2 of 3 sampled residents (#1 and #3). The deficient practice could result in continued psychosocial and/or physical harm to resident. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A care plan dated February 12, 2024, revealed that the resident has a communication problem due to expressive aphasia with an intervention in place that Resident #1 is able to communicate by answering yes/no questions, hand gestures, and utilizing a communication book. Additionally, an intervention was to validate Resident #1's message by repeating aloud. An additional care plan revised April 04, 2024, revealed that Resident #1 has a behavioral problem and can demonstrate physical aggression toward others, with resident-to-resident incidents listed on June 6 and June 18, 2023. Interventions included intervene as necessary to protect the rights and safety of others, and to document behavior and possible causes. There was no evidence of an update to the care plan for an incident occurring January 4, 2025. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A physician order dated January 4, 2025, revealed a change in condition for: redness/ mild edema to left eye orbital, and that the provider was notified. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was no evidence of a physician order for one to one staff monitoring for Resident #1. A review of the facility's Incident Report Log revealed no evidence of any incident report for Resident #1 on January 4, 2025. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that at approximately 9:00 a.m., on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 had slight redness to his eye. The report revealed that the resident is difficult to understand due to aphasia, however said something like '[NAME]' and was hitting/making hitting actions to his left eye. Further, the report revealed that we cannot tell if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. The report revealed that an additional staff member has been placed to provide consistent observation between Resident #1 and his two roommates. The SBAR Communication Form dated January 04, 2025, revealed that a change in condition for Resident #1 happened on January 04, 2025, and that under the patient evaluation section titled Behavioral Evaluation the box was checked for Not clinically applicable to the change in condition being reported. Further, under the section Neurological Evaluation, the box was checked for not clinically applicable to the change in condition being reported. Additionally, under the section titled Skin Evaluation, a box was checked for Abrasion, with an additional description provided: noted redness/ mild swelling to the left eye orbital; no pain - will monitor unless otherwise instructed by MD. The note contained no evidence or description as to how the redness and mild swelling to the resident's left eye occurred. -Regarding Resident #3: Resident #3 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of brain, brief psychotic disorder, and acute kidney failure. A Health Status note dated January 4, 2025, at 2:56 PM, revealed that Resident #3 is on a change in condition for his new admission to the facility. Patient is alert and oriented x 4. Patient is able to make needs known verbally. There was no evidence in the note that the resident was on one to one staff monitoring. There was no evidence of progress notes dated January 4, 2025, documenting a resident to resident incident involving Resident #3. A Physician Progress Note dated January 4, 2025, signed by the Medical Director (Staff #18), revealed that Resident #3 has already been in physical confrontation apparently, and that Behavioral health will be consulted for his aggressive behavior and psychosis. A Health Status Note dated January 5, 2025, revealed that Resident #3 was on a change of condition for a resident to resident altercation. The note stated resident was agitated and noncompliant with medication and vital signs. The note stated the reesident has a one to one staff for monitoring and has no physical or verbal aggression toward peers / staff this shift thus far. A Health Status Note dated January 6, 2025, revealed that Resident #3 was transported out to the hospital to be assessed for altered mental status, aggression, and combativeness with staff and residents, and undressing. A physician order dated January 6, 2025, indicated to send the resident out to the hospital due to altered mental status, possible infection, highly aggressive behaviors, and combativeness. There was no evidence of a physician order for one to one staff monitoring. The resident's baseline care plan, signed January 8, 2025, revealed an initial goal for coping skills and adjustments to situations and new environments, with an intervention to refer to psychiatrist/Psychologist as indicated. There was no evidence of a care plan update to address the resident's aggressive or combative behaviors. A formal request was made to the facility on [DATE], for any written statements from staff members or witnesses and any investigation interviews regarding the incident involving Resident #1 that occurred on January 4, 2025. The facility administrator signed a statement that the facility had none to date. However, despite this signed statement of having no written statements or interviews on January 8, the facility submitted a 5-day investigation report to the state health department on January 10, 2025. The investigation report revealed the following documented interviews: -January 4, 2025: A phone interview between the Administrator and Resident #1 -January 4, 2025: An additional phone interview between the Administrator and Resident #1, where Resident #1 performed a hitting motion toward his eye and stating [NAME] [NAME]. -January 5, 2025: An interview between Resident #1 and staff where Resident #1 identified by pointing that Resident #3 was the individual that [NAME] [NAME] on him. -January 6, 2025: An additional interview between the Administrator and Resident #1. Additional undated interviews included in the 5-day investigation report revealed: -The ADON (Staff #31) and Human Resources staff interviewed a Certified Nursing Assistant (CNA/ Staff #90), who was the assigned CNA during the shift of the alleged incident. Staff #90 stated that she did not witness the incident between the residents but overheard yelling and went to investigate. Resident #1 was outside of his room heading back to his room, and was stating repeated expletives, while making hitting motions toward his eye and stating [NAME], [NAME], [NAME]. Staff #90 asked if Resident #1 was hit and he shook his head, yes. She followed Resident #1 to his room and noticed that Resident #3 was sitting on Resident #1's bed. Staff #90 called on the radio for assistance from the nurse, and the nurse came. As both staff were getting Resident #3 back to his room, Resident #1 was pointing at Resident #3 and stating expletives and [NAME], [NAME]. The staff took statements from each resident after separating them to each of their rooms. Resident #1 stated he was struck by Resident #3. Resident #3 stated that Resident #1 kicked him in the balls 4 times. -The ADON and Human Resources staff interviewed a licensed practical nurse (LPN/ Staff #2) the assigned nurse to Resident #1 and Resident #3 on the night shift of the alleged incident, January 3 - 4, 2025.The interview revealed that the LPN stated that both residents are claiming the other struck them (that Resident #1 was struck in the eye by Resident #3, and that Resident #3 was kicked multiple times by Resident #1). -The Administrator interviewed an LPN (Staff #14), who stated she did not witness the event but that she saw Resident #1 had slight redness to his eye. Resident #1 kept telling her [NAME] and pointing or making a hitting motion to his eye. Additionally, the facility 5-day investigation report revealed that the redness on Resident #1's eye appears to be self-inflicted (from rubbing or touching it) rather from blunt force trauma (being struck by something). An Employee Coaching Form signed January 6, 2025, for the LPN (Staff #2) revealed that the nurse was being terminated. The nurse failed to complete admission requirements for a new resident and failed to report potential resident to resident altercation within the timeframe specified. An interview was conducted on January 8, 2025, at 10:11 AM, with a CNA (Staff #12), who stated that she was familiar with Resident #1, and that he is territorial with his belongings in his room and that he had an altercation with the new resident in his room. She stated that the night shift CNA (Staff #90) told her about the incident. Staff #12 stated that she had heard that the other resident hit Resident #1 in the eye. She stated that Resident #1 would not hit himself in the face. An interview was conducted on January 8, 2025, at 10:15 AM, with the CNA (Staff #90) who was assigned to the residents at the time of the incident. She stated she was in a nearby room providing care to another resident with the door open. She stated that she was not sure of the time, but that it was around 5:00 AM on January 4, 2025, that she heard Resident #1 coming out of his room yelling I hate you along with the expletive motherf*****. Staff #90 stated that she went to see what was wrong, and that Resident #1 was slouched over in his wheelchair in the doorway of his room facing his bed. She stated that she observed Resident #3 in Resident #1's room, sitting on his bed, and wearing Resident #1's jacket and pants. She stated that she called on the radio for the nurse to come assist. She stated that Resident #1 was unresponsive at first, then appeared to regain consciousness. She stated that then the nurse arrived and that Resident #3 was redirected to his room. She stated that Resident #1 was gesturing to indicate that Resident #3 had hit him. She stated that Resident #3 admitted multiple times to hitting Resident #1 and that he further stated that he only hit him because he hit me in the balls. Staff #90 further stated that after the incident that shift, that Resident #1 was very agitated and angry afterward, that he kept bringing up the situation. After the incident, Staff #90 stated that the nurse had told her to make sure that the two residents don't talk to each other, but that Staff #90 then stated back to the nurse that she had to do her round assignments, and that the nurse left it at that. Staff #90 stated that she asked the nurses at the nurse's station what she should do, and that she was advised to make a written statement of the incident and to leave it in the cubby at the nurse's station. Staff #90 stated that a room change was not done, but that staff started a one-to-one monitoring of the residents the following morning shift. A telephonic interview was conducted with an LPN (Staff #14) on January 8, 2025 at 10:40 AM. Staff #14 stated that she arrived for her shift at approximately 6:00 AM on January 4, 2025, after the alleged incident involving Residents #1 and #3 had occurred. She stated that she was informed by the night nurse that there was an allegation that Resident #1 was hit by another resident. She stated that a little later in her shift, she noticed that Resident #1 had redness and swelling to his left eye. She stated that she followed up with the Director of Nursing and the Administrator to make sure that it was reported. She stated that she also notified the Medical Director. The LPN stated that the facility placed a one to one monitor on the residents as soon as we could on my shift. A telephonic interview was conducted on January 8, 2025, at 12:50 PM, with the facility's Medical Director and on-call physician (Staff #18). The Medical Director stated that he recalled being notified of the resident-to-resident physical altercation on January 4, 2025, and that it involved a potential head injury on Resident #1. A telephonic interview was conducted on January 8, 2025, at approximately 2:21 PM, with an LPN (Staff #28), who was the residents' assigned night shift nurse the following night after the incident. Staff #28 stated that I was told there was a resident-to-resident altercation and that Resident #1 was on a change of condition status. She additionally stated that he had bruising on the area of his eye, and that she noticed it the day after it happened. An observation was conducted on January 8, 2025, at 2:33 PM, of Resident #1 in his wheelchair in his room. Resident #1 consented to having the surveyor and a nurse observe his face. On the inside aspect of Resident #1's left eye, on the skin between his eye and his nose, was purple colored bruising. His right eye had no discoloration present. An interview was conducted with Resident #1 at this time. When asked if the resident recalled getting into an incident with another resident, Resident #1 clearly stated yes, then some unintelligible words, and then [NAME], [NAME], [NAME], and motioned toward his face with his fist without making actual contact. When asked who did that?, Resident #1 pointed toward the room of where Resident #3 had resided. An interview was conducted with an LPN (Staff #40) on January 8, 2025, at 2:44 PM, who came to Resident #1's room together for an observation of the resident's face. Regarding the marking on the inside of Resident #1's left eye, Staff #40 stated that she saw discoloration and that she further described the color as diminished purple. Staff #40 stated that she was not sure what the discoloration was from because she was off of work for a few days, but that she knew he had a resident-to-resident altercation. She further stated that she believed the other resident involved in that incident was Resident #3. An interview was conducted on January 8, 2025, at 3:08 PM, with the ADON (Staff #31), who stated that if there is an allegation of abuse, that the facility staff is to respond by separating the two residents, and to report the allegation to the mandatory reporting agencies within a 2-hour window. The facility staff is to protect the residents either through increased supervision, or room changes, or through one to one staff monitoring. A skin assessment is done on the residents, and an incident report should be completed, along with a progress note describing the incident. She stated that if staff did not complete an incident report or document the incident in a progress note, that it would not meet her expectations. When reviewing the medical record of Resident #1 together, the ADON stated that she did not see any notes describing the resident to resident incident. She stated that in regard to the incident, that she did the interview with the nurse (Staff #2), and that there was an allegation of a resident-to-resident incident, but that she was not sure that it happened. She stated that the nurse did not report it to her within the mandatory 2-hour timeframe. She then stated that Staff #2 was terminated for failing to let the facility know of the alleged abuse timely. An interview was conducted on January 8, 2025, at 3:40 PM, with the Director of Nursing (DON/ Staff #63). The DON stated that the facility's process if there is an alleged abuse incident is for staff to notify the clinical managers, to notify the physician, notify the patient's guardian or power of attorney, to complete a risk management (incident report), to place any new orders from the physician, and to place the resident on a change of condition for 72 hour monitoring. The DON stated that the facility then investigates the incident by talking to residents and staff to see what happened, and that a progress note is completed, and a report made to the required reporting agencies. The facility protects the residents after an alleged abuse incident by placing the residents on one to one staff monitoring or providing a room change or by frequent monitoring. The DON further stated that her expectation is for staff to provide documentation in the clinical record of what they observed, to provide statements, to document any injuries, and what action was taken. The DON stated that regarding incident between Resident #1 and #3 on the night between January 3 and 4, 2025, that the Administrator had called her about a potential resident-to-resident allegation of abuse. She stated that we don't know if it truly happened, and that the night nurse did not report the incident within the 2 hours. The clinical record of Resident #1 was reviewed together at that time with the DON. The DON stated that she did not see any progress note about the incident, and that it would not meet her expectation for documentation of an alleged incident. She additionally confirmed that a risk management (incident report) had not been completed. She stated that the night nurse was terminated for not reporting the incident timely. The DON stated that at approximately 10:27 AM after the incident was when she called the staffing coordinator to ensure that one-to-one monitoring was in place for the protection of Resident #1 and Resident #3. A telephonic interview was conducted with the LPN (Staff #2) on January 9, 2024 at 8:04 AM. The LPN stated that she was a new nurse to that facility, and that she confirmed that she was the residents' assigned nurse on the night shift between January 3 and 4, 2024. She stated that she admitted Resident #3 into the facility that evening of January 3, 2024 at approximately 6:30 PM. She stated Resident #3 was confused and was looking for the bathroom. She stated that Resident #1 is hard to understand and that you really have to listen to what he is saying to understand him. She stated that Resident #1 kept coming out of his room saying that Resident #3 was coming into his room. She stated that she kept redirecting Resident #3 back to his own room, and Resident #1 continued to bang on the nurses' room door saying that Resident #3 was still coming to his room. She stated that at approximately 3:30 -3:40 AM, Resident #1 came out of his room pointing at his face and was saying he had been hit. She stated that when the CNA and herself got to Resident #1's room, they observed Resident #3 in the room. She stated that since she is a new nurse at the facility, that she asked the other nurse at the nurses' station what she should do in this situation since a resident is stating that he was hit in the face. She stated that the other nurse instructed her to call the ADON (Staff #31). The interview continued and Staff #2 stated she placed a call to the ADON sometime between 3:35 and 3:45 AM. She stated the ADON did not answer, so a voicemail was left. Approximately sometime between 5:00 and 5:45 AM, she placed another call to the ADON, in which the ADON answered. Staff #2 stated that she told the ADON what had happened with the incident, and that the ADON responded and said that Resident #1 reacts to things like this. Staff #2 stated that the ADON then called someone else and Staff #2 was then speaking to a male's voice on the phone, whom she believed was the facility's Administrator. She stated that this person said that they didn't think this was an altercation. Staff #2 stated that she told the person on the phone that all night I was taking Resident #3 out of Resident #1's room. Further, Staff #2 stated that the ADON had told her not to document the incident in the medical record. Staff #2 told the ADON that she had written paper notes on the incident, and that the ADON had told her to hold on and wait for her guidance on what to write in the charts. Staff #2 stated that I didn't even leave that morning until 8:00 because I had a lady fall. She further stated that she felt overwhelmed that shift. The interview continued and Staff #2 stated that after Resident #1 had told her that he was hit in the face, that she believed he was afraid to lie back down in his bed to sleep because of Resident #3 who kept coming into his room. She stated that she sat with Resident #1 for a while in his room to help him calm down, and that every 30 minutes to an hour that she and the CNAs were checking on him. Staff #2 stated, in regard to her termination, that the ADON had fired her because the CNA's were saying that she was rude to them, and that she did not finish the admission for that night. She stated that the ADON had brought up that she did not report the allegation of abuse within the mandated timeframe, but that Staff #2 had told the ADON that she had first called her around 3:45 AM and that the incident had just happened about 5 minutes before that. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that Residents have the right to be free from abuse. The policy revealed that the facility will ensure adequate staffing and oversight to prevent burnout, stressful working situations, and high turnover rates. The facility will identify and investigate all possible incidents of abuse, and within timeframes required by federal requirements. Additionally, the facility will protect residents from any further harm during investigations.

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 2 of 3 sampled residents (#1 and #3). The deficient practice could lead to a failure of the facility to fully investigate and report allegations of abuse within required timeframes, and could lead to harm to a resident. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A physician order dated January 4, 2025, revealed a change in condition for: redness/ mild edema to left eye orbital, and that the provider was notified. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was no evidence of a physician order for one to one staff monitoring for Resident #1. A review of the facility's Incident Report Log revealed no evidence of any incident report for Resident #1 on January 4, 2025. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that at approximately 9:00 a.m., on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 had slight redness to his eye. The report revealed that the resident is difficult to understand due to aphasia, however said something like '[NAME]' and was hitting/making hitting actions to his left eye. Further, the report revealed that we cannot tell if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. The report revealed that an additional staff member has been placed to provide consistent observation between Resident #1 and his two roommates. There was no evidence of an update to the care plan for an incident occurring January 4, 2025. -Regarding Resident #3: Resident #3 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of brain, brief psychotic disorder, and acute kidney failure. A Health Status note dated January 4, 2025, at 2:56 PM, revealed that Resident #3 is on a change in condition for his new admission to the facility. Patient is alert and oriented x 4. Patient is able to make needs known verbally. There was no evidence in the note that the resident was on one to one staff monitoring. There was no evidence of progress notes dated January 4, 2025, documenting a resident to resident incident involving Resident #3. A Physician Progress Note dated January 4, 2025, signed by the Medical Director (Staff #18), revealed that Resident #3 has already been in physical confrontation apparently, and that Behavioral health will be consulted for his aggressive behavior and psychosis. A Health Status Note dated January 5, 2025, revealed that Resident #3 was on a change of condition for a resident to resident altercation. Resident was agitated and noncompliant with medication and vital signs. Resident has a one to one staff for monitoring. Resident has no physical or verbal aggression toward peers / staff this shift thus far. There was no evidence of a physician order for one to one staff monitoring. There was no evidence of a care plan update to address the resident's aggressive or combative behaviors. A formal request was made to the facility on [DATE], for any written statements from staff members or witnesses and any investigation interviews regarding the incident involving Resident #1 that occurred on January 4, 2025. The facility administrator signed a statement that the facility had none to date. However, despite this signed statement of having no written statements or interviews on January 8, the facility submitted a 5-day investigation report to the state health department on January 10, 2025. The investigation report revealed the following documented interviews: -January 4, 2025: A phone interview between the Administrator and Resident #1 -January 4, 2025: An additional phone interview between the Administrator and Resident #1, where Resident #1 performed a hitting motion toward his eye and stating [NAME] [NAME]. -January 5, 2025: An interview between Resident #1 and staff where Resident #1 identified by pointing that Resident #3 was the individual that [NAME] [NAME] on him. -January 6, 2025: An additional interview between the Administrator and Resident #1. Additional undated interviews included in the 5-day investigation report revealed: -The ADON (Staff #31) and Human Resources staff interviewed a Certified Nursing Assistant (CNA/ Staff #90), who was the assigned CNA during the shift of the alleged incident. Staff #90 stated that she did not witness the incident between the residents but overheard yelling and went to investigate. Resident #1 was outside of his room heading back to his room, and was stating repeated expletives, while making hitting motions toward his eye and stating [NAME], [NAME], [NAME]. Staff #90 asked if Resident #1 was hit and he shook his head, yes. She followed Resident #1 to his room and noticed that Resident #3 was sitting on Resident #1's bed. Staff #90 called on the radio for assistance from the nurse, and the nurse came. As both staff were getting Resident #3 back to his room, Resident #1 was pointing at Resident #3 and stating expletives and [NAME], [NAME]. The staff took statements from each resident after separating them to each of their rooms. Resident #1 stated he was struck by Resident #3. Resident #3 stated that Resident #1 kicked him in the balls 4 times. -The ADON and Human Resources staff interviewed a licensed practical nurse (LPN/ Staff #2) the assigned nurse to Resident #1 and Resident #3 on the night shift of the alleged incident, January 3 - 4, 2025.The interview revealed that the LPN stated that both residents are claiming the other struck them (that Resident #1 was struck in the eye by Resident #3, and that Resident #3 was kicked multiple times by Resident #1). -The Administrator interviewed an LPN (Staff #14), who stated she did not witness the event but that she saw Resident #1 had slight redness to his eye. Resident #1 kept telling her [NAME] and pointing or making a hitting motion to his eye. Additionally, the facility 5-day investigation report revealed that the redness on Resident #1's eye appears to be self-inflicted (from rubbing or touching it) rather from blunt force trauma (being struck by something). An Employee Coaching Form signed January 6, 2025, for the LPN (Staff #2) revealed that the nurse was being terminated. The nurse failed to complete admission requirements for a new resident and failed to report potential resident to resident altercation within the timeframe specified. An interview was conducted on January 8, 2025, at 10:11 AM, with a CNA (Staff #12), who stated that she was familiar with Resident #1, and that he is territorial with his belongings in his room and that he had an altercation with the new resident in his room. She stated that the night shift CNA (Staff #90) told her about the incident. Staff #12 stated that she had heard that the other resident hit Resident #1 in the eye. She stated that Resident #1 would not hit himself in the face. An interview was conducted on January 8, 2025, at 10:15 AM, with the CNA (Staff #90) who was assigned to the residents at the time of the incident. She stated she was in a nearby room providing care to another resident with the door open. She stated that she was not sure of the time, but that it was around 5:00 AM on January 4, 2025, that she heard Resident #1 coming out of his room yelling I hate you along with the expletive motherf*****. Staff #90 stated that she went to see what was wrong, and that Resident #1 was slouched over in his wheelchair in the doorway of his room facing his bed. She stated that she observed Resident #3 in Resident #1's room, sitting on his bed, and wearing Resident #1's jacket and pants. She stated that she called on the radio for the nurse to come assist. She stated that Resident #1 was unresponsive at first, then appeared to regain consciousness. She stated that then the nurse arrived and that Resident #3 was redirected to his room. She stated that Resident #1 was gesturing to indicate that Resident #3 had hit him. She stated that Resident #3 admitted multiple times to hitting Resident #1 and that he further stated that he only hit him because he hit me in the balls. Staff #90 further stated that after the incident that shift, that Resident #1 was very agitated and angry afterward, that he kept bringing up the situation. After the incident, Staff #90 stated that the nurse had told her to make sure that the two residents don't talk to each other, but that Staff #90 then stated back to the nurse that she had to do her round assignments, and that the nurse left it at that. Staff #90 stated that she asked the nurses at the nurse's station what she should do, and that she was advised to make a written statement of the incident and to leave it in the cubby at the nurse's station. Staff #90 stated that a room change was not done, but that staff started a one-to-one monitoring of the residents the following morning shift. A telephonic interview was conducted with an LPN (Staff #14) on January 8, 2025 at 10:40 AM. Staff #14 stated that she arrived for her shift at approximately 6:00 AM on January 4, 2025, after the alleged incident involving Residents #1 and #3 had occurred. She stated that she was informed by the night nurse that there was an allegation that Resident #1 was hit by another resident. She stated that a little later in her shift, she noticed that Resident #1 had redness and swelling to his left eye. She stated that she followed up with the Director of Nursing and the Administrator to make sure that it was reported. She stated that she also notified the Medical Director. The LPN stated that the facility placed a one to one monitor on the residents as soon as we could on my shift. A telephonic interview was conducted on January 8, 2025, at 12:50 PM, with the facility's Medical Director and on-call physician (Staff #18). The Medical Director stated that he recalled being notified of the resident-to-resident physical altercation on January 4, 2025, and that it involved a potential head injury on Resident #1. A telephonic interview was conducted on January 8, 2025, at approximately 2:21 PM, with an LPN (Staff #28), who was the residents' assigned night shift nurse the following night after the incident. Staff #28 stated that I was told there was a resident-to-resident altercation and that Resident #1 was on a change of condition status. She additionally stated that he had bruising on the area of his eye, and that she noticed it the day after it happened. An observation was conducted on January 8, 2025, at 2:33 PM, of Resident #1 in his wheelchair in his room. Resident #1 consented to having the surveyor and a nurse observe his face. On the inside aspect of Resident #1's left eye, on the skin between his eye and his nose, was purple colored bruising. His right eye had no discoloration present. An interview was conducted with Resident #1 at this time. When asked if the resident recalled getting into an incident with another resident, Resident #1 clearly stated yes, then some unintelligible words, and then [NAME], [NAME], [NAME], and motioned toward his face with his fist without making actual contact. When asked who did that?, Resident #1 pointed toward the room of where Resident #3 had resided. An interview was conducted with an LPN (Staff #40) on January 8, 2025, at 2:44 PM, who came to Resident #1's room together for an observation of the resident's face. Regarding the marking on the inside of Resident #1's left eye, Staff #40 stated that she saw discoloration and that she further described the color as diminished purple. Staff #40 stated that she was not sure what the discoloration was from because she was off of work for a few days, but that she knew he had a resident-to-resident altercation. She further stated that she believed the other resident involved in that incident was Resident #3. An interview was conducted on January 8, 2025, at 3:08 PM, with the ADON (Staff #31), who stated that if there is an allegation of abuse, that the facility staff is to respond by separating the two residents, and to report the allegation to the mandatory reporting agencies within a 2-hour window. The facility staff is to protect the residents either through increased supervision, or room changes, or through one to one staff monitoring. A skin assessment is done on the residents, and an incident report should be completed, along with a progress note describing the incident. She stated that if staff did not complete an incident report or document the incident in a progress note, that it would not meet her expectations. When reviewing the medical record of Resident #1 together, the ADON stated that she did not see any notes describing the resident to resident incident. She stated that in regard to the incident, that she did the interview with the nurse (Staff #2), and that there was an allegation of a resident-to-resident incident, but that she was not sure that it happened. She stated that the nurse did not report it to her within the mandatory 2-hour timeframe. She then stated that Staff #2 was terminated for failing to let the facility know of the alleged abuse timely. An interview was conducted on January 8, 2025, at 3:40 PM, with the Director of Nursing (DON/ Staff #63). The DON stated that the facility's process if there is an alleged abuse incident is for staff to notify the clinical managers, to notify the physician, notify the patient's guardian or power of attorney, to complete a risk management (incident report), to place any new orders from the physician, and to place the resident on a change of condition for 72-hour monitoring. The DON stated that the facility then investigates the incident by talking to residents and staff to see what happened, and that a progress note is completed, and a report made to the required reporting agencies. The facility protects the residents after an alleged abuse incident by placing the residents on one to one staff monitoring or providing a room change or by frequent monitoring. The DON further stated that her expectation is for staff to provide documentation in the clinical record of what they observed, to provide statements, to document any injuries, and what action was taken. The DON stated that regarding incident between Resident #1 and #3 on the night between January 3 and 4, 2025, that the Administrator had called her about a potential resident-to-resident allegation of abuse. She stated that we don't know if it truly happened, and that the night nurse did not report the incident within the 2 hours. The clinical record of Resident #1 was reviewed together at that time with the DON. The DON stated that she did not see any progress note about the incident, and that it would not meet her expectation for documentation of an alleged incident. She additionally confirmed that a risk management (incident report) had not been completed. She stated that the night nurse was terminated for not reporting the incident timely. The DON stated that at approximately 10:27 AM after the incident was when she called the staffing coordinator to ensure that one-to-one monitoring was in place for the protection of Resident #1 and Resident #3. A telephonic interview was conducted with the LPN (Staff #2) on January 9, 2024 at 8:04 AM. The LPN stated that she was a new nurse to that facility, and that she confirmed that she was the residents' assigned nurse on the night shift between January 3 and 4, 2024. She stated that she admitted Resident #3 into the facility that evening of January 3, 2024 at approximately 6:30 PM. She stated Resident #3 was confused and was looking for the bathroom. She stated that Resident #1 is hard to understand and that you really have to listen to what he is saying to understand him. She stated that Resident #1 kept coming out of his room saying that Resident #3 was coming into his room. She stated that she kept redirecting Resident #3 back to his own room, and Resident #1 continued to bang on the nurses' room door saying that Resident #3 was still coming to his room. She stated that at approximately 3:30 -3:40 AM, Resident #1 came out of his room pointing at his face and was saying he had been hit. She stated that when the CNA and herself got to Resident #1's room, they observed Resident #3 in the room. She stated that since she is a new nurse at the facility, that she asked the other nurse at the nurses' station what she should do in this situation since a resident is stating that he was hit in the face. She stated that the other nurse instructed her to call the ADON (Staff #31). The interview continued and Staff #2 stated she placed a call to the ADON sometime between 3:35 and 3:45 AM. She stated the ADON did not answer, so a voicemail was left. Approximately sometime between 5:00 and 5:45 AM, she placed another call to the ADON, in which the ADON answered. Staff #2 stated that she told the ADON what had happened with the incident, and that the ADON responded and said that Resident #1 reacts to things like this. Staff #2 stated that the ADON then called someone else and Staff #2 was then speaking to a male's voice on the phone, whom she believed was the facility's Administrator. She stated that this person said that they didn't think this was an altercation. Staff #2 stated that she told the person on the phone that all night I was taking Resident #3 out of Resident #1's room. Further, Staff #2 stated that the ADON had told her not to document the incident in the medical record. Staff #2 told the ADON that she had written paper notes on the incident, and that the ADON had told her to hold on and wait for her guidance on what to write in the charts. Staff #2 stated that I didn't even leave that morning until 8:00 because I had a lady fall. She further stated that she felt overwhelmed that shift. The interview continued and Staff #2 stated that after Resident #1 had told her that he was hit in the face, that she believed he was afraid to lie back down in his bed to sleep because of Resident #3 who kept coming into his room. She stated that she sat with Resident #1 for a while in his room to help him calm down, and that every 30 minutes to an hour that she and the CNAs were checking on him. Staff #2 stated, in regard to her termination, that the ADON had fired her because the CNA's were saying that she was rude to them, and that she did not finish the admission for that night. She stated that the ADON had brought up that she did not report the allegation of abuse within the mandated timeframe, but that Staff #2 had told the ADON that she had first called her around 3:45 AM and that the incident had just happened about 5 minutes before that. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that Residents have the right to be free from abuse. The policy revealed that the facility will ensure adequate staffing and oversight to prevent burnout, stressful working situations, and high turnover rates. The facility will identify and investigate all possible incidents of abuse, and within timeframes required by federal requirements. Additionally, the facility will protect residents from any further harm during investigations. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised April 2021, revealed that if resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as two hours in any allegation involving abuse. Upon receiving any allegation of abuse, the administrator is responsible for determining what actions are needed for the protection of residents. All allegations are thoroughly investigated. The individual conducting the investigation as a minimum: reviews the documentation and evidence, observes the alleged victim, interviews the person reporting the incident and any witnesses, and the residents, and documents the investigation completely and thoroughly. The administrator or designee provide the appropriate agencies of the findings of the investigation within five working days of the occurrence of the incident. Review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed that all incidents involving residents will be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or department supervisor will promptly initiate and document investigation of the incident, and complete a Risk Management/ Report of Incident.

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that an allegation of abuse was reported to mandatory reporting agencies within the required timeframe for 2 of 3 sampled residents (#1 and #3). The deficient practice could result in abuse allegation not being reported. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that at approximately 9:00 a.m., on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 had slight redness to his eye. The report revealed that the resident is difficult to understand due to aphasia, however said something like 'pow' and was hitting/making hitting actions to his left eye. Further, the report revealed that we cannot tell if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. -Regarding Resident #3: Resident #3 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of brain, brief psychotic disorder, and acute kidney failure. A Health Status Note dated January 5, 2025, revealed that Resident #3 was on a change of condition for a resident to resident altercation. Resident was agitated and noncompliant with medication and vital signs. Resident has a one to one staff for monitoring. Resident has no physical or verbal aggression toward peers / staff this shift thus far. An Employee Coaching Form signed January 6, 2025, for a licensed practical nurse (LPN / Staff #2) revealed that the nurse was being terminated. The nurse failed to complete admission requirements for a new resident and failed to report potential resident to resident altercation within the timeframe specified. An interview was conducted on January 8, 2025, at 10:15 AM, with a certified nursing assistant (CNA / Staff #90) who was assigned to the residents at the time of the incident. She stated she was in a nearby room providing care to another resident with the door open. She stated that she was not sure of the time, but that it was around 5:00 AM on January 4, 2025, that she heard Resident #1 coming out of his room yelling I hate you along with the expletive motherf*****. Staff #90 stated that she went to see what was wrong, and that Resident #1 was slouched over in his wheelchair in the doorway of his room facing his bed. She stated that she observed Resident #3 in Resident #1's room, sitting on his bed, and wearing Resident #1's jacket and pants. She stated that she called on the radio for the nurse to come assist. She stated that Resident #1 was unresponsive at first, then appeared to regain consciousness. She stated that then the nurse arrived and that Resident #3 was redirected to his room. She stated that Resident #1 was gesturing to indicate that Resident #3 had hit him. She stated that Resident #3 admitted multiple times to hitting Resident #1 and that he further stated that he only hit him because he hit me in the balls. An interview was conducted on January 8, 2025, at 3:08 PM, with the ADON (Staff #31), who stated that if there is an allegation of abuse, that the facility staff is to respond by separating the two residents, and to report the allegation to the mandatory reporting agencies within a 2-hour window. She stated that in regard to the incident, that she did the interview with the nurse (Staff #2), and that there was an allegation of a resident-to-resident incident, but that she was not sure that it happened. She stated that the nurse did not report it to her within the mandatory 2-hour timeframe. She then stated that Staff #2 was terminated for failing to let the facility know of the alleged abuse timely. An interview was conducted on January 8, 2025, at 3:40 PM, with the Director of Nursing (DON/ Staff #63). The DON stated that the facility's process if there is an alleged abuse incident is for staff to notify the clinical managers, to notify the physician, notify the patient's guardian or power of attorney, to complete a risk management (incident report), to place any new orders from the physician, and a report is made to the required reporting agencies. The DON stated that regarding incident between Resident #1 and #3 on the night between January 3 and 4, 2025, that the Administrator had called her about a potential resident-to-resident allegation of abuse. She stated that we don't know if it truly happened, and that the night nurse did not report the incident within the 2 hours. A telephonic interview was conducted with the LPN (Staff #2) on January 9, 2024 at 8:04 AM. The LPN stated that she was a new nurse to that facility, and that she confirmed that she was the residents' assigned nurse on the night shift between January 3 and 4, 2024. She stated that she admitted Resident #3 into the facility that evening of January 3, 2024 at approximately 6:30 PM She stated that at approximately 3:30 -3:40 AM, Resident #1 came out of his room pointing at his face and was saying he had been hit. She stated that another nurse instructed her to call the ADON (Staff #31). Staff #2 stated she placed a call to the ADON sometime between 3:35 and 3:45 AM. She stated the ADON did not answer, so a voicemail was left. Approximately sometime between 5:00 and 5:45 AM, she placed another call to the ADON, in which the ADON answered. Staff #2 stated that she told the ADON what had happened with the incident. Staff #2 stated that I didn't even leave that morning until 8:00 because I had a lady fall. She further stated that she felt overwhelmed that shift. She stated that the ADON had brought up that she did not report the allegation of abuse within the mandated timeframe, but that Staff #2 had told the ADON that she had first called her around 3:45 AM and that the incident had just happened about 5 minutes before that. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised April 2021, revealed that all reports of resident abuse are reported to local, state, and federal agencies (as required by current regulations). The administrator or the individual making the allegation reports to the state licensing agency immediately, which is defined as within 2 hours for allegations involving abuse.

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that residents were protected from further abuse during an ongoing investigation of an allegation of abuse for 2 of 3 sampled residents (#1 and #3). The deficient practice could result in continued psychosocial and/or physical harm to a resident. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was no evidence of a physician order for one to one staff monitoring for Resident #1. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that at approximately 9:00 a.m., on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 had slight redness to his eye. The report revealed that the resident is difficult to understand due to aphasia, however said something like 'pow' and was hitting/making hitting actions to his left eye. Further, the report revealed that we cannot tell if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. The report revealed that an additional staff member has been placed to provide consistent observation between Resident #1 and his two roommates. A care plan, revised April 04, 2024, revealed that Resident #1 has a behavioral problem and can demonstrate physical aggression toward others, with resident-to-resident incidents listed on June 6 and June 18, 2023. Interventions included intervene as necessary to protect the rights and safety of others, and to document behavior and possible causes. There was no evidence of an update to the care plan for an incident occurring January 4, 2025. -Regarding Resident #3: Resident #3 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of brain, brief psychotic disorder, and acute kidney failure. A Health Status note dated January 4, 2025, at 2:56 PM, revealed that Resident #3 is on a change in condition for his new admission to the facility. Patient is alert and oriented x 4. Patient is able to make needs known verbally. There was no evidence in the note that the resident was on one to one staff monitoring. There was no evidence of progress notes dated January 4, 2025, documenting a resident to resident incident involving Resident #3. A Physician Progress Note dated January 4, 2025, signed by the Medical Director (Staff #18), revealed that Resident #3 has already been in physical confrontation apparently, and that Behavioral health will be consulted for his aggressive behavior and psychosis. There was no evidence of a physician order for one to one staff monitoring. The resident's baseline care plan, signed January 8, 2025, revealed an initial goal for coping skills and adjustments to situations and new environments, with an intervention to refer to psychiatrist/Psychologist as indicated. There was no evidence of a care plan update to address the resident's aggressive or combative behaviors. An interview was conducted on January 8, 2025, at 10:15 AM, with the certified nursing assistant (CNA / Staff #90) who was assigned to the residents at the time of the incident. She stated she was in a nearby room providing care to another resident with the door open. She stated that she was not sure of the time, but that it was around 5:00 AM on January 4, 2025, that she heard Resident #1 coming out of his room yelling I hate you along with the expletive motherf*****. Staff #90 stated that she went to see what was wrong, and that Resident #1 was slouched over in his wheelchair in the doorway of his room facing his bed. She stated that she observed Resident #3 in Resident #1's room, sitting on his bed, and wearing Resident #1's jacket and pants. She stated that she called on the radio for the nurse to come assist. She stated that Resident #1 was unresponsive at first, then appeared to regain consciousness. She stated that then the nurse arrived and that Resident #3 was redirected to his room. She stated that Resident #1 was gesturing to indicate that Resident #3 had hit him. She stated that Resident #3 admitted multiple times to hitting Resident #1 and that he further stated that he only hit him because he hit me in the balls. Staff #90 further stated that after the incident that shift, that Resident #1 was very agitated and angry afterward, that he kept bringing up the situation. After the incident, Staff #90 stated that the nurse had told her to make sure that the two residents don't talk to each other, but that Staff #90 then stated back to the nurse that she had to do her round assignments, and that the nurse left it at that. Staff #90 stated that she asked the nurses at the nurse's station what she should do, and that she was advised to make a written statement of the incident and to leave it in the cubby at the nurse's station. Staff #90 stated that a room change was not done, but that staff started a one-to-one monitoring of the residents the following morning shift. A telephonic interview was conducted with a licensed practical nurse (LPN / Staff #14) on January 8, 2025 at 10:40 AM. Staff #14 stated that she arrived for her shift at approximately 6:00 AM on January 4, 2025, after the alleged incident involving Residents #1 and #3 had occurred. She stated that she was informed by the night nurse that there was an allegation that Resident #1 was hit by another resident. The LPN stated that the facility placed a one to one staff monitor on the residents as soon as we could on my shift. An interview was conducted on January 8, 2025, at 3:08 PM, with the ADON (Staff #31), who stated that if there is an allegation of abuse, that the facility staff is to respond by separating the two residents, and the facility staff is to protect the residents either through increased supervision, or room changes, or through one to one staff monitoring. An interview was conducted on January 8, 2025, at 3:40 PM, with the Director of Nursing (DON/ Staff #63). The DON stated that the facility's process if there is an alleged abuse incident is that the facility protects the residents after an alleged abuse incident by placing the residents on one to one staff monitoring or providing a room change or by frequent monitoring. The clinical record of Resident #1 was reviewed together at that time with the DON. She additionally confirmed that a risk management (incident report) had not been completed. She stated that the night nurse was terminated for not reporting the incident timely. The DON stated that on January 4, 2025, at approximately 10:27 AM, after the incident was when she called the staffing coordinator to ensure that one-to-one monitoring was in place for the protection of Resident #1 and Resident #3. A telephonic interview was conducted with the LPN (Staff #2) on January 9, 2024 at 8:04 AM. The LPN stated that she was a new nurse to that facility, and that she confirmed that she was the residents' assigned nurse on the night shift between January 3 and 4, 2024. She stated Resident #3 was confused and was looking for the bathroom. She stated that Resident #1 is hard to understand and that you really have to listen to what he is saying to understand him. She stated that Resident #1 kept coming out of his room saying that Resident #3 was coming into his room. She stated that she kept redirecting Resident #3 back to his own room, and Resident #1 continued to bang on the nurses' room door saying that Resident #3 was still coming to his room. She stated that at approximately 3:30 -3:40 AM, Resident #1 came out of his room pointing at his face and was saying he had been hit. She stated that when the CNA and herself got to Resident #1's room, they observed Resident #3 in the room. The interview continued and Staff #2 stated that after Resident #1 had told her that he was hit in the face, that she believed he was afraid to lie back down in his bed to sleep because of Resident #3 who kept coming into his room. She stated that she sat with Resident #1 for a while in his room to help him calm down, and that every 30 minutes to an hour that she and the CNAs were checking on him, but that the two residents were still sharing a room area. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that the facility will protect residents from any further harm during investigations.

Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure an accessible bathroom was readily available for resident use for two residents (#34 and #46); and, failed to ensure that the bathroom of two residents (#23 and #28) were not used by other residents. The deficient practice could result in residents not receiving necessary assistance to help maintain their independence. The Census was 55. Findings include: -Resident #34 was admitted on [DATE] with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident may need extra help with specific activities, had experienced social isolation on rare occasions and was receiving an antidepressant. -Resident #46 was admitted on [DATE] with diagnoses of major depressive disorder, unspecified hearing loss, and personal history of traumatic brain injury. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. -Resident #28 was admitted on [DATE] with diagnoses of chronic systolic (congestive) heart failure, type 2 diabetes mellitus, and mild stage 2 chronic kidney disease. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident had moderate cognitive impairment. The bedroom of resident #28 was located on the south side next to the dining room; and, this is one of the resident bathrooms that residents #34 and #46 use. -Resident #23 was admitted on [DATE] with diagnoses of schizoaffective disorder, bipolar type, post-traumatic stress disorder, and difficulty walking. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. The resident's bedroom was located on the north side next to the dining room; and, this is one of the resident bathrooms that residents #34 and #46 use. An observation was conducted on December 4, 2024 at 11:21 a.m. and revealed there were two residents were in the dining room. The tables and chairs were not placed in the main dining room area for the residents to eat at. The tables were in front of the kitchen food serving area, with the dining room chairs stacked up together. Uncovered white clothing racks were placed around the dining room walls. There were no bathrooms for residents to use inside the dining room area; and, no public restroom located immediately outside of the dining room. An attempt to interview resident #46 was conducted on December 4, 2024 immediately following the observation but the resident refused. An interview was conducted on December 4, 2024 at 11:32 a.m. with resident #34 who stated that he had been living in the dining room for about one month; and that, there were five to six other residents (male) who had been staying in the dining room with him. Resident #34 further stated that he had to use another resident's bathroom when he needed to. An interview was conducted on December 4, 2024 at 12:43 p.m. with a Staffing Coordinator (staff #48) who stated that there were no bathrooms available for resident use in the dining room. An interview with Director of Nursing (DON/staff #57) was conducted on December 4, 2024 at 1:13 p.m. The DON stated that residents using the dining room as their bedroom need to use another resident's bathroom since their own room had been sealed off for remodeling. The DON said that there were two male resident rooms located on either side of the dining room; and that, the residents in these rooms had agreed to let residents #34 and #28 use their bathrooms. A random interview was conducted on December 4, 2024 at 2:35 p.m. with resident #28 who stated that his room was remodeled maybe a month ago; and that, the residents who were currently staying in the dining room were using his bathroom. An interview was conducted on December 04, 2024 at 2:38 p.m. with resident #23 who stated that he resident was pleased with the update of his room; and that, his room now was more homey. He said that his new bathroom was being used by other residents who were not as clean as him. Further, resident #23 stated that nobody likes to find feces on the toilet seat and he had to wipe feces off of the toilet seat. The facility's policy on Activities of Daily Living (ADLs) revealed that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.

Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure a safe, comfortable and homelike environment was provided to two residents (#34 and #46). The deficient practice could result in residents' preferences were not honored and residents being prevented from having individualized area. The census was 55. Findings include: -Resident #34 was admitted on [DATE] with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident may need extra help with specific activities, had experienced social isolation on rare occasions and was receiving an antidepressant. A psychiatric note dated November 26, 2024 included the resident was alert and oriented x 4. -Resident #46 was admitted on [DATE] with diagnoses of major depressive disorder, unspecified hearing loss, and personal history of traumatic brain injury. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. An observation on December 4, 2024 at 11:21 a.m. the facility had one dining room for the 55 residents that were residing in the skilled and long term care units. The tables and chairs were not placed in the main dining room area for the residents to eat at; and, the tables were in front of the kitchen food serving area, with the dining room chairs stacked up together. There were two hospital-type beds in the dining room that were used by two residents (#34 and #46). The beds had black screens which were approximately 2 feet on the left and right sides of the bed and approximately a foot from the end of the bed. An uncovered white clothing racks were placed around the dining room walls. There were no bathrooms/restrooms readily available for resident use inside of the dining area. There was also no call light system in the dining room. Regarding resident #34's area in the dining, there were black privacy screens with rolling wheels on the left and the right side of the bed. The head of the bed was against the window; and, there was a black screen over the window. The black privacy screen at the foot of the bed was open and resident #34 was laying in the bed. At this point of the observation, resident #34 asked for privacy and the staff present in the room then pulled the black privacy screen closed. Regarding resident #46, the resident, his belongings, hospital-type bed, recliner and bedside table was in the alcove of the dining room which was approximately 8 feet deep and 5 feet wide. Resident #46 was sitting in a recliner next to his bed. An attempt to interview resident #46 was conducted on December 4, 2024 immediately following the observation but the resident refused. An interview was conducted on December 4, 2024 at 11:32 a.m. with resident #34 who stated that he had been living in the dining room for about one month; and that, there were five to six other residents (male) who had been staying in the dining room with him. Resident #34 further stated that he had to use another resident's bathroom when he needed to; and that, there were no call light to use in the dining room. The resident stated that he had to wait for someone to walk by or he would snap his fingers to get the attention of the staff. An interview with the cook (staff #53) was conducted on December 4, 2024 at 12:28 p.m. The cook stated the facility was doing renovations of resident rooms; and, the residents affected (#34 and #46) were using the dining room as their bedrooms. The cook said that the other residents not affected by the renovation were either eating outside in the patio or in their rooms. The kitchen Manager (staff #31) joined the interview and stated that there were no residents eating in the dining room; and that, residents #34 and #46 had been using the dining room as their bedroom for about one month now. A random interview was conducted on December 4, 2024 at 12:33 p.m. with a female resident (#35) who stated that she had been eating her meal outside in the patio at the picnic tables while the cafeteria was getting fixed. She stated that there were about six residents at a time staying in the dining room because there were 2 rooms being renovated at a time. She said that each of these rooms had 3 residents. An interview was conducted on December 4, 2024 at 12:43 p.m. with a staffing coordinator (staff #48) who stated that there were no call lights or bathrooms in the dining room. In an interview conducted with Director of Nursing (DON/staff #57) on December 4, 2024 at 1:13 p.m., the DON stated that residents using the dining room as their bedroom need to use another resident's bathroom since their own room had been sealed off for remodeling/renovation. The DON said that there were two male resident rooms located on either side of the dining room; and that, the residents in these rooms had agreed to let residents #34 and #28 use their bathrooms. An interview was conducted on December 4, 2024 at 2:38 PM with resident #23 who stated that he resident was pleased with the update of his room; and that, his room now was [NAME]. Resident #23 stated that his new bathroom was being used by other residents. Review of the facility policy on Resident Rights included that employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness and dignity, and privacy and confidentiality. The facility's policy on Activities of Daily Living (ADLs) revealed that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.

Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure an accessible, working call light was available for use for two residents (#34 and #46). The deficient practice could result in residents not having the means to communicate with staff. The census was 55. Findings include: -Resident #34 was admitted on [DATE] with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident may need extra help with specific activities, had experienced social isolation on rare occasions and was receiving an antidepressant. A psychiatric note dated November 26, 2024 included the resident was alert and oriented x 4. -Resident #46 was admitted on [DATE] with diagnoses of major depressive disorder, unspecified hearing loss, and personal history of traumatic brain injury. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. An observation on December 4, 2024 at 11:21 a.m. the facility had one dining room for the 55 residents that were residing in the skilled and long term care units. The tables and chairs were not placed in the main dining room area for the residents to eat at; and, the tables were in front of the kitchen food serving area, with the dining room chairs stacked up together. There were two hospital-type beds in the dining room that were used by two residents (#34 and #46). The beds had black screens which were approximately 2 feet on the left and right sides of the bed and approximately a foot from the end of the bed. An uncovered white clothing racks were placed around the dining room walls. There was also no call light system in the dining room. An attempt to interview resident #46 was conducted on December 4, 2024 immediately following the observation but the resident refused. An interview was conducted on December 4, 2024 at 11:32 a.m. with resident #34 who stated that he had been living in the dining room for about one month; and that, there were no call light to use in the dining room. The resident stated that he had to wait for someone to walk by or he would snap his fingers to get the attention of the staff. In another interview with resident #34 conducted on December 4, 2024 at 12:47 p.m., the resident stated that he had to wait for someone to walk by to get a hold of the nurse and had to snap fingers, since there were no call lights in the dining room to use for help. Further, resident #34 said that it would take a few minutes to an hour to get assistance from staff. An interview was conducted on December 4, 2024 at 12:40 p.m. with the Maintenance Director (staff #34) who said that there was no call light or call bells located in the dining room. In an interview with the staffing coordinator (staff #48) conducted on December 4, 2024 at 12:43 p.m., the staffing coordinator said that she did not remember when the housing in the dining room started; but, she had scheduled a certified nurse assistant (CNA) in the area for the past couple of weeks. An interview with a CNA (staff #6) was conducted on December 4, 2024 at 12:53 p.m. The CNA stated that residents had been housed in the dining room for one month; and that, there could have been up to eight residents residing at a time in the dining room. The CNA stated that there were no call lights available for the residents to use in the dining room; but, a CNA would be stationed in the dining room, stay in the dining room for one hour and then swap out with another CNA. An interview was conducted with the Director of Nursing (DON/staff #57) on December 04, 2024 at 1:13 p.m. The DON said that the renovations had been going on for one month and it takes from one week to three weeks if plumbing needs to be replaced. The DON stated that all of the resident's belongings goes in with them to the dining room, so the residents have all of the items they need. The DON said that staffing was increased so a CNA can be in the dining room with the resident at all times. Further, the DON stated that in the area where the CNAs were stationed, the CNAs should be able to see the residents; and that, the CNAs should be up interacting with the residents. The DON further stated that the CNAs had radios to notify the nurse and activate other staff should they need assistance or there was an emergency. Review of the facility policy on Resident Rights included that employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness and dignity, and privacy and confidentiality. The facility's policy on Activities of Daily Living (ADLs) revealed that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.

Based on observations, clinical record reviews, interviews and policy review, the facility failed to provide a designated room to accomodate resident dining while undergoing renovations. The deficient practice could result in residents individual needs and preferences not accommodated. The census was 55. Findings include: An observation on December 4, 2024 at 11:21 a.m. the facility had one dining room for the 55 residents that were residing in the skilled and long term care units. The tables and chairs were not placed in the main dining room area for the residents to eat at; and, the tables were in front of the kitchen food serving area, with the dining room chairs stacked up together. There were two hospital-type beds in the dining room and there were black screens approximately 2 feet on the left and right sides of the bed and approximately a foot from the end of the bed. An uncovered white clothing racks were placed around the dining room walls. The dining room was used as a bedroom by two residents An interview was conducted on December 4, 2024 at 11:32 a.m. with one of the residents residing in the dining room. The resident stated that he had been living in the dining room for about one month; and that, there were five to six other residents (male) who had been staying in the dining room with him. An interview with the cook (staff #53) was conducted on December 4, 2024 at 12:28 p.m. The cook stated the facility was doing renovations of resident rooms; and, the residents affected (#34 and #46) were using the dining room as their bedrooms. The cook said that the other residents not affected by the renovation were either eating outside in the patio or in their rooms. The kitchen Manager (staff #31) joined the interview and stated that there were no residents eating in the dining room; and that, two residents had been using the dining room as their bedroom for about one month now. An interview was conducted on December 4, 2024 at 12:33 p.m. with a female resident who stated that she had been eating her meal outside in the patio at the picnic tables while the cafeteria was getting fixed. She stated that there were about six residents at a time staying in the dining room because there were 2 rooms being renovated at a time. He/she said that each of these room had 3 residents. Another interview was conducted on December 4, 2024 at 12:35 p.m. with another resident who stated that all meals were eaten outside of the dining room; and that, nobody can eat inside the dining room right now. In an interview conducted with another resident on December 4, 2024 at 12:37 p.m., the resident pointed to an area where a picnic table was and stated that it was the area where the birds don't S**t on it and that was where he eat their meals. The resident further stated that residents at the facility do not eat inside the dining room. An interview was conducted on December 4, 2024 at 12:53 p.m. with a Certified Nursing Assistant (CNA/staff #6) who stated that the residents usually eat outside in the patio or go in their rooms. The CNA said that some residents can eat in the dining room, but resident do not do this all the time when there are residents staying in the dining room. An interview was conducted with the Director of Nursing (DON/staff #57) on December 4, 2024 at 1:13 p.m. The DON said that the renovations had been going on for one month and it takes from one week to three weeks if plumbing needs to be replaced. The DON stated that when residents attempt to enter the dining room, they were redirected since there were residents residing inside the dining room. The DON said that for the most part, the residents do not go into the dining room if the residents were looking for activities. The Resident's Right policy reveals that the resident's have the right to a dignified existence, be treated with respect, kindness and dignity. The facility's policy on Activities of Daily Living (ADLs) revealed that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.

Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#4) was not abused by another resident (#5). The deficient practice could result in residents being abused. Findings include: -Regarding Resident #4: Resident #4 admitted to the facility on [DATE] with diagnosis that included Post Traumatic Stress Disorder, alcohol abuse, depression and pain. The Minimum Data Set (MDS) assessment from May 30, 2024 revealed that the resident's Brief Interview for Mental Status (BIMS) score was 09 which indicated moderate cognitive impairment. The assessment also revealed that the resident had verbal behaviors directed towards others 1 to 3 days during 7 day look back period Care plan initiated on June 15, 2024, Resident #4 was care planned for legal blindness and extreme hard of hearing. A progress note from July 16, 2024 documented a change in condition due to Resident #4 and Resident #5 becoming verbally aggressive with each other. Resident #4 alleged he had been hit in the face by Resident #5. Resident #5 stated he did hit Resident #4 because resident hit him first. A month later on August 13, 2024, another change of condition note was entered regarding a resident to resident altercation with Resident #4 and Resident #5 again. The note stated Resident found on ground, laying on right side in fetal position following an altercation with another resident. There were no changes to the resident #4's care plan post incident on July 16 and/or August 13, 2024 -Regarding Resident #5: Resident #5 admitted to the facility on [DATE] with diagnosis that included schizophrenia, bipolar disorder, anxiety disorder, delirium due to physiological condition, altered mental status, disorientation and cognitive communication deficit. The MDS assessment dated [DATE] revealed resident #5's BIMS score was 13, which indicated he was cognitively intact. The assessment revealed resident #5 had physical behaviors directed towards others 1 to 3 days in a 7 day look back period. The Care plan initiated on February 19, 2024 revealed resident #5 was care planned for being physically abusive with interventions that included identifying triggers. In a progress note dated August 13, 2024 included a nursing observation that stated Resident was seen sitting in wheelchair outside of room with door open yelling with a cane in his hand which appeared as though he was trying to hit another resident who was on the ground in front of his room door. A follow up note the same day documented that the alleged perpetrator was moved to a different room for safety concerns. Review of resident #5 record revealed no interventions for the incident on 07/16/24 and/or 08/13/2024 on his care plan. In an interview with licensed practical nurse (LPN/ Staff #23) on August 27, 2024 at 2:05 pm, she stated that she had witnessed the August altercation between Residents #4 and #5. She stated she heard yelling, saw resident #4 on the ground and resident #5 was holding his cane. She stated she checked resident #4 for injuries, asked what happened to which he stated he had gotten lost (resident is blind) and was using his white cane when Resident #5 opened the door onto him and pushed him down. Staff #23 said resident #4 stated resident #5 beat him up. Staff #23 stated that while she did not see resident #5 physically hit Resident #4, when she asked him if he had, resident #5 said yes, it was intentional, and that he was trying to harm resident #4. She stated they also had a history of altercations and staff in general know not to keep the two of them together. Resident's #4 and #5 were not available for interview. In an interview with the Director of Nursing (DON/ Staff #12) on August 27, 2024 at 2:29 pm, she stated that in instances of resident to resident altercations, her expectations are that if there is physical contact, then the facility will report to Department of Health, Adult protective services, and guardians if applicable. The DON stated that the staff will conduct a skin check and send the resident out for injuries they may have sustained. The DON further stated a follow up would be to get new orders and update the care plan. In a policy titled Resident to Resident Altercations last revised December 2016, it states If two residents are involved in an altercation, staff will: Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; Make any necessary changes in the care plan approaches to any or all of the involved individuals; Document in the resident's clinical record all interventions and their effectiveness; Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team.

Based on observation, clinical record review, resident and staff interviews and policies and procedures, the facility failed to complete thorough and timely assessments for one of two sampled residents (#16) who developed a pressure ulcer. The deficient practice resulted in a lack of consistent monitoring of skin breakdown/pressure ulcers and a delay in identifying any wound deterioration and implementing additional interventions. Findings include: Resident #16 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan identified that the resident was at risk for skin breakdown related to decreased mobility, weakness and a right above the knee amputation and a left [MEDICAL CONDITION]. The goal was to keep the resident free from pressure injuries with preventative measures. The interventions included extensive assistance in turning and repositioning as needed or requested, monitoring nutritional status, monitoring skin daily and use of a pressure reducing mattress on the bed and a pressure reducing cushion to the wheelchair. A nurses note dated 7/11/2019 at 5:16 p.m. included the resident had no new skin issues. A weekly skin check dated 7/11/2019 at 5:44 p.m. revealed the resident's skin was in good condition. There are no wounds identified on this assessment. A nurses note dated 7/12/2019 2:57 p.m. revealed the resident refused to have her skin checked by the nursing staff. The resident told the staff that she wanted it done at night when she got into bed. Per the note, the nurse told the resident that there's a certain amount of time that we have to obtain a skin check. Another nurses note dated 7/12/2019 at 4:25 p.m. revealed the resident refused a second attempt at a skin check. A Braden Scale for Predicting Pressure Sore Risk was completed on 7/12/2019 and the resident was at risk for developing a pressure sore. A physician's orders [REDACTED]. Review of the clinical record revealed there was no documentation that the resident had a pressure ulcer to the buttocks area from readmission on (MONTH) 11 through (MONTH) 18. A weekly skin check was completed on 7/19/2019 at 2:44 p.m. and identified that the resident had an area on the right and left ischium that required follow-up. No further information was included. According to a Skin and Wound Evaluation dated 7/19/2019 at 2:47 p.m., the resident had moisture associated skin damage, but no wounds were identified. The documentation included that the issues on the right and left ischium were resolved, but the resident was still at risk for impaired skin related to staying in her wheelchair the majority of the day, without offloading. A weekly skin check dated 7/24/2019 revealed the resident's skin did not have any open areas or redness. A quarterly admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Per the MDS, the resident required extensive assistance with bed mobility and transfers and was at risk for pressure injuries, however none were present. A Braden scale was completed on 8/2/2019 and the resident was at risk for developing a pressure sore. A weekly skin check was completed on 8/8/2019 and the resident's skin was described as being in good condition. There were no wounds identified on this assessment. The nurses monthly summary completed on 8/9/19 revealed the resident did not have any skin conditions requiring treatment or monitoring. Review of the (MONTH) 2019 Medication Administration Record/Treatment Administration records (MAR/TAR) revealed no documentation that barrier cream had been applied to the buttocks area. The nurses monthly summary completed on 9/9/19 revealed the resident did not have any skin conditions requiring treatment or monitoring. Weekly skin checks were completed on 9/11/2019 and 9/18/19 and revealed the resident's skin was in good condition. There were no wounds identified on the assessments. A physician's orders [REDACTED]. A weekly skin check was completed on 9/25/2019 and the resident's skin was identified as being in good condition. There were no wounds identified on this assessment. Review of the (MONTH) 2019 MAR/TAR revealed no documentation that barrier cream had been applied to the buttocks area. The TAR did include the order for a Roho cushion to wheelchair, check for proper inflation every day. Per the documentation, this was done from (MONTH) 21-30. A physician's orders [REDACTED]. Per the (MONTH) 2019 MAR/TAR, the Zinc Oxide was applied on (MONTH) 1 and 2. Despite a physician's orders [REDACTED]. A weekly skin check dated 10/3/19 included that the resident's skin was in good condition. There was no mention of excoriation to the buttocks area and no wounds were identified on this assessment. The order for Zinc Oxide 25% paste was discontinued on 10/3/2019. A physician's orders [REDACTED]. According to the MAR/TAR for (MONTH) 2019, the Zinc Oxide was applied as ordered from (MONTH) 3-7. A nurses note dated 10/7/19 revealed that a CNA reported the resident had a skin issue to the buttocks. It was determined by the nurse practitioner (NP) on site that the area was excoriated and she would order [MEDICATION NAME] cream and a dressing to the area. Per the note, the resident was instructed to rotate positions while sitting and to lay down to offload pressure on the site. A physician's orders [REDACTED]. Per the (MONTH) 2019 TAR, this treatment was initiated on (MONTH) 8 on the evening shift. In addition, the (MONTH) 2019 MAR indicated [REDACTED]. As a result, the [MEDICATION NAME] treatment to the buttocks was completed twice a day from (MONTH) 8-17, once on the day shift and once on the evening shift, instead of once a day as ordered. A weekly skin check was completed on 10/8/19 and noted that the resident had excoriation to the buttocks (left and right gluteal fold) that required follow-up. The nurses monthly summary dated 10/9/2019 at 5:36 p.m. revealed the resident had excoriation that required treatment and monitoring. A nursing note entered on 10/9/19 at 6:00 p.m. included the resident was on Change of Condition (C[NAME]) for treatment of [REDACTED]. The note stated treatment done as ordered and the nurse will continue to monitor. A weekly skin check was completed on 10/11/19 which identified that the resident had excoriation to the buttocks. A weekly skin check was completed on 10/17/2019 and the resident had excoriation to the buttocks. A nurses note dated 10/17/2019 revealed the resident was on a C[NAME] for excoriation to the buttocks and complained of generalized pain. Despite ongoing documentation that the resident had excoriation to the buttocks area, there was no documentation of a thorough assessment of the area, which included a description, measurements and specific location of the excoriated area from 10/1/19 through 10/17/19, for a period of 17 days. A nurses note dated 10/18/2019 at 2:43 p.m. revealed the resident spent a good time up in her wheelchair and complained of pain, and that the resident was on a C[NAME] for excoriation of the buttocks. Further review of the (MONTH) 2019 TAR revealed the order for a Roho cushion to wheelchair and to check for proper inflation every day. Per the documentation, this was done from (MONTH) 1-18. Review of a Skin and Wound Evaluation dated 10/18/19 at 7:29 p.m., revealed the resident had a medical device related pressure injury on the left ischeal tuberosity, which was identified as a stage 3 (full thickness skin loss). The documentation included it was a new in-house acquired injury. Per the documentation, the pressure ulcer wound bed was pink/red, measured 0.9 centimeters (cm) by 2.5 cm by 0.0 cm in depth, no undermining or tunneling, had a light amount of serosanguineous exudate, no odor, the wound edges appeared flush with the wound and the surrounding tissue was denuded. The evaluation indicated therapy to monitor for proper wheelchair cushion. A physician's orders [REDACTED]. Another order on 10/18/19 included to monitor the stage 3 pressure injury to the left ischium for signs and symptoms of infection or deterioration every day with wound care. A care plan was initiated on 10/18/19 for the mechanical stage 3 pressure injury to the left ischium related to cushion placement. The goals were that the resident would have no complications related to the left ischium pressure injury and that the injury would show signs of healing. Interventions were to assist the resident to change positions frequently in bed and chair, educate the resident and caregivers of causative factors and measures to prevent skin injury, follow the facility protocols for treatment of [REDACTED]. Nurses notes dated (MONTH) 19, 20 and 21, 2019 included the resident was on a C[NAME] for excoriation to the buttocks. An interview was conducted with the resident on 10/21/19 at 11:47 a.m. Resident #16 stated the wounds on her bottom started at the facility over the last few months. She stated the cushion on her chair hurts her bottom and it feels like a sharp pressure. She said that she has told the staff many times that she is in pain and sometimes when she needs to lay down to get off her bottom, the staff are too busy to help. She stated that every time the staff touches her bottom or when she sits in the wheelchair it hurts. A nurses note dated 10/21/2019 at 8:09 p.m. stated the resident was on a C[NAME] for excoriation to buttocks and complained of generalized pain. A nurses note dated 10/22/2019 at 5:21 a.m. stated the resident was on a C[NAME] for excoriation to buttocks and complained of generalized pain. A wound observation was conducted on 10/22/19 at 12:51 p.m., with a Licensed Practical Nurse (LPN/staff #65). Resident #16 was placed on her right side and staff #65 removed the old dressing. The nurse then cleansed the pressure ulcer to the left ischeal tuberosity with a wound cleanser. The entire wound area was observed to be approximately 4 cm long by 4 cm wide and was beefy red, except for an area at the top of the wound which was approximately the size of a dime and was dark in color. Within this area, there was a hole with depth. No odor or drainage were noted. At this time, staff #65 only measured the dime sized area and did not measure the entire wound area. Staff #65 was then asked to measure the entire wound. When asked about the depth of the wound, she stated that the wound had no depth. The nurse then completed the wound treatment as ordered. An interview was conducted with staff #65 on 10/23/19 at 10:03 a.m. She stated that the Restorative Nursing Assistant (RNA) manages the resident's ROHO cushion. She stated she was not aware of any current issues with the cushion. An interview was conducted with a CNA (staff #11) on 10/23/19 at 11:41 a.m. She stated that the wound started out as a small little wound that just got bigger over time. She stated she first noticed it about three weeks ago. She stated that anytime she notices any changes in the resident during showers she gets the nurse right away. She stated that over the past week, the resident has been complaining about the ROHO cushion, but the provider was aware. An interview was conducted with a RNA (staff #52) on 10/23/19 at 12:03 p.m. She stated sometimes the resident complains that the cushion is not balanced. She stated to adjust the cushion she continues to add air until she doesn't hear it anymore. Then she placed her hand between the resident and the cushion to ensure there was a space. She said the resident likes to have the air taken out so that it is softer for her and so she can move around from side to side. She stated that she spoke with the provider on 10/22/2019 about the cushion and was instructed to adjust the air in the cushion. She stated the resident has never told her of any issues with her cushion except on 10/22/2019. She stated the resident told her it didn't fit right. An observation of the resident was conducted on 10/23/19 at 8:25 a.m. The resident was observed approaching the nurse and reported that she was in pain and would like some Tylenol. The nurse asked the resident what her pain level was and the resident stated her pain was a 10 out of 10. The resident said to the nurse that she needs a new ROHO cushion, because hers is too hard. A clinical record review revealed that on 10/23/19 at 2:24 p.m., a new ROHO cushion for the wheelchair was ordered. An interview was conducted with a LPN (wound nurse/staff #89) on 10/23/19 at 12:45 p.m. She stated that she was notified of the wound on the 10/18/19. She stated the injury was related to the ROHO cushion being too small for the resident's wheelchair. She stated that she did not notify the provider herself. An interview was conducted with the Director of Nursing (DON/staff #44) and the Corporate Educator (staff #86) on 10/24/19 at 10:31 a.m. The DON stated that CNA's should be looking at the residents' skin daily and should report changes to the nurse, and the nurse should then assess the resident and report their findings in the electronic health record (EHR) and to the physician. She stated the nurses complete a weekly skin assessment and the wound nurse should do an assessment based on the physician orders. Staff #86 said the excoriation on this resident was first identified on (MONTH) 8 and it became an open wound on (MONTH) 18. Staff #86 said the resident has had previous pressure ulcers and she doesn't have normal skin, so she is more likely to develop such wounds. She stated a pressure injury can develop within hours. Staff #44 stated that the previous interventions in place was an overlay mattress and the ROHO cushion. She said the nursing staff are responsible for documenting that a resident refuses care or treatment for [REDACTED].#86 stated the staff would then educate the resident on the risks related to not receiving the treatment and notify the physician that the resident is not wanting care. The DON and staff #86 both stated the pressure injury is improving. The DON further stated if the team meets and notices changes in the resident's condition, then the provider is notified. She stated those meetings are held weekly to review the resident's record, checking the resident to assess the current status and speaking with the resident, and asking staff if the care plan is working. She stated that appropriate interventions for a resident at risk for a pressure injury would include a pressure reducing mattress, a referral to occupational therapy for a wheelchair cushion, an order for [REDACTED]. Continued in this same interview staff #86 stated that she did not believe the cushion caused the wound, as it did not have sole ownership of the wound. She stated it does not matter if the cushion is too small or too big. Review of a policy titled, Wound Management Guidelines revealed It is the philosophy of this facility to ensure that resident skin status is assessed and appropriate interventions are implemented. The goal is to maintain skin integrity, assist in wound healing and prevent avoidable skin breakdown as determined for each individual resident. The policy included that the pressure injury wound treatment and prevention program will focus on the following strategies: Evaluate the resident for risk of pressure injuries and any existing pressure injuries; manage tissue loads (i.e. support surfaces); wound care and treatment; managing infection, education and quality improvement; providing adequate nutrition and nutritional supplementation and treatment as ordered. A policy titled, Change of Condition, Resident revealed It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner . The policy included that upon noting or receiving a report of a change in the resident's status, the nurse will evaluate the resident's condition and notify the resident's physician of the clinical findings and implement new orders as given and to document assessments and interventions in the clinical record. Review of a policy titled, Licensed Nurses - Assessments and Notes revealed Meaningful and informative notes shall be written by a licensed nurse to reflect the care and treatment, observations and assessments and other appropriate entries.

Based on observations, clinical record review, resident and staff interviews and policy and procedures, the facility failed to thoroughly assess and adequately manage one of two sampled resident's (#16) pain. The deficient practice could result in unrelieved pain for residents. Findings include: Resident #16 was re-admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A care plan was initiated due to chronic pain related to spinal stenosis of the lumbar region with placement of a neurostimulator, phantom limb syndrome from bilateral amputations and bladder pain (being seen by urology). The goal was to provide normal activities uninterrupted by pain. The interventions included the following: anticipating the resident's need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions every shift and as needed; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results; impact on functional ability; give scheduled and as needed pain medications as ordered and as requested; adjust neurotransmitter as needed and charge battery of transmitter as ordered; monitor and record pain characteristics every shift and as needed: quality (e.g. sharp, burning), severity (1-10 scale), anatomical location, onset, duration (e.g. continuous, intermittent), aggravating factors and relieving factors and monitor/record/report to nurse any signs or symptoms of non-verbal pain such as; labored breathing, grunting, moaning, yelling out, mood/behavior changes, restlessness, sadness, crying, aggressive behaviors and grimacing. The interventions further included to notify the physician if interventions were unsuccessful or if current complaint is a significant change from past experience of pain. Review of the (MONTH) 2019 Medication Administration Record (MAR) revealed the resident was receiving the following medications: [REDACTED]. Also included in these orders were non pharmacological interventions (NPI) which were to be implement: one-on-one, activity, adjust room temperature, back rub, change position, give fluids, give food, redirect, refer to nurses notes, remove resident from environment, return to room and toilet. Nurses notes dated (MONTH) 12, 13 and 14, 2019 included the resident complained of chronic pain and was medicated with good results. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident required extensive assistance with bed mobility and transfers and received scheduled and as needed pain medication for almost constant pain. According to the (MONTH) 2019 MAR, the resident received [MEDICATION NAME] 1 tablet as needed approximately 46 times for pain levels between 5-10. The documentation also showed that the medication was effective when given. However, review of the clinical record revealed there was no consistent documentation in (MONTH) 2019 regarding non pharmacological interventions which were implemented to address the resident's pain, and there was no consistent documentation regarding the monitoring and recording of pain characteristics which included quality, location, onset, duration, aggravating factors and relieving factors as care planned, which corresponded to when the resident was experiencing pain. A nurses monthly summary completed on 8/9/19 included the resident had a pain level of 5 (indicating moderate pain), which was partially or fully controlled by medication. Review of the (MONTH) 2019 MAR revealed the orders for [MEDICATION NAME] and Tylenol, including the non pharmacological interventions to be implemented. Further review revealed the resident was administered [MEDICATION NAME] as needed approximately 73 times for pain levels between 4-9. Review of the clinical record revealed there was no consistent documentation in (MONTH) 2019 regarding non pharmacological interventions which were implemented to address the resident's pain, and there was no consistent documentation regarding the monitoring and recording of pain characteristics which included quality, location, onset, duration, aggravating factors and relieving factors as care planned, which corresponded to when the resident was experiencing pain. Another physician's order dated 9/1/19 included for [MEDICATION NAME] 10-325 mg 1 tablet by mouth every 6 hours as needed for pain levels of 5-10. The order also included for non pharmacological interventions as follows: one-on-one, activity, adjust room temperature, back rub, change position, give fluids, give food, redirect, refer to nurses notes, remove resident from environment, return to room and toilet. This order was discontinued on 9/3/2019. A physician's order dated 9/3/2019 included for [MEDICATION NAME] 10-325 mg 1 tablet by mouth every 6 hours as needed for pain levels of 5-10. A physician's order dated 9/3/2019 also included for Tylenol 325 mg 2 tablets by mouth every 8 hours as needed for pain levels of 1-4. A nurses monthly summary dated 9/9/19 revealed the resident had a pain level of 6 (indicating moderate pain), which was partially or fully controlled by medication. The pain was described as [MEDICAL CONDITION], phantom, chronic and back pain. Review of a nurses note dated 9/14/19 at 12:26 p.m. revealed the resident approached the nurses station requesting pain medication and the nurse told the resident that it was too early, and it was unavailable at this time. Per the note, the resident became agitated and stated that she knew when she received it and could she have it now. The nurse told the resident it would be available in a half hour. According to the (MONTH) 2019 MAR, the resident received the last dose of [MEDICATION NAME] at 5:30 a.m. on 9/14. The order stated the resident could receive the medication every 6 hours as needed for pain. Based on the MAR documentation, the resident could have had the next dose of [MEDICATION NAME] at 11:30 a.m. However, the MAR showed the next [MEDICATION NAME] was administered to the resident at 2:15 p.m. Also included on the (MONTH) 2019 MAR was an order to adjust the spinal cord stimulator level as needed for comfort (the start date was noted as 9/17/2014). However, there was no documentation on the MAR that the spinal cord stimulator level had been adjusted. There were also no physician orders for any parameters for the spinal cord stimulator levels. Further review of the (MONTH) 2019 MAR revealed the orders for [MEDICATION NAME] 10-325 mg 1 tablet by mouth every 6 hours and for Tylenol 325 mg 2 tablets every 8 hours. The MAR also included the following non pharmacological interventions to be implemented for each medication: one-on-one, activity, adjust room temperature, back rub, change position, give fluids, give food, redirect, refer to nurses notes, remove resident from environment, return to room and toilet. The (MONTH) 2019 MAR also included documentation that the resident was administered [MEDICATION NAME] as needed approximately 87 times for pain levels between 5-10, and that Tylenol was given on two occasions. The documentation included that the medications were effective. Review of the clinical record revealed there was no consistent documentation in (MONTH) 2019 regarding non pharmacological interventions which were implemented to address the resident's pain, and there was no consistent documentation regarding the monitoring and recording of pain characteristics which included quality, location, onset, duration, aggravating factors and relieving factors as care planned, which corresponded to when the resident was experiencing pain. A physician's order dated 10/8/19 included for Tylenol 325 mg 2 tablets by mouth every 8 hours as needed for pain levels of 1-4. Review of a nurse practitioners (NP) note dated 10/9/19 revealed the resident reports 9-10 pain consistently. Resident asks for increased pain medication during every visit and asks for pain medication early multiple times per day. Resident becomes very tearful when told no. Resident does not exhibit facial grimacing, writhing, moaning or restlessness. When asked where location of pain is she often states back and bladder, but does not pinpoint. Resident displays signs of drug seeking behaviors. Despite documentation by the NP that the resident displays drug seeking behaviors, there was no care plan developed to address this, nor were there any interventions implemented to address any drug seeking behaviors. A nurses monthly summary completed on 10/9/19 revealed the resident had a pain level of 8 (indicating excruciating pain), which was partially or fully controlled by medication. Nurses notes from (MONTH) 10-13, 2019 indicated the resident complained of tactile pain and back pain and was medicated with good results. A nurses note dated 10/14/19 at 6:15 p.m. stated the resident was requesting something for pain from the nurse and the nurse told the resident it was too early for a pain pill. Review of the (MONTH) 2019 MAR revealed [MEDICATION NAME] was given at 12:45 p.m. A nurses note dated 10/17/19 at 5:19 a.m. revealed the resident was receiving treatment for [REDACTED]. Per the note, the resident received as needed medication with positive effect. Review of a Skin and Wound Evaluation dated 10/18/19 revealed the resident developed a medical device related pressure injury on the left ischeal tuberosity, which was identified as a stage 3. The documentation included the resident experienced intermittent pain. Nurses notes dated (MONTH) 18 and 19 included the resident was complaining of pain and was administered medication with positive effects and that the resident frequently requests as needed pain medication. A physician's order dated 10/20/19 included for Tylenol 325 mg 2 tablets by mouth every 8 hours as needed for pain levels of 1-4. The orders included for non pharmacological interventions as follows: redirect, 1:1, activity, return to room, toilet, give food, give fluids, change position, adjust room temperature and back rub. Nurses notes dated (MONTH) 21 and 22, 2019 revealed the resident complains of pain and was medicated with good results. Review of the MAR from (MONTH) 1 through 22, 2019 revealed the resident was provided as needed pain medication approximately 57 times. Continued review of the clinical record revealed there was no consistent documentation in (MONTH) 2019 regarding non pharmacological interventions which were implemented to address the resident's pain, and there was no consistent documentation regarding the monitoring and recording of pain characteristics which included quality, location, onset, duration, aggravating factors and relieving factors as care planned, which corresponded to when the resident was experiencing pain. An interview was conducted with the resident on 10/21/19 at 11:47 a.m. She stated that she was told to lay down when her pressure injury sores on her bottom get too painful from sitting in the wheelchair. She said the staff is often too busy to get her into bed to help ease some of the pain. She stated that she is in so much pain all the time. A wound care observation was conducted on 10/22/19 at 12:51 p.m., with a Licensed Practical Nurse (LPN/staff #65). Resident #16 was placed on her right side and then staff #65 removed the old dressing by pulling out and down away from the wound. As this was done, the resident yelled out in pain. Staff #65 stated that the resident did not get pain medication prior to this procedure, because the resident is on scheduled pain medication. At this time, the resident informed the nurse that she was in pain. The nurse replied to the resident that the pain was from the removal of the dressing and that she already received pain medication earlier that morning. A few minutes later, the resident informed the nurse that the wound felt like it was burning. Staff #65 continued providing wound care to the resident. In a review of the (MONTH) 2019 MAR, the documentation showed that resident was last medicated at 4:30 a.m. on (MONTH) 22, with 1 tablet of [MEDICATION NAME]. In reviewing the Narcotic Count Sheet for the resident, the documentation showed that 1 tablet of [MEDICATION NAME] had been signed out at 10:30 a.m. on (MONTH) 22, by staff #65. However, this was not documented on the MAR. Staff #65 acknowledged that the medication was signed out on the narcotic count sheet, but was not documented on the MAR. An interview was conducted with the resident on 10/22/19 at 1:56 p.m. She stated that she is still in pain from the dressing change on her pressure injury. She said that during the entire dressing change she was in pain. The resident said that she was told that she has to wait until 4:30 p.m. for her next pain medication. An observation of the resident was conducted on 10/23/19 at 8:25 a.m. The resident approached the nurse administering medications and reported that she was in pain and would like Tylenol. The nurse prepared the resident's morning medications and then asked the resident what her pain level was. The resident stated her pain was 10 out of 10. An interview was conducted with staff #65 on 10/23/19 at 10:03 a.m. She stated that she would consider several things when assessing if a resident is in pain. She said that she would look at how they are moving their body if they are guarding, if they have verbal or facial expressions of pain or any changes in behaviors. She said that she would ask the resident what their pain level was using the 1-10 pain scale and would have the resident describe their pain. She said she would then medicate and re-evaluate in 30 minutes. She stated that she charts the assessment in the electronic health record. She stated the reason she did not give the resident pain medication during the dressing change was because the resident did not have pain, until the dressing was taken off. An interview was conducted with the Director of Nursing (DON/staff #44) and the Corporate Educator (staff #86) on 10/24/19 at 10:31 a.m. The DON stated that staff use the 1-10 pain scale to assess a resident's pain and they need to ask residents their pain level. She stated the staff need to identify residents on pain management and anticipate their needs. She said the nurses are to check the order to make sure the correct medication is being administered for the pain level, and reassess within an hour to see if the medication was effective or not. She said that even if a resident is on scheduled pain medication, they may also have an order for [REDACTED]. The DON stated that care is driven by the provider orders which are used to develop the plan of care for each individual resident. She also said the documentation of care should be entered into the electronic medical record, per facility policy. Review of a policy titled, Pain Management revealed This facility recognizes a patient's right to be free of pain and promotes pain relief through the use of the Pain Management Plan during the patient duration of stay at the facility to help the patient attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. Staff are able to recognize when the patient is experiencing pain and identify circumstances when pain can be anticipated, evaluate the existing pain and the cause(s), pain is assessed when a patient complains of pain and after an [MEDICATION NAME] is given to determine effectiveness of the [MEDICATION NAME]. When pain is identified assessment and documentation includes pain scale rating, location, duration, intensity, and character. Effectiveness of current pain management techniques is discussed in the interdisciplinary patient team conference according to divisional requirements. A policy titled, Record Content: Licensed Nurses - Assessments and Notes included Meaningful and informative notes shall be written by a licensed nurse to reflect the care and treatment, observations and assessments and other appropriate entries.