Every finding on record at Mission Palms Post Acute

Based on clinical records, staff interviews, review of facility documentation, policies and procedures, and the State Agency (SA) database, the facility failed to implement its policy regarding reporting allegations of abuse to appropriate agencies for one of two sampled resident (#12). The deficient practice could result in abuse continuing and not being prevented. The universe was 154.Findings include:Resident #12 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of the shaft of the left femur subsequent encounter for closed fracture with routine healing, chronic pain syndrome, generalized anxiety disorder, and major depressive disorder.A comprehensive care plan focus area for psychotropic medication use was initiated on January 16, 2025, and revised on August 13, 2026, to manage the resident's major depressive disorder, generalized anxiety, insomnia, and aggressive behaviors. A quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment further revealed that Resident #12 required substantial or maximal assistance with personal hygiene and toilet transfers, was dependent on staff for bathing and showers, was frequently incontinent of bladder and bowel, and received psychotropic medications including antipsychotics, antianxiety, antidepressants, and hypnotics on a routine basis.A clinical record progress note, dated August 13, 2026, revealed no documentation of the physical altercation, physical force used, or the resident's subsequent allegation of physical abuse.A facility Grievance Resolution Form, dated August 14, 2026, and submitted by the Charge Nurse, revealed that Resident #12 reported having an issue with the way Staff #92, CNA (Certified Nursing Assistant), transferred him into the shower chair. The form stated that the resident attempted to hit Staff #92 but was able to be redirected and took his shower. The resolution stated that a new CNA was assigned for the rest of the shift and that the DON (Director of Nursing) was aware of the resolution to have a different CNA assigned going forward. The form further documented that the resident denied any abuse occurred and was marked satisfactory. An internal facility Investigation Report, dated August 14, 2026, and completed by the DON, revealed that he was notified at approximately 4:15 p.m. by Charge Nurse that Resident #12 was upset regarding the way he was treated by a CNA. The report noted that the resident insisted on calling the police because he felt the staff were trying to beat him up. It further revealed that a police Officer responded to the facility, interviewed the staff and the resident, and noted they also had no suspicion of abuse or neglect, stating that no evidence of abuse was found and a case number was not generated. The report noted that Staff #92 was asked to leave for the day until further investigation was able to be completed. However, upon interviewing the resident at 5:45 p.m., the resident directly asked if he felt abuse had occurred, and he stated no, instead stating he was just upset with the staff. The DON concluded that no reportable event was identified because the resident denied abuse and the police officer noted no suspicion, resolving the matter internally through the grievance process. A State Agency intake report, dated August 18, 2026, stated that on August 13, 2026, at approximately 5:00 p.m., Resident #12 refused to shower and began cursing at female staff members in the hallway. The report further revealed that Resident #12 had soiled his clothing with feces and urine and was sitting in his wheelchair when Licensed Nursing Assistant (LNA/Staff #92) went over to assist and grabbed Resident #12's arms and hands to prevent being struck, using a physical tactic to lift him from his wheelchair into a shower chair.An interview was conducted on August 20, 2026, at 11:17 a.m. with Resident #12. He stated that Staff #92 sat next to him behind the fully closed privacy curtain and hit him everywhere he could, smacking him. He stated that the curtain was fully closed so nobody could see. He stated having three purple spots and bruising on his right arm from where Staff #92 grabbed him, which were observed. He also stated he felt safe and had since taken steps to protect himself, including keeping a rock in his drawer for defense. He opened the drawer, and no rock was observed inside the drawer next to his bed, which he stated was because somebody had taken the rock. An interview was conducted on August 20, 2026, at 11:53 a.m. with the Adult Protective Services complainant. He stated that staff members went in and got a report, and he then met with the resident, who reported that a staff member came in and started beating him up. He stated that he spoke with the Director of Nursing, who mentioned that the LNA had just walked in to help the client get into the chair, and that the resident was angry because he wanted to do things on his own. He stated that a nurse told him the incident was race-related.An interview was conducted on August 20, 2026, at 12:25 p.m. with the human resources director (HRD/Staff #16). She stated that Staff #92 had no prior internal complaints, grievances, or disciplinary warnings on file at the facility during his two and a half years of employment. She stated that Staff #92 was not placed on administrative suspension or restricted from entering the building or having direct care contact during the active investigation of the current allegation on August 13, 2026, August 14, 2026, and August 15, 2026. She stated that he had completed all mandatory training on abuse prevention and de-escalation.A verification report from the State Board of Nursing for Staff #92, reviewed at 12:25 p.m. with the HRD, revealed that Staff #92 was issued an administrative Board order dated September 24, 2004, which imposed a publicly available fine and monetary penalty. The same verification report revealed an administrative Board order dated October 17, 2011, revoking his license, which was subsequently reinstated and restored to an active status. The report further revealed an administrative complaint dated September 23, 2020, alleging that Staff #92 accepted money from a resident while employed at a previous facility. The report revealed a subsequent administrative complaint dated April 19, 2022, alleging that Staff #92 used disparaging language towards a resident by repeatedly telling the resident, You are nasty, after the resident urinated in a cup instead of using a urinal, bedside commode, or call light, which resulted in his termination from that facility. The same licensing board records, including a job application dated June 14, 2022, revealed that Staff #92 subsequently failed to disclose his termination when applying to another facility. Finally, the same verification report revealed a Consent Agreement and Reprimand, dated November 29, 2022, resolving the previous administrative complaints.A facility electronic payroll punch record for Staff #92, dated August 14, 2026, at 6:05 a.m., revealed that he clocked in for his shift and subsequently clocked out on August 14, 2026, at 5:10 p.m., completing a full 11.08-hour shift on the floor on the day of the alleged physical altercation.A facility electronic payroll punch record for Staff #92, dated August 15, 2026, at 5:51 a.m., revealed that he clocked in for his shift and subsequently clocked out on August 15, 2026, at 6:01 p.m., completing a full 12.17-hour shift on the floor during the next day after the alleged physical altercation.An interview was conducted on August 20, 2026, at 12:55 p.m., with Licensed Nursing Assistant (LNA/Staff #92). He stated that he has worked at the facility for two and a half years and does not typically interact with Resident #12. He stated that during the incident, he was caring for another resident across the hall when he heard Resident #12 swinging at female staff and refusing to be changed. He stated that he went over to assist, grabbed the resident under the armpits nicely to lift him into the shower chair, and cleaned up the resident while he showered. He stated that he had received training on abuse prevention and de-escalation every three months. An interview was conducted on August 20, 2026, at 1:31 p.m. with the registered charge nurse (RN/Staff #82). He stated that he has worked at the facility for two years and typically interacts with Resident #12 four to ten times a day. He stated that on the day of the incident on Friday, August 14, 2026, Staff #92 reported the physical altercation directly to him. He stated he then interviewed Resident #12, who reported Staff #92 had roughed him up and choked him behind the closed privacy curtain. He stated that he examined the resident's skin and did not see any bruising or markings, but contacted the non-emergency police department because he is a mandated reporter. He stated that he had Staff #92 clock out and then be interviewed by the police. He stated that he then sent Staff #92 home that day. He stated that he subsequently notified the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and another nurse who was working that day. He stated that the resident had a history of becoming irrational and combative, but that staff generally use non-pharmacological interventions, therapy, and communication. A review of the clinical record revealed no documentation of any physical skin assessment, head-to-toe examination, or injury review being completed by a licensed nurse following the resident's allegation of physical abuse.An interview was conducted on August 20, 2026, at 2:10 p.m. with a restorative nursing assistant (RNA/Staff #34). She stated that Resident #12 did not like showers and began fighting and fussing in the hallway, and the hallway was soiled with feces and urine. She stated that she requested assistance from Staff #92 to help transfer the resident. She stated that Staff #92 grabbed the resident nicely under the armpits and lifted him from his wheelchair into the shower chair. She stated that the resident was swinging during the transfer and has a history of combativeness. She stated that the resident did not mention any abuse to her and only said that Staff #92 put him in the shower.An interview was conducted on August 20, 2026, at 2:19 p.m. with the director of nursing (DON/Staff #21). He stated that there was no formal facility investigation or incident report initiated for Staff #92 or Resident #12 because the resident denied any abuse during a brief conversation. He stated that the facility did not notify any state agencies of the allegation. He stated that he conducted a two-hour inquiry and asked the resident point-blank if there was abuse, and because both the resident and the police officer said no, he saw no reason to contact the state survey agency. He stated that the resident has a true mental illness, is on trazodone and Seroquel, and has a history of physical combativeness. An interview was conducted on August 20, 2026, at 2:39 p.m. with a certified nursing assistant (CNA/Staff #32). She stated that Resident #12 gets aggressive and frequently refused showers. She stated that she was changing him when he began yelling, and Staff #92 came in to assist with the transfer. She stated that the resident was hitting and kicking, but Staff #92 was never abusive towards him. She stated that she noticed a small mark on the resident's left arm, which occurred when he hit his arm on the shower room door frame while trying to strike Staff #92. She stated that after the shower, the resident went outside to warm up and was found to have brought a rock into his room, stating he was going to get Staff #92 with it. She stated that she reported the rock to management, and the nurse stated it was to kill, and she later found more rocks hidden in his room. An interview was conducted on August 20, 2026, at 3:23 p.m. with the executive director (Staff #39). He stated that he has served as the abuse coordinator for six and a half years and that abuse allegations are usually reported to him or the DON. He stated that the charge nurse, called the police and sent Staff #92 home. He stated that DON subsequently interviewed the staff and the resident to determine if there were allegations of abuse. He stated that Resident #12 calmed down after talking to DON because they have a good rapport. He stated that he did not know if there was a written investigation report, but confirmed that no self-report was submitted to the state agency or adult protective services because Staff #92 and the resident both stated there was no physical abuse.A review of the facility policy titled Abuse: Prevention and Prohibition Against, last revised on September 2025, revealed: 1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below). 3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Section G, Protection, revealed: 1. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Respond immediately to protect the alleged victim and integrity of the investigation; Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increase supervision of the alleged victim and residents; Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protect the involved persons from retaliation; and Provide emotional support and counseling to the resident during and after the investigation, as needed. The policy under Section H, Reporting / Response, revealed: 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that an allegation of physical abuse for one of two sampled resident (#12) was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies. The universe was 154. Findings include:Resident #12 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of the shaft of the left femur, chronic pain syndrome, generalized anxiety disorder, and major depressive disorder.A comprehensive care plan focus area for psychotropic medication use was initiated on January 16, 2025, and revised on August 13, 2026, to manage the resident's major depressive disorder, generalized anxiety, insomnia, and aggressive behaviors. A quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment further revealed that Resident #12 required substantial or maximal assistance with personal hygiene and toilet transfers, was dependent on staff for bathing and showers, was frequently incontinent of bladder and bowel, and received psychotropic medications including antipsychotics, antianxiety, antidepressants, and hypnotics on a routine basis.A review of progress notes in August revealed no documentation of any physical altercation, physical force used, or the resident's subsequent allegation of physical abuse.A facility Grievance Resolution Form, dated August 14, 2026, submitted by the charge nurse (Staff #82) revealed that Resident #12 reported having an issue with the way Staff #92, a Licensed Nursing Assistant (LNA), transferred him into the shower chair. This form noted that the resident attempted to hit Staff #92, but was able to be redirected and took his shower. This form also revealed that a new Certified Nursing Assistant (CNA) was assigned for the rest of the shift and that the Director of Nursing (DON) was aware of the resolution to have a different CNA assigned going forward. This form further documented that the resident denied any abuse occurred, and the resolution was marked as satisfactory and signed by the DON and the MDS Coordinator on August 14, 2026.An internal facility Investigation Report, dated August 14, 2026, completed by the DON (Staff #21), revealed that he was notified at approximately 4:15 p.m. by Charge Nurse (RN/Staff #82) that Resident #12 was upset regarding the way he was treated by Staff #92. This report noted that the resident insisted on calling the police because he felt the staff were trying to beat him up. This report further revealed that a local police officer responded to the facility, interviewed the staff and the resident, and noted that they also had no suspicion of abuse or neglect, stating that no evidence of abuse was found and a case number was not generated. This report noted that Staff #92 was asked to leave for the day until further investigation was able to be completed. This report also revealed that upon interviewing the resident at 5:45 p.m., the resident was directly asked if he felt abuse had occurred, and he stated no, instead stating he was just upset with the staff. This report documented that the DON concluded no reportable event was identified because the resident denied abuse and the police officer noted no suspicion, resolving the matter internally through the grievance process.A facility electronic payroll punch record, dated August 14, 2026, at 6:05 a.m., revealed that Staff #92 clocked in for his shift and subsequently clocked out on August 14, 2026, at 5:10 p.m., completing a full 11.08-hour shift on the floor on the day of the alleged physical altercation.A facility electronic payroll punch record, dated August 15, 2026, at 5:51 a.m., revealed that Staff #92 clocked in for his shift and subsequently clocked out on August 15, 2026, at 6:01 p.m., completing a full 12.17-hour shift on the floor during the next day after the alleged physical altercation.A State Agency intake report, dated August 18, 2026, at 5:43 a.m., revealed that on August 13, 2026, at approximately 5:00 p.m., Resident #12 refused to shower and began cursing at female staff members in the hallway. This report further revealed that Resident #12 had soiled his clothing with feces and urine and was sitting in his wheelchair when LNA Staff #92 went over to assist and grabbed Resident #12's arms and hands to prevent being struck, using a physical tactic to lift him from his wheelchair into a shower chair behind a closed privacy curtain, resulting in three purple spots and bruising on Resident #12's right arm.An interview was conducted on August 20, 2026, at 11:17 a.m. with Resident #12. He stated that LNA Staff #92 sat next to him behind the fully closed privacy curtain and hit him everywhere he could, smacking him. He stated that the curtain was fully closed so nobody could see. He reported having three purple spots and bruising on his right arm from where Staff #92 grabbed him, which were observed. He also stated he felt safe and had since taken steps to protect himself, including keeping a rock in his drawer for defense. He opened the drawer, and no rock was observed inside the drawer next to his bed, which he stated was because somebody had taken the rock.An interview was conducted on August 20, 2026, at 11:53 a.m. with the Adult Protective Services complainant. He stated that staff members went in and got a report, and he then met with resident #12, who reported that a staff member came in and started beating him up. He stated that he spoke with the Director of Nursing, who mentioned that the LNA had just walked in to help the client get into the chair, and that the resident was angry because he wanted to do things on his own. He stated that a nurse told him the incident was race-related.An interview was conducted on August 20, 2026, at 12:25 p.m. with the human resources director (HRD/Staff #16). She stated that Staff #92 had no prior internal complaints, grievances, or disciplinary warnings on file at the facility during his two and a half years of employment. She stated that Staff #92 was not placed on administrative suspension or restricted from entering the building or having direct care contact during the active investigation of the current allegation on August 13, 2026, August 14, 2026, and August 15, 2026. She stated that he had completed all mandatory training on abuse prevention and de-escalation. A verification report from the State Board of Nursing for Staff #92 was reviewed at 12:25 p.m. with the HRD. The report revealed that Staff #92 was issued an administrative Board order dated September 24, 2004, which imposed a publicly available fine and monetary penalty. The same verification report revealed an administrative Board order dated October 17, 2011, revoking his license, which was subsequently reinstated and restored to an active status. The report further revealed an administrative complaint dated September 23, 2020, alleging that Staff #92 accepted money from a resident while employed at a previous facility. The report revealed a subsequent administrative complaint dated April 19, 2022, alleging that Staff #92 used disparaging language towards a resident by repeatedly telling the resident, You are nasty, after the resident urinated in a cup instead of using a urinal, bedside commode, or call light, which resulted in his termination from that facility. The same licensing board records, including a job application dated June 14, 2022, revealed that Staff #92 subsequently failed to disclose his termination when applying to another facility. Finally, the same verification report revealed a Consent Agreement and Reprimand, dated November 29, 2022, resolving the previous administrative complaints.An interview was conducted on August 20, 2026, at 12:55 p.m. with a licensed nursing assistant (LNA/Staff #92). He stated that he has worked at the facility for two and a half years and does not typically interact with Resident #12. He stated that during the incident, he was caring for another resident across the hall when he heard Resident #12 swinging at female staff and refusing to be changed. He stated that he went over to assist, grabbed the resident under the armpits nicely to lift him into the shower chair, and cleaned up the resident while he showered. He stated that he had received training on abuse prevention and de-escalation every three months. He stated that he understood his obligation to report any suspicious issues directly to the police, and had reported the physical altercation to the registered nurse the same day. An interview was conducted on August 20, 2026, at 1:31 p.m. with a registered charge nurse (RN/Staff #82). He stated that he has worked at the facility for two years and typically interacts with Resident #12 four to ten times a day. He stated that on the day of the incident, Friday, August 14, 2026, Staff #92 reported the physical altercation directly to him. He stated he then interviewed Resident #12, who reported Staff #92 had roughed him up and choked him behind the closed privacy curtain. He stated that he examined the resident's skin and did not see any bruising or markings, but contacted the non-emergency police department because he is a mandated reporter. He stated that he then sent Staff #92 home that day. He stated that he subsequently notified the Director of Nursing, the Assistant Director of Nursing, and another nurse who was working that day. He stated that the resident had a history of, but that staff generally use non-pharmacological interventions, therapy, and communication. A review of the clinical record revealed no documentation of any physical skin assessment, head-to-toe examination, or injury review being completed by a licensed nurse following the resident's allegation of physical abuse.An interview was conducted on August 20, 2026, at 2:10 p.m. with a restorative nursing assistant (RNA/Staff #34). She stated that Resident #12 did not like showers and began fighting and fussing in the hallway. She stated that she requested assistance from Staff #92 to help transfer the resident. She stated that Staff #92 An interview was conducted on August 20, 2026, at 2:19 p.m. with the director of nursing (DON/Staff #21). He stated that there was no formal facility investigation or incident report initiated for Staff #92 or Resident #12 because the resident denied any abuse during a brief conversation. He stated that the facility did not notify any state agencies of the allegation. He stated that he conducted a brief two-hour inquiry and asked the resident point-blank if there was abuse, and because both the resident and the police officer said no, he saw no reason to contact the state survey agency. He stated that the resident has a true mental illness, is on trazodone and Seroquel, and has a history of physical combativeness. An interview was conducted on August 20, 2026, at 3:23 p.m. with the executive director (ED/Staff #39). He stated that he has served as the abuse coordinator for six and a half years and that abuse allegations are usually reported to him or the DON. He stated that RN Staff #82, the charge nurse, called the police and sent Staff #92 home. He stated that DON Staff #21 subsequently interviewed the staff and the resident to determine if there were allegations of abuse. He stated that Resident #12 calmed down after talking to DON Staff #21 because they have a good rapport. He stated that he did not know if there was a written investigation report, but confirmed that no self-report was submitted to the state agency or adult protective services because LNA Staff #92 and the resident both stated there was no physical abuse. A review of the facility policy titled Abuse: Prevention and Prohibition Against, last revised in September 2025, revealed under Section H, Reporting / Response: 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to complete a thorough investigation regarding allegation of physical abuse for one of two sampled resident (#12). The deficient practice could result in abuse continuing and not being prevented. The universe was 154.Findings include:Resident #12 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of the shaft of the left femur, chronic pain syndrome, generalized anxiety disorder, and major depressive disorder.A comprehensive care plan focus area for psychotropic medication use was initiated on January 16, 2025, and revised on August 13, 2026, to manage the resident's major depressive disorder, generalized anxiety, insomnia, and aggressive behaviors. The care plan established goals that the resident would remain free of drug-related complications and experience fewer episodes of tearfulness, restlessness, sleeplessness, and aggressive behavior. Interventions initiated on January 16, 2025, included administering ordered psychotropics, consulting with the pharmacy and physician to consider dose reductions, educating the resident on medication risks, and monitoring the resident for side effects. Daily non-pharmacological behavioral interventions were initiated, which included back rubs, redirection, calm communication, pain assessments, a quiet environment, snacks, and reassurance. Progressive medication adjustments were documented, including starting Lorazepam on January 31, 2025, discontinuing Quetiapine on December 10, 2025, restarting Quetiapine following a failed dose reduction on January 2, 2026, and adding a specific target behavior focus for fewer episodes of aggressive behavior on January 4, 2026. A quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment further revealed that Resident #12 required substantial or maximal assistance with personal hygiene and toilet transfers, was dependent on staff for bathing and showers, was frequently incontinent of bladder and bowel, and received psychotropic medications including antipsychotics, antianxiety, antidepressants, and hypnotics on a routine basis.A review of progress notes in August revealed no documentation of any physical altercation, physical force used, or the resident's subsequent allegation of physical abuse.A facility Grievance Resolution Form, dated August 14, 2026, submitted by the charge nurse (Staff #82) revealed that Resident #12 reported having an issue with the way Staff #92, a Licensed Nursing Assistant (LNA), transferred him into the shower chair. This form noted that the resident attempted to hit Staff #92, but was able to be redirected and took his shower. This form also revealed that a new Certified Nursing Assistant (CNA) was assigned for the rest of the shift and that the Director of Nursing (DON) was aware of the resolution to have a different CNA assigned going forward. This form further documented that the resident denied any abuse occurred, and the resolution was marked as satisfactory and signed by the DON and the MDS Coordinator on August 14, 2026.An internal facility Investigation Report, dated August 14, 2026, completed by the DON (Staff #21), revealed that he was notified at approximately 4:15 p.m. by Charge Nurse (RN/Staff #82) that Resident #12 was upset regarding the way he was treated by Staff #92. This report noted that the resident insisted on calling the police because he felt the staff were trying to beat him up. This report further revealed that a local police officer responded to the facility, interviewed the staff and the resident, and noted they also had no suspicion of abuse or neglect, stating that no evidence of abuse was found and a case number was not generated. This report noted that Staff #92 was asked to leave for the day until further investigation was able to be completed. This report also revealed that upon interviewing the resident at 5:45 p.m., the resident was directly asked if he felt abuse had occurred, and he stated no, instead stating he was just upset with the staff. This report documented that the DON concluded no reportable event was identified because the resident denied abuse and the police officer noted no suspicion, resolving the matter internally through the grievance process.A facility electronic payroll punch record, dated August 14, 2026, at 6:05 a.m., revealed that Staff #92 clocked in for his shift and subsequently clocked out on August 14, 2026, at 5:10 p.m., completing a full 11.08-hour shift on the floor on the day of the alleged physical altercation.A facility electronic payroll punch record, dated August 15, 2026, at 5:51 a.m., revealed that Staff #92 clocked in for his shift and subsequently clocked out on August 15, 2026, at 6:01 p.m., completing a full 12.17-hour shift on the floor during the next day after the alleged physical altercation.A State Agency intake report, dated August 18, 2026, at 5:43 a.m., revealed that on August 13, 2026, at approximately 5:00 p.m., Resident #12 refused to shower and began cursing at female staff members in the hallway. This report further revealed that Resident #12 had soiled his clothing with feces and urine and was sitting in his wheelchair when LNA Staff #92 went over to assist and grabbed Resident #12's arms and hands to prevent being struck, using a physical tactic to lift him from his wheelchair into a shower chair behind a closed privacy curtain, resulting in three purple spots and bruising on Resident #12's right arm.An interview was conducted on August 20, 2026, at 11:17 a.m. with Resident #12. He stated that LNA Staff #92 sat next to him behind the fully closed privacy curtain and hit him everywhere he could, smacking him. He stated that the curtain was fully closed so nobody could see. He reported having three purple spots and bruising on his right arm from where Staff #92 grabbed him, which were observed. He also stated he felt safe and had since taken steps to protect himself, including keeping a rock in his drawer for defense. He opened the drawer, and no rock was observed inside the drawer next to his bed, which he stated was because somebody had taken the rock.An interview was conducted on August 20, 2026, at 11:53 a.m. with the Adult Protective Services complainant. He stated that staff members went in and got a report, and he then met with resident #12 who reported that a staff member came in and started beating him up. He stated that he spoke with the Director of Nursing who mentioned that the LNA had just walked in to help the client get into the chair, and that the resident was angry because he wanted to do things on his own. He stated that a nurse told him the incident was race-related.An interview was conducted on August 20, 2026, at 12:25 p.m. with the human resources director (HRD/Staff #16). She stated that Staff #92 had no prior internal complaints, grievances, or disciplinary warnings on file at the facility during his two and a half years of employment. She stated that Staff #92 was not placed on administrative suspension or restricted from entering the building or having direct care contact during the active investigation of the current allegation on August 13, 2026, August 14, 2026, and August 15, 2026. She stated that he had completed all mandatory training on abuse prevention and de-escalation. A verification report from the State Board of Nursing for Staff #92 was reviewed at 12:25 p.m. with the HRD. The report revealed that Staff #92 was issued an administrative Board order dated September 24, 2004, which imposed a publicly available fine and monetary penalty. The same verification report revealed an administrative Board order dated October 17, 2011, revoking his license, which was subsequently reinstated and restored to an active status. The report further revealed an administrative complaint dated September 23, 2020, alleging that Staff #92 accepted money from a resident while employed at a previous facility. The report revealed a subsequent administrative complaint dated April 19, 2022, alleging that Staff #92 used disparaging language towards a resident by repeatedly telling the resident, You are nasty, after the resident urinated in a cup instead of using a urinal, bedside commode, or call light, which resulted in his termination from that facility. The same licensing board records, including a job application dated June 14, 2022, revealed that Staff #92 subsequently failed to disclose his termination when applying to another facility. Finally, the same verification report revealed a Consent Agreement and Reprimand, dated November 29, 2022, resolving the previous administrative complaints.An interview was conducted on August 20, 2026, at 12:55 p.m. with a licensed nursing assistant (LNA/Staff #92). He stated that he has worked at the facility for two and a half years and does not typically interact with Resident #12. He stated that during the incident, he was caring for another resident across the hall when he heard Resident #12 swinging at female staff and refusing to be changed. He stated that he went over to assist, grabbed the resident under the armpits nicely to lift him into the shower chair, and cleaned up the resident while he showered. He stated that he had received training on abuse prevention and de-escalation every three months. He stated that he understood his obligation to report any suspicious issues directly to the police, and had reported the physical altercation to the registered nurse the same day. An interview was conducted on August 20, 2026, at 1:31 p.m. with a registered charge nurse (RN/Staff #82). He stated that he has worked at the facility for two years and typically interacts with Resident #12 four to ten times a day. He stated that on the day of the incident on Friday, August 14, 2026, Staff #92 reported the physical altercation directly to him. He stated he then interviewed Resident #12, who reported Staff #92 had roughed him up and choked him behind the closed privacy curtain. He stated that he examined the resident's skin and did not see any bruising or markings, but contacted the non-emergency police department because he is a mandated reporter. He stated that he then sent Staff #92 home that day. He stated that he subsequently notified the Director of Nursing, the Assistant Director of Nursing, and another nurse who was working that day. He stated that the resident had a history of but that staff generally use non-pharmacological interventions, therapy, and communication. A review of the clinical record revealed no documentation of any physical skin assessment, head-to-toe examination, or injury review being completed by a licensed nurse following the resident's allegation of physical abuse.An interview was conducted on August 20, 2026, at 2:10 p.m. with a restorative nursing assistant (RNA/Staff #34). She stated that Resident #12 did not like showers and began fighting and fussing in the hallway. She stated that she requested assistance from Staff #92 to help transfer the resident. She stated that Staff #92 An interview was conducted on August 20, 2026, at 2:19 p.m. with the director of nursing (DON/Staff #21). He stated that there was no formal facility investigation or incident report initiated for Staff #92 or Resident #12 because the resident denied any abuse during a brief conversation. He stated that the facility did not notify any state agencies of the allegation. He stated that he conducted a brief two-hour inquiry and asked the resident point-blank if there was abuse, and because both the resident and the police officer said no, he saw no reason to contact the state survey agency. He stated that the resident has a true mental illness, is on trazodone and seroquel, and has a history of physical combativeness. An interview was conducted on August 20, 2026, at 3:23 p.m. with the executive director (ED/Staff #39). He stated that he has served as the abuse coordinator for six and a half years and that abuse allegations are usually reported to him or the DON. He stated that RN Staff #82, the charge nurse, called the police and sent Staff #92 home. He stated that DON Staff #21 subsequently interviewed the staff and the resident to determine if there were allegations of abuse. He stated that Resident #12 calmed down after talking to DON Staff #21 because they have a good rapport. He stated that he did not know if there was a written investigation report, but confirmed that no self-report was submitted to the state agency or adult protective services because LNA Staff #92 and the resident both stated there was no physical abuse. A review of the facility policy titled Abuse: Prevention and Prohibition Against, last revised in September 2025, revealed under Section F, Investigation, that: 1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below). 3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Section G, Protection, revealed that: 1. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Respond immediately to protect the alleged victim and integrity of the investigation; Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increase supervision of the alleged victim and residents; Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protect the involved persons from retaliation; and Provide emotional support and counseling to the resident during and after the investigation, as needed.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that the facility's abuse and neglect policies are followed for one out of 145 residents (resident #145) regarding abuse reporting to appropriate agency. This deficient practice had the potential to further endanger the resident and impede a timely and thorough investigation.Findings included:Resident #176 was admitted to the facility on [DATE], with diagnoses that included fracture of an unspecified part of the neck of the femur, generalized muscle weakness, dysphagia, difficulty walking, cognitive communication deficit, protein-calorie malnutrition, epilepsy, chronic kidney disease, vascular dementia, depression, hypertension, and other comorbid conditions. The resident was discharged on October 10, 2025.Resident #176 had a care plan initiated on September 23, 2025, addressing risks for impaired cognitive function and impaired thought processes related to dementia. The goal was for the resident to maintain her level of cognitive functioning during her stay at the facility. Interventions included communicating at the resident's level of understanding, maintaining eye contact, using simple and directive sentences with appropriate cues, and stopping and returning if the resident became agitated.The resident's annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The total mood severity score was 0, indicating no depressive or observable mood symptoms. There were no documented indicators of psychosis or behavioral symptoms. An additional MDS assessment dated [DATE], revealed a BIMS score of 9, which remained at the lower end of moderate cognitive impairment scale. This level of cognitive impairment presented a potential risk for decision-making, including the ability to assess personal safety within the facility.A nurse encounter note dated October 9, 2025, at 6:37 p.m., entered into the electronic health record by Registered Nurse (RN) Staff #116, documented that Certified Nursing Assistant (CNA) Staff #64 observed a friend of Resident #176 assisting the resident with feeding and flicking the resident's nose in an aggressive manner. CNA Staff #64 instructed the visitor not to engage in that behavior. The visitor then approached CNA Staff #64 in a confrontational manner and began yelling at her. Staff #116 documented that the resident's daughter, who was present at the facility that same day, was notified. The daughter requested that the matter be reported to the resident's case worker, and Staff #64 indicated that the incident had been reported.A review of the facility's visitor log dated October 9, 2025, revealed that the alleged perpetrator and her husband visited the resident's room on that date. However, there was no documentation of any intervention related to the visitor's behavior or any action taken in response to the allegation. Additionally, Director of Nursing (DON), Staff #22, did not describe any specific intervention implemented regarding the visitor on the date of the incident.Furthermore, a review of the electronic health record revealed no documented evidence that an allegation of abuse was reported on October 9, 2025, or thereafter. A review of the grievance log for October 2025 revealed no evidence that a grievance had been filed related to the incident.On February 10, 2026, at 10:13 a.m., an interview was conducted with Staff #64. Staff #64 stated that she reported to RN, Staff #116, that the resident's family friend flicked the resident's nose while assisting with feeding. She stated that when she attempted to stop the behavior and reassure the resident, the visitor turned and yelled at her in an aggressive manner. Staff #64 stated that this interaction was the reason she reported the encounter to Staff #116 on the same day.On February 19, 2026, at 1:45 p.m., an interview was conducted with Staff #116. Staff #116 stated that she was aware of the incident and had reported it to the DON, Staff #22. She stated that Staff #64 informed her that the visitor assisted with feeding and, during the process, grabbed the resident while instructing her to eat. When Staff #64 advised the visitor not to do so, the visitor turned and yelled at her.An interview was conducted with the DON, Staff #22, who recalled the date of the allegation. Staff #22 stated that he received a call from Staff #116 reporting that the resident's friend had become frustrated and was yelling at Staff #64 for attempting to reassure the resident. Staff #22 stated that he went to the facility immediately to assess the situation and conduct an initial evaluation. He stated that the resident reported she was okay and felt safe with both staff and visiting friends. Staff #22 further stated that, based on the outcome of his interview with the resident and discussions with the Abuse Coordinator, he determined that there were no elements of abuse or neglect and, therefore, did not report the allegation to the appropriate authorities.On February 20, 2026, at 11:59 a.m., an interview was conducted with the Abuse Coordinator, who also served as the Administrator, Staff #147. Staff #147 stated that he was aware of the allegation and had discussed it with the DON, Staff #22, regarding the nature of the incident. Staff #147 stated that the decision not to report the allegation was based on the resident interview and the resident's statement that she felt safe with both staff and the visiting friend.A review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised September 9, 2025, indicated that if an allegation of abuse, neglect, misappropriation of resident property, or exploitation involved a visitor or vendor, the facility was to immediately escort the visitor from the building and report the allegation to local law enforcement, as well as to the appropriate state and federal agencies, within the required timeframes. The policy further indicated that all allegations of abuse and neglect were to be thoroughly investigated through a detailed analysis of the nature of the allegation and a determination of whether the conduct implicated resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPAA). The policy specified that the investigation should include: (1) interviews with the individual(s) reporting the incident; (2) interviews with the resident(s); (3) interviews with any witnesses to the incident, including the alleged perpetrator; (4) review of the resident's medical record; (5) interviews with staff members who may have relevant information; and (6) review of all circumstances surrounding the incident.

Number of residents sampled: 145Number of residents cited: 1TFFTE that an allegation of abuse was reported to the applicable agencies for one resident (#176)Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that an allegation of abuse was reported to the state agency for one out of 145 residents (resident #145). This deficient practice had the potential to further endanger the resident and impede a timely and thorough investigation.Findings included:Resident #176 was admitted to the facility on [DATE], with diagnoses that included fracture of an unspecified part of the neck of the femur, generalized muscle weakness, dysphagia, difficulty walking, cognitive communication deficit, unspecified protein-calorie malnutrition, epilepsy, chronic kidney disease, vascular dementia, depression, hypertension, and other comorbid conditions. The resident was discharged on October 10, 2025.Resident #176 had a care plan initiated on September 23, 2025, addressing risks for impaired cognitive function and impaired thought processes related to dementia. The stated goal was for the resident to maintain her level of cognitive functioning during her stay at the facility. Interventions included communicating at the resident's level of understanding, maintaining eye contact, using simple and directive sentences with appropriate cues, and stopping and returning if the resident became agitated.The resident's annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The total mood severity score was 0, indicating no depressive or observable mood symptoms. There were no documented indicators of psychosis or behavioral symptoms. An additional MDS assessment dated [DATE], revealed a BIMS score of 9, which remained at the lower end of moderate cognitive impairment scale. This level of cognitive impairment presented a potential risk for decision-making, including the ability to assess personal safety within the facility.A nurse's encounter note dated October 9, 2025, at 6:37 p.m., entered into the electronic health record by Registered Nurse (RN) Staff #116, documented that Certified Nursing Assistant (CNA) Staff #64 observed a friend of Resident #176 assisting the resident with feeding and flicking the resident's nose in an aggressive manner. CNA Staff #64 instructed the visitor not to engage in that behavior. The visitor then approached CNA Staff #64 in a confrontational manner and began yelling at her. RN Staff #116 documented that the resident's daughter, who was present at the facility that same day, was notified. The daughter requested that the matter be reported to the resident's case worker, and CNA Staff #64 indicated that the incident had been reported.A review of the electronic health record revealed no documented evidence that an allegation of abuse was reported on October 9, 2025, or thereafter. A review of the grievance log for October 2025 revealed no evidence that a grievance had been filed related to the incident.On February 10, 2026, at 10:13 a.m., an interview was conducted with CNA Staff #64. Staff #64 stated that she reported to RN Staff #116 that the resident's family friend flicked the resident's nose while assisting with feeding. She stated that when she attempted to stop the behavior and reassure the resident, the visitor turned and yelled at her in an aggressive manner. Staff #64 stated that this interaction prompted her to report the encounter to RN Staff #116 on the same day.On February 19, 2026, at 1:45 p.m., an interview was conducted with RN Staff #116. RN Staff #116 stated that she was aware of the incident and had reported it to the Director of Nursing (DON), Staff #22. She stated that CNA Staff #64 informed her that the visitor assisted with feeding and, during the process, grabbed the resident while instructing her to eat. When CNA Staff #64 advised the visitor not to do so, the visitor turned and yelled at her.An interview was conducted with the DON, Staff #22, who recalled the date of the allegation. Staff #22 stated that he received a call from RN Staff #116 reporting that the resident's friend had become frustrated and was yelling at CNA Staff #64 for attempting to reassure the resident. Staff #22 stated that he immediately went to the facility to assess the situation and complete an initial evaluation. He stated that the resident reported she was okay and felt safe with both staff and visiting friends. Staff #22 further stated that, based on his interview with the resident and discussion with the Abuse Coordinator, he determined that there were no aspects of abuse or neglect and, therefore, did not report the allegation to the appropriate authorities.On February 20, 2026, at 11:59 a.m., an interview was conducted with the Abuse Coordinator, who also served as the Administrator, Staff #147. Staff #147 stated that he was aware of the allegation and had discussed it with the DON, Staff #22, regarding the nature of the incident. Staff #147 stated that the decision not to report the allegation was based on the resident interview and the resident's statement that she felt safe with both staff and the visiting friend.A review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised September 9, 2025, indicated that if an allegation of abuse, neglect, misappropriation of resident property, or exploitation involved a visitor or vendor, the facility was to immediately escort the visitor from the building and report the allegation to local law enforcement, as well as to applicable federal or state agencies, within the required timeframes.

Number of residents sampled: 145Number of residents cited: 1TFFTE that an abuse investigation was conducted for one resident following an allegation of abuse (#176)Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that an allegation of abuse was investigated for one out of 145 residents (resident #145). This deficient practice had the potential to further endanger the resident and impede a timely and thorough investigation.Findings included:Resident #176 was admitted to the facility on [DATE], with diagnoses that included fracture of an unspecified part of the neck of the femur, generalized muscle weakness, dysphagia, difficulty walking, cognitive communication deficit, unspecified protein-calorie malnutrition, epilepsy, chronic kidney disease, vascular dementia, depression, hypertension, and other comorbid conditions. The resident was discharged on October 10, 2025.Resident #176 had a care plan initiated on September 23, 2025, addressing risks for impaired cognitive function and impaired thought processes related to dementia. The goal was for the resident to maintain her level of cognitive functioning during her stay at the facility. Interventions included communicating at the resident's level of understanding, maintaining eye contact, using simple and directive sentences with necessary cues, and pausing and returning if the resident became agitated.The resident's annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The total mood severity score was 0, indicating no depressive or observable mood symptoms. There were no documented indicators of psychosis or behavioral symptoms. An additional MDS assessment dated [DATE], revealed a BIMS score of 9, which remained at the lower end of moderate cognitive impairment scale. This level of cognitive impairment placed the resident at potential risk for decision-making, including the ability to assess personal safety within the facility.A nurse's encounter note dated October 9, 2025, at 6:37 p.m., entered into the electronic health record by Registered Nurse (RN) Staff #116, indicated that Certified Nursing Assistant (CNA) Staff #64 observed a friend of Resident #176 assisting the resident with feeding and flicking the resident on the nose in an aggressive manner. CNA Staff #64 instructed the visitor not to engage in that behavior. The visitor then approached CNA Staff #64 in a confrontational manner and began yelling at her. RN Staff #116 documented that the resident's daughter, who was also present at the facility that day, was notified. The daughter requested that the matter be reported to the resident's case worker.A review of the electronic health record revealed no documented evidence that an allegation of abuse was reported on October 9, 2025, or thereafter. A review of the facility's grievance log for October 2025 revealed no evidence of a grievance filed related to this incident.On February 10, 2026, at 10:13 a.m., an interview was conducted with CNA Staff #64. Staff #64 stated that she informed RN Staff #116 that the resident's friend flicked the resident's nose while feeding her. She further stated that when she attempted to intervene and reassure the resident, the visitor became aggressive and yelled at her. Staff #64 reported that this behavior prompted her to report the incident to RN Staff #116 on the day it occurred.On February 19, 2026, at 1:45 p.m., an interview was conducted with RN Staff #116, who confirmed that she reported the incident to the Director of Nursing (DON), Staff #22. RN Staff #116 stated that CNA Staff #64 reported that the visitor assisted with feeding the resident and, during the process, grabbed the resident while instructing her to eat. When CNA Staff #64 advised the visitor not to do so, the visitor turned and yelled at her.An interview was conducted with the DON, Staff #22, who recalled the date of the allegation. Staff #22 stated that he received a call from RN Staff #116 reporting that the resident's friend had become frustrated and was yelling at CNA Staff #64 for attempting to reassure the resident. Staff #22 stated that he immediately went to the facility to assess the situation and complete an initial evaluation. He reported that the resident stated she was okay and felt safe with both staff and visiting family friends. Staff #22 further stated that, based on his interview with the resident and discussions with the Abuse Coordinator, he determined that the incident did not meet criteria for abuse or neglect and, therefore, did not report the allegation to the state agency.On February 20, 2026, at 11:59 a.m., an interview was conducted with the Abuse Coordinator, who was also the Administrator, Staff #147. Staff #147 stated that he was aware of the allegation and had discussed it with the DON, Staff #22. Staff #147 stated that the decision not to report the allegation was based on the resident interview and the resident's statement that she felt safe with both staff and the visiting friend.A review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised September 9, 2025, indicated that all allegations of abuse and neglect were to be thoroughly investigated through a detailed analysis of the nature of the allegation and a determination of whether the conduct implicated resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPAA). The policy further indicated that the investigation should include: (1) interviews with the individual(s) reporting the incident; (2) interviews with the resident(s); (3) interviews with any witnesses to the incident, including the alleged perpetrator; (4) review of the resident's medical record; (5) interviews with staff members who may have relevant information; and (6) review of all circumstances surrounding the incident.

Based on clinical record review, interviews, review of facility documentation, and the facility's policy and procedures, the facility failed to ensure assessments accurately reflected one resident's, #108, status. The census was 145. The deficient practice could lead to residents not receiving personalized care that fits their needs.Findings include:Resident #108 was admitted to the facility on [DATE] with diagnoses of a fracture of the right humerus, muscle weakness, and type 2 diabetes.An admission assessment, completed on February 4, 2026, revealed the resident was alert and oriented to person, place, time, and situation. An admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment.Review of the admission Note in the clinical record revealed an entry, dated February 4, 2026 at 8:19 P.M. indicated that the resident was admitted to the facility with a primary diagnosis of GLF (ground level fall). It further stated that upon arrival, Resident #108 was alert and oriented x4 (person, place, time and situation).Review of the NP/PA (Nurse Practitioner/Physician's Assistant) Progress Note, dated February 5, 2026 at 5:30 P.M.) indicated that the resident was alert and oriented x3 (person, place, and time).Review of a Daily Skilled Note, dated February 6, 2026 at 6:21 P.M. indicated Resident #108 was alert and oriented x3. It was also noted that there were no active symptoms or treatments affecting the resident's level of consciousness, cognition, sleep, mood or behavior.Further review of the Progress Notes in the clinical chart did not reveal charting related to Resident #108's cognitive status, confusion or inability to participate in assessments due to altered level of consciousness.The Care Plan, initiated on February 4, 2026 and revised on February 10, 2026, indicated there was a focus on Resident #108's risk of impaired cognitive function/dementia or impaired thought process related to him being newly admitted to the facility. Interventions included identifying oneself at each interaction, facing the resident when speaking to him and making eye contact, and reducing distractions.An interview was conducted with Resident #108 on February 18, 2026 at 11:59 A.M. During the interview, the resident did not exhibit any signs of confusion and was able to stay on the topic at hand. An interview was conducted with Resident #108's roommate, Resident #139, on February 18, 2026 at 12:05 P.M. Resident #139 shared that since he shared a room with Resident #108, they have been able to have conversations on a variety of topics. He further shared that he had not experienced Resident #108 showing signs of confusions during their conversations.An interview was conducted with Certified Nursing Assistant (CNA/Staff #123) on February 18, 2026 at 12:10 P.M. Staff #123 recalled that when she first worked with Resident # 108, she didn't have much information about him and his mobility level. She further recalled Resident #108 telling her that he could walk and she felt that he was pretty with it. Staff #123 further indicated that during her time in working with him, he was alert, able to follow conversations and exhibited no altered level of consciousness.An interview was conducted with Registered Nurse (RN/Staff #196) on February 18, 2026 at 12:19 P.M. Staff #196 indicated that she was familiar with Resident #108 and that he is able to tell you what is going on. She also described Resident #108 as someone who is adamant about the medications he is and is not taking as he wants to manage his own healthcare. She also describes him as groggy when he first wakes up but is able to engage once he comes to. After checking the clinical chart, she added that he is his own Power of Attorney (POA).An interview was conducted on February 19, 2026 at 2:05 P.M. with the MDS Coordinator/Staff #43. Staff #43 explained that while she is responsible for the MDS assessment packet, there are multiple staff members who each do their portions of the assessments and it is all consolidated together. She indicated that Social Services will typically do the BIMS assessments. Once they complete that part, she will review it and if she saw a red flag, she will either review it with Social Services or discuss it with the other MDS coordinator. Staff #43 shared that she knew of Resident #108 but had never interacted with him. When asked to review Resident #108's BIMS, she shared that the BIMS was a 00. When asked to review Progress Notes when the resident arrived to the facility, she shared that she had never seen anyone who was alert and oriented x4 and have a BIMS of 00, however, she added that anything is possible. Staff #43 explained that it was important that the assessments of the residents are accurate because it helps with figuring out where the resident is at in terms of their medical and functional status and where their baseline is. Everything needs to be accurate because you want to know everything you can about the resident to provide accurate care to them. She added that personalized care helps the residents.An interview was conducted with Social Services (SS/Staff #7) on February 19, 2026 at 2:48 P.M. Staff #7 explained that he does the BIMS assessments on Residents and it is a snapshot of the resident's cognitive status. He shared that sometimes residents come in and they are groggy or confused about where they are and when that happens, he will assess the residents later when they are more alert. He shared that he was familiar with Resident #108 and when he first arrived to the facility, he was hard to arouse so Staff #7 continued to do his rounds. Staff #7 further shared that he ended up doing the BIMS assessment with Resident #108 a few days later and he scored a 00 because Staff #7 was not able to get his attention. Staff #7 was asked what the Nurses' progress notes revealed about the resident's cognitive status when the resident arrived. After looking at the clinical chart, Staff #7 shared that when the resident arrived on the 4th, he was alert and oriented x4. Staff #7 then shared that since the resident had arrived to the facility in the evening on the 4th, he would have gone to see the resident on the morning of the 5th. When asked what the clinical record noted about the resident's cognitive status on the 5th, Staff #7 indicated that a note done by the NP said the resident was alert and oriented x3. Staff #7 shared that it could have been that every time he went to see the resident, he was hard to arouse.An interview was conducted with the Director of Nursing (DON/Staff #22) on February 20, 2026 at 10:59 A.M. Staff #22 explained that it was important that assessments accurately reflect the residents because it is important to paint a good picture of what is going on. He also explained that when residents first arrive, they might appear confused that first day or two, which is why they do a baseline and comprehensive. He stated that assessments are a living document because it is an ongoing document. He further stated that the BIMS assessment are a brief snapshot of the resident at that time and he is not going to refer to it when reviewing the residents' status. He explained that he is going to refer to the nursing and provider documents instead. He further explained that because of this, there is no risk to the residents for having an inaccurate BIMS assessment. Staff #22 shared that he was not familiar with Resident #108 and he has never attempted to engage with him. After looking at the clinical chart, Staff #22 indicated that his BIMS assessment was a 00 while the progress note completed during the admission on indicated the resident was alert and oriented x4. He also shared that a note entered on February 5, 2026 indicated the resident was alert and oriented x4. Staff #22 indicated that he did not have a reasonable explanation of why the BIMS was a 00 when several progress notes indicated the resident was alert and oriented.Review of the facility's Policy and Procedure titled, Resident Assessments: Assessments, Frequency of revealed it was last reviewed in March 2025. The policy indicated that resident assessments will be developed and reviewed on a timely basis.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure appropriate monitoring of negative pressure wound therapy (NPWT) (wound vac) for 1 of 4 residents (Resident #4). The deficient practice could result in the potential for the wound vac therapy to be ineffective and cause wounds to get worse. Findings include:Resident # 4 was admitted [DATE], with diagnosis of Parkinson's, type 2 diabetes mellitus, and peripheral vascular disease. Review of Resident #4's care plan dated March 20, 2025 revealed that resident has potential for pressure ulcer development with actual skin impairment, including left lateral foot diabetic foot ulcer. Interventions included administering treatments as ordered and monitoring for effectiveness, as well as monitoring the dressing to ensure it is intact and adhering. The Minimum Data Set (MDS) dated [DATE] revealed that Resident # 4's Brief Interview for Mental Status (BIMS) score was 14 which indicated Resident # 4 is cognitively intact. The MDS also revealed that Resident # 4 was at risk for developing pressure ulcers. Review of surgical debridement note dated July 16, 2025, revealed wounds located on the left lateral foot measuring 2.0 cm x 1.0 cm x 0.6 cm and left lateral ankle measuring 2.7 cm x 2.0 cm. x 0.5 cm. Review of a skin evaluation dated August 11, 2025, revealed a wound vac treatment to the patient's left foot. An order dated August 11, 2025, revealed wound vac monitoring every shift for functioning and placement. The order clarified if the wound vac malfunctions or must be off for more than two hours staff would need to follow as needed (PRN) orders in treatment administration record (TAR) for additional instructions. Review of the additional instructions included to cleanse wound to left foot and left lateral ankle with wound cleanser and to apply wet to moist dressing and secure with tape. This dressing was to be changed every 12 hours until the wound vac is replaced, and to notify the wound nurse that the wound vac is off. Review of the wound team administration record for August 2025 revealed that monitoring wound vac placement was not marked as completed on August 17, 2025, for the overnight shift. Review of MAR administration note dated August 18, 2025 at 12:44 p.m. revealed that Resident # 4 reported discomfort to left foot. Wound vac was removed and skin to peri wound was macerated from drainage due to seal broken. Wound was cleansed with wound cleanser, patted dry and skin prep was applied to peri wound as well as triad paste, Medi honey, and silver alginate. Wound was wrapped and Hospice was notified. It also revealed that wound vac was held for remainder of the night and the wound would be reassessed tomorrow. Review of MAR administration note dated August 19, 2025 at 7:31 a.m. revealed that wound vac was still on hold due to maceration of peri wound and discomfort reported by resident. Review of wound team administration record for August 2025 revealed that cleansing of the wound and changing of the dressing every 12 hours while wound vac was off was not completed on August 18, 19, and 20th, 2025. Review of surgical debridement note dated August 20, 2025, revealed wounds located on left lateral foot measuring 1.5 cm x 1.1 cm x 0.5 cm and left lateral ankle measuring 2.5 cm x 2.3 cm. x 0.6 cm. An interview with Resident # 4 on August 25, 2025 at 11:58 a.m. revealed that he had started the wound vac on his left foot in mid-August and had it on for about five days when he started to feel pain in his left foot. He informed staff and they took it off and wrapped it. Resident # 4 revealed that he felt the wound vac had made the wounds worse. An interview with Licensed Practical Nurse (LPN/Staff # 128) on August 25, 2025 at 3:00 p.m. revealed that Resident # 4 had a wound vac on but it was removed last week due to a leak in the seal. Staff #128 revealed that they help monitor the wound vac each shift to ensure there are no leaks in the seal. After the vac is monitored then they mark the MAR and follow any other orders given by the physician. If there is a leak in the seal, they need to stop wound vac and notify physician immediately and follow any instructions they give.An interview with Director of Nursing (DON/Staff # 193) on August 25, 2025 at 4:02 p.m. revealed that it is his expectation that the floor nurses monitor the wound vac every 12 hours for any seals and notify the physician if there are any problems with the wound vac such as a break in the seal. DON Staff # 193 revealed that the overnight nurse did not sign off on monitoring the wound vac the night of August 17, 2025 and that it is his expectation that the wound vac be monitored every shift. A Policy and Procedure titled Wound Management dated as reviewed on September 2024, revealed that a resident having a pressure ulcer receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's order. The policy also revealed that all wound or skin treatments should be documented in the resident's clinical record at the time they are administered.

Based on staff interviews and policy review, the facility failed to ensure that nursing staff had the qualifications and competencies to provide direct care to residents. The deficient practice could result in underqualified staff providing inadequate direct care to residents, and potential for medical error.Findings include:Review of personnel files for five Hospitality Aides, Staff #21, Staff #111, Staff #130, Staff #142, and Staff #167, revealed that none of them possessed the qualifications or certifications to provide direct care to residents. Review of training for all hospitality aides at the facility revealed that none of them possessed the training, qualifications, or certifications to provide direct care to residentsReview of the job description for a Hospitality Aide revealed that the primary purpose of their job position is to work alongside the nursing department to provide non-nursing/non-directcare for residents. Some of the duties would include, making beds, passing ice and water, answering call lights, and other non-nursing duties. There was no evidence in the job description that hospitality aides would be expected to take vitals or provide direct care to residents.An interview was conducted on August 20, 2025 at 10:18 a.m. with a Certified Nursing Assistant (CNA/Staff#45) who stated that the role of a hospitality aide at the facility is to help answer call lights, take vitals, hand out water, pass trays, and communicate resident needs to the CNA's. The CNA stated that the difference between CNA's and hospitality aides is that they are not allowed to do transfers or catheter care, but they may assist in brief changes if a CNA is present. An interview was conducted on August 20, 2025 at 10:23 a.m. with a CNA, Staff #76, who stated that the role of a hospitality aide at the facility is to pass linens, hand out water, take vitals, and answer call lights. The CNA stated that she always sees the hospitality aides doing vitals, but she prefers to do her own vitals for her residents. An interview was conducted on August 20, 2025 at 10:26 a.m. with a Licensed Practical Nurse (LPN/Staff#88) who stated that the role of a hospitality aide at the facility is to pass ice and help answer call lights to assist staff in identifying what residents need. The LPN stated that the difference between a CNA and hospitality aide is that CNA's do direct care like showers and grooming, but hospitality aides cannot do that because they aren't trained to do it. The LPN stated that the hospitality aides were allowed to do vitals and the nurses will sometimes educate hospitality aides on the floor to do vitals before they do them. An interview was conducted on August 20, 2025 at 10:29 a.m. with a LPN, Staff #10, who stated that the role of a hospitality aide at the facility is to help out with vitals, answer call lights, and do bed changes. The LPN further stated that the difference between CNA's and hospitality aides is licensing, and that the hospitality aides do vitals and beds, but the CNA's do brief changes. An interview was conducted on August 20, 2025 at 10:40 a.m. with a Hospitality Aide (Aide/Staff#21) who stated that the role of a hospitality aide was to answer call lights, get water and help identify resident needs. The aide stated that she was not supposed to do personal care, but sometimes she takes vitals for residents and that if residents are independent and don't require transfers she will help them to the bathroom. The aide further stated that she was not trained as a CNA, she has gotten training at the facility on taking vitals, and she takes vitals for residents including temperature and pulse. An interview was conducted on August 20, 2025 at 11:08 a.m. with the Director of Nursing (DON/Staff#66) who stated that the role of a hospitality aide at the facility is to do non-skilled work because they are just extra staff. The DON stated that the hospitality aides do bed changes, remake beds, pass ice, pass water, tray delivery, resident transportation, and they listen to the residents and their needs. The DON further stated that the hospitality aides can restock supplies and answer call lights without touching the residents. The DON stated that the difference between CNA's and hospitality aides is that CNA's can do direct care like Activities of Daily Living (ADL) care, whereas hospitality aides can do errands and document things. The DON stated that the CNA's can take vitals and the hospitality aides will input the numbers to document, but they do not do ADLs. The DON stated that one hospitality aide, Staff #21, was trying to get into CNA school, but she only does hospitality work at the facility and was not enrolled in a program. The DON stated that hospitality aides should not be the ones taking vitals, but they can document it. The DON stated that the risk of hospitality aides taking vitals would be that if they are doing something they are untrained for, there would be inherent risk, and they are not supposed to be doing vitals. A follow- up interview was conducted on August 20, 2025 at 12:41 a.m. with the DON, Staff #66, who stated that hospitality aides do not take vitals, so there was no additional floor training for them to learn to take vitals. The DON further stated that even if a hospitality aide were to be enrolled in a CNA program, they would not be permitted to take vitals for residents. The DON further stated that it would not be his expectation for Staff #21 to be taking vitals because she did not pass her test in her CNA program, and it was not within her role as a hospitality aide to take vitals. Review of a policy titled, Nursing Staff Competency, was reviewed in January of 2025 and revealed that it is the policy of the facility to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The policy also revealed that all nursing staff must meet the specific competency requirements as part of their license and certification requirements defined under State law or regulations.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure treatment requiring oxygen was ordered by the physician for 1 out of 3 sampled residents (#480). The deficient practice could result in the potential for the resident not receiving the appropriate treatment. Findings include: Resident #480 was admitted on [DATE] with diagnoses of Cirrhosis of the liver, ascites, type 2 diabetes mellitus, and depression. Review of the Resident's orders revealed an order dated November 17, 2021 to document temperature and oxygen stats and to monitor for the following symptoms: fever, cough, shortness of breath or difficulty breathing for every shift. Further review revealed no orders for oxygen. Review of the Resident's care plan had no indication of oxygen therapy from the time of initial admission until September 12, 2022. Review of Daily Skilled Nursing note dated December 21, 2021 indicated that Resident #480's oxygen therapy was continuous oxygen set at 2 Liters (L). It goes on to state that the resident is on continuous oxygen and de-stats to 70s when oxygen is off and that the resident's stats are stable at 95% while on oxygen. Review of the Daily Skilled Note dated December 23, 2021 revealed that Resident #480's oxygen stats were 88%. The method of administration was oxygen via nasal cannula. Review of a hospital admission note dated December 24, 2021 revealed that Resident #480 was placed on 6 L of oxygen and his normal baseline was 2 to 4 L of oxygen. Upon re-admission a Nurse Practitioner note dated December 29, 2021 at 4:20 p.m., revealed that Resident #480 will return to the facility with no new medical concerns and is on room air with saturation rate of 91%. However, a Nursing note dated December 29, 2021 at 10:52 p.m., revealed that the Resident arrived at 6:00pm with no shortness of breath or labored breathing on 2 L of oxygen. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6. Further review of the MDS revealed no indication of Oxygen Therapy was performed. Further review of the facility orders revealed an oxygen order was not obtained until September 12, 2022. An interview was conducted on May 16, 2025 at 10:10 a.m. with a Licensed Practical Nurse (LPN/staff #31), who stated that if a resident's oxygen stats were to drop, especially below 88%, they would get a hold of the charge nurse to see if she can increase their oxygen to get their stats back up. If the resident is not on oxygen, she would put them on 2 L of oxygen and get ahold of the charge nurse and the doctor to obtain an order for further oxygen. In an interview with the Assistant Director of Nursing (ADON/staff #69) conducted on May 16, 2025 at 11:42 a.m., the ADON stated that they check oxygen stats on long term residents at least once a day every shift and if the stats drop, depending on the resident's order for oxygen, we may titrate the oxygen up and notify the doctor. In reviewing Resident 480's chart the ADON stated there was probably a standing order for oxygen for this resident during that time but was unable to provide the actual order. Review of the facility policy titled, Oxygen Administration, revised on July, 2013 and reviewed July, 2021, revealed that oxygen therapy is administered by licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#2) was reported to the State Agency. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, acute kidney failure, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 2, which suggests moderate cognitive impairment. The MDS also included the resident had verbal behaviors towards others 1-3 days a week. She was also care planned for behaviors problems on her care plan initiated on January 10, 2024, with interventions that included administering medications as ordered and consulting with Pastoral Care, Social Services, and Psych services. A physician's order dated January 13, 2024 indicated she would be transferred to the hospital. Her discharge paperwork for the same day revealed she was transferred to the hospital for altered mental status. In a nursing progress note time stamped January 13, 2024 at 1:46 PM, a Licensed Practical Nurse (LPN/Staff #23) documented the resident had alleged that night staff had tried to finger fuck her. The note further documents behaviors of yelling at, attempting to bite, and throwing things at staff. In a follow up progress note at 2:00 PM the same day, the patient was sent out to the hospital per the provider to get a psychiatric evaluation done due to behaviors. The patient's son and power of attorney were notified of the change in condition. On January 15, 2024 a Social Services note entered at 1:12 PM by the Social Service Supervisor and the Assistant Director of Nursing indicated they had followed up regarding Resident #2's statements of being sexually assaulted. The resident denied making these statements. During an interview conducted on January 18, 2024 at 12:15 PM, with the Charge Nurse, (Staff #23) on the phone, she stated that on the night of the incident, she was made aware by the nurse that the patient was refusing all medications, and stating that the staff was trying to rape her. Staff #23 called the ADON for support, and ultimately the patient was sent out for a psychiatric evaluation. During an interview with the ADON, (Staff #67), on January 18, 2024 at 12:41 PM, she stated she had received a call from the charge nurse the day of the incident about Resident #2 making weird comments and concerning statements. She denies that the charge nurse told her the resident reported sexual assault. She further stated that she and the Social Services Supervisor, (Staff #89) immediately came into the building to investigate. When they interviewed Resident #2, she denied she had alleged sexual assault. The Director of Nursing (DON) was notified of the situation. During an interview conducted on January 18, 2024 at 12:47 PM with the DON, when asked if the facility is required to report before investigating, she stated they investigate immediately on the spot and it is a very fast process. In this instance she would not have reported because she stated she did not know what the patient was alleging. In the facility policy entitled Abuse: Prevention of and Prohibition Against last reviewed on 10/2022, it states Residents also have the right to be free from verbal, sexual, physical, and mental abuse . Under section H. Reporting/Response it states All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State of Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on record review, staff and family interviews, as well as policy and facility documentation, the facility failed to ensure a resident's privacy during medication administration. Failure to respect privacy has the potential to erode trust, dignity, and a sense of well-being. Findings include: Resident #331 was admitted on [DATE] with diagnosis including metabolic encephalopathy, fracture of the left femur, congestive heart failure, atherosclerotic heart disease, chronic obstructive pulmonary disease, dysphagia and cognitive communication deficit. A review of the MDS (minimum data set) dated March 29, 2023 revealed a BIMS (brief interview of mental status) score of 6, indicating severe cognitive impairment. A review of the consents section in the electronic medical record revealed a communication method request form dated March 22, 2023, noting the following: I do not want information regarding my condition to be given to any of my friends/ family members. The document was noted to be signed by telephonic consent by the resident's spouse, who was observed to have signed all other admission consent forms telephonically. A review of the grievance log for May 2023, noted a grievance for resident #331 logged by the case manager at the Veterans Administration on May 25, 2023, citing lost items. However, further review of the grievance resolution form, noted an additional concern regarding the resident's protected health information. The grievance resolution form addressed a question regarding the resident's PHI (protected health information), stating that it had not been given to an unauthorized person. It further stated that the nurse was telling the resident which medications were being administered while a family member was visiting at bedside. The grievance investigation further revealed that the nurse asked the resident if it was okay to give him his medications with a visitor in the room. The resident was stated to have given his permission; however, the resident is noted to have BIMS score of 6. An interview was conducted on November 14, 2023 at 12:50 P.M. with the spouse (#205) of resident #331. The spouse stated that the resident's nurse (LPN, #36) had admitted that she had relayed information regarding the resident's medication to the sister-in-law, who was not authorized to receive the information. She stated that she had advised the director of nursing but had not heard back from the facility. An interview was conducted on November 15, 2023 at 7:30 A.M. with the director of nursing, staff #70. Staff #70 stated that she was aware of the incident where the nurse had advised resident #331 of the medications she was administering with the resident's sister-in-law in the room. She stated that it was likely that the nurse was unaware of the communication method preference noted in the resident's electronic health record. She stated that the expectation is that staff be aware of the resident's privacy preferences. She stated that the risk would be that information would be shared with unauthorized individuals. An interview was conducted on November 15, 2023 at 8:25 A.M. with staff #63, medical records supervisor and HIPAA compliance officer for the facility. She stated that HIPAA breaches can occur in a number of different ways, to include: incoming faxes if observed by non-authorized personnel, mail delivered to the wrong room, giving out information to unauthorized individuals over the phone or in person. She stated that staff can discern who is authorized to have a resident's information by the facesheet. She stated that if someone is not listed on the facesheet, outside of staff, they are not authorized to obtain information on the resident or their medical record. When staff #63 reviewed the electronic medical record for resident #331, she stated that only the spouse and wife were noted to be authorized to receive the resident's medical information; however, the information had been shared with the resident's sister-in-law, per facility documentation and staff interviews. She stated that if there is a HIPAA violation, the staff would report it her, she would discuss it with the administrator and it would then be sent to the compliance team. She stated that she was not made aware that medication information for resident #331 had been shared with an unauthorized individual. She stated that the risk could be a barrier to trust and information could be taken out of context. An interview was conducted on November 15, 2023 at 8:47 A.M with the administrator, staff #90. Staff #90 stated that communication regarding the resident and their medical record occurs only with the resident and their approved family members and stated that the expectation is that no information is shared forward to those not designated in the medical record. A review of the HIPPA compliance policy dated May 2022 revealed that all staff, volunteers and vendors must not disclose any potential medical information about a resident, either verbally, written or electronically; however, medication information for resident #331 was revealed to the resident's sister-in-law, who was not an authorized person, per the medical record.

Based on observation, staff interviews, and facility policy and procedures, the facility failed to ensure one resident's (#93) environment was free from hazards. The deficient practice could result in accidents occurring. Findings include: Resident #93 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinsonism unspecified, seizure disorder, and hypertension. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the fall risk evaluation dated August 3, 2023 revealed that the resident had fallen 2 times in the past three months and was a high risk for falling. A nurse progress note dated September 27, 2023 at 7:14 p.m. revealed that a loud noise was heard coming from the resident's room along with the resident's roommate yelling for help. Upon entering the resident's room, she was found lying on her left side between the bed and the nightstand. A very small lesion was found on the left brow with minimal bleeding and no pain. The resident was assessed from head to toe. The resident was experiencing pain in the left shoulder, trapezius, scapula area. Upon palpation, a hard bump was found on the scapula area with no pain. An X-ray was ordered to rule out a fracture. Passive range of motion (ROM) was performed on left side due to history of a stroke causing hemiplegia. Pain was experienced at full point of (ROM) with the upper left extremity. The resident stated that she was having muscle spasm in right mid back that causes all pain to worsen. Vitals were taken and the resident was transferred to bed. The nurse practitioner (NP) was notified and ordered Baclofen 5 mg three times a day for muscle spasms and an X-ray. The resident's daughter and Director of Nursing were notified. An ice pack and pain medications were given as needed, neurological assessment sheet was started as of 5:40 p.m. and resident is stable. A nurse progress note dated September 27, 2023 at 11:44 p.m. revealed that the resident was sent out to the hospital. A nurse progress note dated September 28, 2023 at 11:50 a.m. revealed that the resident returned from the hospital with a fractured shoulder. A fall committee interdisciplinary team meeting note dated September 28, 2023 revealed that the resident is alert and oriented with a brief interview for mental status score of 15 and is able to make needs known. The resident requires extensive to total assistance for safety with bed mobility, toileting, and transfers. On September 27, 2023 a loud noise was heard coming from the resident's room, followed by the resident being heard yelling out for help along with the resident's roommate. The nurse entered the room and found the resident lying on her left side between the bed and the nightstand. The resident had her bed in the high position. The resident stated that she was attempting to reach for an item from the nightstand, but the item was too far to reach and she fell off of the bed. The resident complained of pain in her left shoulder. A full head to toe assessment was performed by the nurse and noted a small lesion by brow, hard lump found on the left shoulder. The provider was notified and ordered an X-ray of the left shoulder. The X-ray showed a fracture to the left clavicle. The provider was informed and ordered for the resident to be sent to the hospital for further evaluation and treatment. The resident returned from the hospital on September 28, 2023 with a sling. New interventions for the fall care plan: bed in low position, resident educated to use call-light and ask for assistance when reaching for items not within reach. Review of a physician progress note dated November 15, 2023 at 8:38 AM revealed that the resident was seen and examined after a fall on September 27, 2023. The resident was sent to the emergency room (ER) where she was evaluated. A X-ray of the left shoulder showed acromioclavicular (ac) distal left clavicle fracture and was placed in sling and sent back to facility September 28, 2023. The resident complained of pain and is on oxycodone. Pain is controlled with medications. An interview was conducted on November 15 2023 at 8:44 AM with resident #93, who stated that - she fell off the bed, while reaching in the drawer of her nightstand for her arthritis cream, Blue Emu, and broke her collarbone. During the interview, a jar of Blue Emu was observed on the resident's mobile tray. During an interview was conducted on November 15, 2023 at 8:52 AM with a hospitality aide (staff #113), staff observed the Blue Emu on the resident's mobile tray; she picked jar up, read the label, and she stated she would have to ask the nurse if the cream needed to be locked up. Staff #113 went to get a licensed practical nurse (LPN/staff #180), who stated that he would need to check with the supervisor to see if the Blue Emu needed to be locked up. After talking to his supervisor, (LPN/staff #180) stated that the Blue Emu needed to be removed and he would be reaching out to the physician to get an order for the Blue Emu. An interview was conducted on November 17, 2023 at 8:09 AM with the Director of Nursing (DON/staff #70), who stated that an evaluation would need to be completed to determine if resident #93 can self-administer the Blue Emu, which was not done. She stated that the Blue Emu was removed and there is now an order in place for the nurse to administer. Also, staff #70 stated that the resident fell on [DATE] and broke her collarbone, while reaching for something. She stated that the team met after the fall on September 28, 2023 to determine the reason for the fall and it was determined that the resident had her bed in the high position and the resident stated that she went to reach for an item. Staff #70 stated that the fall care plan was updated to include ensuring the bed is in the lowest position. The facility's policy Incidents and Accidents stated that it is the policy of this facility to implement and maintain measures to avoid hazards and accidents.

Based on observation, interview, and record review, the facility did not ensure that a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections. Findings include: Resident #37 was admitted to the facility January 10, 2023 with several diagnosis including dysphasia and aphasia following cerebral infarction, neuromuscular dysfunction of the bladder, depression, bipolar disorder, post traumatic stress disorder, schizoaffective disorder, and anxiety disorder. A review of the medical record revealed that the resident had an indwelling catheter. Review of the most recent MDS assessment revealed that Resident #37 had a BIMS (brief interview of mental status) score of 15, indicating no cognitive impairment but was dependent on staff for all activities of daily living. Initial physician's order written on January 11, 2023 read may change suprapubic catheter PRN (as needed) for malfunctioning or dislodged. Suprapubic catheter care every shift and PRN. Further review of the medical record revealed Resident #37 was being treated for a UTI (urinary tract infection) during the dates of November 9, 2023 through November 16, 2023. Review of the physician's order sheet revealed an order dated January 17, 2023 that read irrigate suprapubic catheter with 60 mL sterile water every day shift. Review of the medical record revealed Resident #37 was seen by Southeast Valley Urology on February 3, 2023 to change the catheter. A note from Southeast Valley Urology was returned to facility after Resident #37 appointment stating catheter hole in her stomach was dirty and smelly. Please help keep it clean by cleaning when undergarment is changed daily and put a new bandage on it. Thank you. Next appointment is March 3, 2023 at 1:00 PM. Please schedule transportation. Daughter will meet her there. Thank you. Further review of the medical record revealed Resident #37 was seen by Southeast Valley Urology on March 3, 2023 for catheter change. Review of the physician's orders written on April 3, 2023 read suprapubic catheter # 16 FR/ 10 ML (LATEX) to closed drainage system. Review of medical record revealed on April 14, 2023 for catheter change. A note was returned to facility following Resident #37 appointment stating The catheter was filthy. The bandage has not been cleaned in a very long time. The bandage needs cleaned daily to avoid infection. She needs ointment on the skin to reduce redness and irritation. The bandage needs cleaned AGAIN TONIGHT due to A LOT of blood. NEXT APPOINTMENT May 12, 2023 at 1:00 PM. Review of medical record revealed physician's order written on July 5, 2023 5:00 PM read cleanse suprapubic catheter site with wound cleanser or normal saline, pat dry, cover with split gauze, secure with tape. every night shift. Review of of medical record revealed Resident #37 was seen by Southeast Valley Urology on May 12, 2023 for catheter change, and June 13, 2023 for catheter change. Resident #37 had a scheduled appointment at Southeast Valley Urology on July 21, 2023 that had to be canceled. On November 16, 2023 at 12:12 PM an interview was conducted with the Director of Nursing, (DON staff #70), revealed that best practice is to change a catheter every 30 days unless there is specific order for prn (as needed). Staff #70 revealed that the Assistant Director of Nursing, (ADON staff #47), monitors catheter care and if the catheters are changed monthly. On November 17, 2023 at 09:23 AM an interview was conducted with the Unit Secretary, (staff #171), who stated the patient goes to urology monthly. It can be the facility scheduler who schedules the appointments or residents family. When the patient returns she usually has a packet with her from urology that has her next appointment on it. Sometimes she doesn't have the packet but we call to get the notes and the next appointment. Staff #171 also stated that sometimes the patient's daughter calls and tell us when the next appointment is. The appointment on July 21, 2023 had to be canceled because patients daughter called a day or two before the appointment and we did not have enough time to schedule for transportation. When further questioned to why Resident #37 did not have any scheduled urology appointments in August 2023, September 2023, Staff #171 did not know why. Medical record revealed that Resident #37 did attend her October 27, 2023 Southeast Valley Urology appointment and did have an appointment on November 17, 2023 at 1:00 PM and was scheduled for transportation. On November 17, 2023 at 09:10 AM an interview was conducted with Licensed Practical Nurse, (LPN staff #46), who stated there is an order to flush or clean the catheter every day or every shift. We check for any redness or signs of infection. If there are signs we notify the Dr. If the catheter needs changed and we do not have an order to change it monthly, or if there are concerns, we call the Urology Doctor. I know that the catheter has been changed but I don't know where the documentation is. Review of the record revealed that the catheter had not been changed July 2023, and resident #37 had her Southeast Valley Urology appointment canceled. Further record review revealed that Resident #37 did not have a scheduled urology appointment in August 2023, September 2023 or October 2023. In a progress note dated September 18, 2023 that the catheter had been changed by a nurse at the facility. More documentation revealed that a nurse at the facility also changed the catheter on October 20, 2023 and October 25, 2023. Review of the facilities policy states, It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling to promote hygiene, comfort and decrease the risk of infection for catheterized residents.

Based on clinical review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident's (#66) pain medication was administered within parameters. The deficient practice could result in residents being overly medicated. Findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included dementia, wedge compression fracture, and hypertensive heart and chronic kidney disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the order summary report revealed an order dated October 13, 2023 for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB Refer to NPI Review of the medication administration record (MAR) dated October 2023 revealed that Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB was administered on October 15,2023 for a pain level of 2 and on October 23, 2023 for a pain level of 3. Review of the care plan dated October 16, 2023 revealed that the resident is currently prescribed an opioid for pain management; potential for adverse outcomes form opioid use. Interventions included to administer opioid as prescribed and to provide education to the resident on the potential risks, adverse outcomes, complications, and medication interactions associated with opioid use including death. An interview was conducted on November 16, 2023 with the licensed practical nurse/MDS Coordinator (LPN/staff #110), who stated that an order for a pain mediation as needed requires a pain scale. She reviewed the MAR dated October 2023 and stated that the Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB was administered on October 15, 2023 for a pain level of 2 and on October 23, 2023 for a pain level of 3. She stated that administering pain medication outside of the parameters can result in overmedicating the resident and sedation. An interview was conducted on November 17, 2023 at 8:05 AM with the Director of Nursing (DON/staff #70), who stated that pain medication prescribed as needed requires a pain scale on the order and the risk to not following the pain scale parameters depends on the type of medication. She stated that she wasn't sure if there was a risk to administering an opioid outside of the parameters because some residents have been on opioids for long periods. The facility's policy Physician Orders states that It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on observation, the clinical record, staff and resident interviews, and the policy and procedures, the facility failed to obtain dental services to meet the needs of one resident (#14). The deficient practice could result in tooth decay, pain, and affect nutrition. Findings include: Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphagia oropharyngeal phase, obstructive and reflux uropathy. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 2 indicating the resident had a moderate cognitive impairment. It also included that the the resident didn't have obvious or a likely cavity or broken natural teeth and the resident needed a one-person supervised assistance for hygiene tasks. Review of the care plan for activities of daily living (ADL) performance deficit related to decreased mobility, weakness, and fatigue included the interventions to explain all procedures/tasks before starting, encourage to participate to the fullest extent possible with each interaction, and to converse with resident while providing care. Review of a progress note dated November 16, 2023 revealed that an oral cavity/dental assessment was performed in the resident's room with the resident's permission. The resident had visible tooth/teeth decay, missing teeth, broken teeth with complaints of occasional pain not occurring on a daily basis. The resident expressed no or discomfort during the assessment. The patient is currently on a regular texture diet. Review of the clinical record did not reveal that the resident was scheduled or attended any dental appointments. During an interview conducted on November 14, 2023 at 9:41 AM with resident #14), multiple teeth were observed to be dark brown in some places and multiple teeth were missing. The resident stated that her bottom teeth are rotted and she has requested to see a dentist because she had a toothache, but the nurse never followed up with her. She stated that the top teeth are still hurting and she experiences sharp pain, but it doesn't hurt all the time. She wasn't sure when she made the request, but thinks that it was sometime between now and last January. She stated that the dentist has been here and cleaned her roommate's teeth and pulled her tooth, but she has not received dental care. An interview was conducted on November 16, 2023 at 12:11 PM with the Social Services Supervisor (staff #144) and the Social Services Supervisor (staff #25). Staff #144 stated that the resident has dental coverage and she would have scheduled dental appointment if knew there was a problem. She stated that the dentist comes to the facility on average of every two to three months and agreed that resident should have seen the dentist at least once. Staff #25 stated that she has no knowledge about the resident complaining of a toothache. During the interview, neither staff was able to provide any documention showing that the resident was scheduled to see the dentist or that the resident was seen by the dentist on any prior dates and stated that they would need to review the clinical record. An interview was conducted on November 16, 2023 at 12:42 PM with a certified nursing assistant (CNA/staff #121), who stated that the resident requires assistance with brushing her teeth on one side because she doesn't have full use of her arm. Staff #121 has assisted the resident with brushing her teeth and did notice a little tooth decay on the bottom teeth, some brown areas, but not too much on the top. The staff stated that the CNAs are supposed to report the tooth decay to the nurse on the shift and he doesn't think he let the nurse know about the tooth decay or documented the concern in the clinical record. Staff #121 has no knowledge of the resident reporting tooth pain. An interview was conducted on November 16, 2023 at 12:49 PM with a licensed practical nurse/MDS Coordinator (LPN/staff #406), who stated that it is her expectation that the CNAs assist the residents with brushing their teeth if needed, which would include observing any concerns related to the teeth/mouth. She stated that the CNAs should report tooth decay and any discomfort the residents are experiencing to the nurse on duty. She stated that it is the nurse's responsibility to document the concern in a progress note and follow up on the problem. She stated that a full mouth assessment would have been completed during the annual MDS, which was completed in January 2023. Then she reviewed the annual MDS and stated the resident had no cavities at that time. On November 16, 2023 at 1:10 PM, (LPN/staff #406) was observed assessing the resident's teeth and stated she observed multiple cavities and multiple missing teeth. During the assessment, the resident stated that she has experienced discomfort and thinks that she saw a dentist approximately one and half years ago. An interview was conducted on November 17, 2023 8:21 AM with the Director of Nursing (DON/staff #70), who stated that resident #14 has insurance coverage for dental care and the resident should see the dentist at least once a year. It is her expectation that if a CNA sees something concerning the resident's teeth, such as tooth decay, it should be reported to the nurse. The facility's policy Referrals (Dental Appointments) reviewed February 2023 stated that if the facility does not employ a qualified professional to furnish a specific service ordered by the physician, the facility will make necessary arrangements for services to be furnished to the resident by a person or agency outside the facility.

Based on observation, staff interviews, and facility policy and procedures, the facility failed to ensure that one staff (#113) sanitized her hands prior to handling the one resident's (#93) food/container. The deficient practice could result in food being contaminated. Findings include: Resident #93 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinsonism unspecified, seizure disorder, and hypertension. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. During an interview conducted on November 15, 2023 at 8:44 AM with resident #93, she asked the hospitality aide (staff #113), to get her peanut butter. Staff #113 was observed retrieving a large jar of peanut butter from the resident's cupboard. Staff #113 twisted the plastic lid off and removed the seal covering the peanut butter from the jar. As she removed the seal, her fingers were observed touching the lip of the jar. Then, she handed the jar to the resident, who spread the peanut butter on her toast. Staff #113 was not observed sanitizing her hands before or after opening the jar. During an interview was conducted on November 15, 2023 at 8:57 AM with a hospitality aide (staff #113), she stated that she received training on hand hygiene. She stated that she did not wash/sanitize hands before opening the resident's jar of peanut butter and did not clean around the lip of jar before replacing the lid and putting it back in the resident's cupboard. She stated that there was a risk of cross contamination. An interview was conducted on November 17, 2023 at 11:42 AM with the Director of Nursing (DON/staff #70), who stated that staff should sanitize hands during food service and if the staff touched the lip of the container, staff should get a new container because the jar is potentially contaminated. The facility's policy Hand Hygiene states that It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident (#1) was not administered an unnecessary medication. The sample size was 5. The deficient practice could result in resident receiving unnecessary medication. Findings include: Resident #1 was admitted on [DATE] with diagnoses of metabolic encephalopathy, left femur fracture, ventricular tachycardia, congestive heart failure, and chronic obstructive pulmonary disease. The clinical record revealed no documentation that the resident had diagnosis of type I or type II diabetes. The physician order summary included an order dated May 4, 2023 to monitor blood sugar levels every shift for 3 days, due to change in condition related to a wrong medication administration. The electronic medical record (EMAR) from May 4 thorough 7, 2023 revealed to monitor the resident's blood sugar levels every shift for 3 days due to change of condition regarding a wrong medication administration; and that, the resident's blood sugar levels from May 4 through 7 were recorded as between 134-205. A review of medication error investigation report dated May 4, 2023 revealed that on May 4, resident #1 had been administered 50 units of Glargine (insulin) subcutaneously, without a physician order; and that, a licensed practical nurse (LPN/staff #161) had been identified as the staff making the error. A telephone interview was conducted on May 24, 2023 at 12:05 p.m. with the LPN (staff #161) who stated that on May 4, 2023 at approximately 9:00 a.m., resident #1 was administered 50 units of Glargine subcutaneously. Staff #161 stated that she had drawn the insulin to administer to a resident in another room; however, she said she got distracted by two residents requesting pain medications. Staff #161 stated that she then went into the room of resident #1 and administered the insulin. Staff #161, stated she immediately realized she had administered the insulin to the wrong resident; had explained to resident #1 what happened and then went and notified the charge nurse, director of nursing (DON), physician and resident's family. Staff #161 stated that monitoring of resident's blood sugar levels began every shift and the resident's blood sugar levels did not drop to a critical level, below 100. Further, staff #161 stated she should have been paying attention to her EMAR and verified the resident and medication to be administered prior to giving the medication. Staff #161 also said that she met with the DON (staff #171) and she was counseled on minimizing distractions from other residents during the medication pass by acknowledging requests or concerns, documenting them, redirecting the residents back to their rooms or away from the medication cart, and to focus on completing the medication administration. In an interview conducted with the DON (staff #171) on May 24, 2023 at 12:20 p.m., the DON stated she met with the LPN (staff #161) on May 4, 2023 regarding the medication error. The DON stated that staff #161 administered Glargine 50 units subcutaneously to resident #1 in error; and that, the resident's blood sugar levels were monitored every shift per the physician orders and no adverse drug reactions were observed. The DON said that the LPN was counseled regarding focusing on medication administration pass and to minimize distraction during the medication administration pass; and that, there were no further disciplinary actions taken. The facility policy on Medication Administration revealed that medications were to be administered as prescribed by the attending physician. Further, the policy included that identification of the resident must be made prior to administering the medication to the resident and that medications were to be administered according to appropriate indication/diagnosis.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#92) was not verbally abused by a temporary nurse aide (TNA/staff #175). The census was 139. The deficient practice can result in additional incidents of staff to resident abuse. Findings include: -Resident #92 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 14 indicating the resident was cognitively intact. Review of the care plan dated September 6, 2022 revealed the resident had the potential to demonstrate verbally abusive behaviors related to mental/emotional illness, poor impulse control as evidenced by a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included for staff to intervene before agitation escalates; to guide the resident away from source of distress; engage calmly in conversation; if response is aggressive, staff is to ensure resident is safe and walk calmly away and approach at a later date. -Resident #16 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 was the roommate of resident #92. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating resident had intact cognition. The grievance resolution form dated August 27, 2022 and completed by the resident who reported that on August 27, 2022 at 7:00 p.m., the TNA (staff #175) refused to take his vitals. Per the report, at 7:45 p.m., staff #175 returned and told the resident that a CNA would take his vitals; and that, staff #175 became upset and called the resident a prick and a nigger. The report also included the resident told the nurse that he did not feel safe with staff #175 assisting him with going to bed. The undated facility investigation revealed that on August 29, 2022 at 8:30 a.m., the facility received a grievance written by the resident stating that a CNA refused to take his vitals and called him names such as Nigger and Prick. The investigation included that the facility cannot substantiate the allegation of abuse; and, resident #16 who was the roommate of resident #92 witnessed the interaction and denied the TNA made any comments. During an interview conducted on September 13, 2022 at 8:55 a.m., resident #92, he stated that a male staff was fired for using inappropriate language and a racial slur with him. An interview with resident #16 (roommate) was conducted on September 14, 2022 at 11:43 a.m. Resident #16 stated the TNA (staff #175) came to take his vitals and left without taking the vitals of resident #92. The roommate said resident #92 became upset because he needed his vitals taken before he could take his medication. He also stated resident #92 called the TNA to ask about his vitals; and, the TNA told him that another staff was going to do it. The roommate said resident #92 used inappropriate language and told the TNA to get out of his room. The roommate said the TNA got upset and called resident #92 an inappropriate name and walked away. Further, the roommate stated he reported the TNA for calling resident #92 an inappropriate name to the social services director (staff #16). On September 14, 2022 at 12:13 p.m., an interview was conducted with the social services director (staff #16) who stated that resident #92 filed a grievance regarding an allegation that staff #175 was verbally abusive; and that, she conducted the investigation. The social services director stated she interviewed resident #16 who was the roommate of resident #92. She also said that resident #16 had a BIMS score of 15 and was oriented x 4. She stated resident #16 told her the TNA (staff #175) called resident #92 an inappropriate name. The social services director stated that calling residents inappropriate names was emotional and verbal abuse. She further stated she reported the outcome of the investigation to the Director of Nursing (DON/staff #135) and the Administrator (staff #165). An interview was conducted on September 14, 2022 at 12:57 p.m. with the DON (staff #135) who stated that resident #16 was oriented x 4, had a BIMS score of 14 or 15 and she considered resident #16 a credible witness. The DON said the social services director (staff #16) interviewed resident #16 first; and then she conducted her interview and took the statement of resident #16. She stated she does not recall staff #16 telling her that resident #16 reported hearing the TNA (staff #175) call resident #92 an inappropriate name. Further, the DON said that she considered the inappropriate language as verbal abuse. The facility's policy, Abuse: Prevention of and Prohibition Against, reviewed January 2022 states it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Verbal abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure restorative nursing program/services (RNA) was provide as ordered for one resident (#57). The deficient practice could result in resident not receiving the needed services to maintain, improve or prevent avoidable decline in function. Findings include: Resident #57 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physical therapy (PT) discharge summary dated April 6, 2022 included highest practical level achieved as reason for the discharge to long term care setting. Discharge recommendation included to transition to the RNA program A care plan revised on May 15, 2022 included the resident was at risk for fall related to decreased mobility, weakness, and amputation. Interventions included PT and occupational therapy (OT) evaluation and treatment per physician orders. The OT discharge summary dated May 17, 2022 revealed the resident was discharged to long term care setting because maximum potential was achieved and was referred to restorative nursing program. Per the documentation the resident made good progress with OT services and was not ready to transition to RNA for fine motor coordination and strengthening RNA program. Discharge recommendations included assistance with IADLs (instrumental activities of daily living) and fine motor and hand strengthening RNA program. In another PT discharge summary dated June 22, 2022 it included the resident was discharged to transition to RNA program A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The assessment also included that AROM restorative program was performed for 2 days in the last 7 calendar days of the assessment. The restorative nursing note dated July 20, 2022 revealed the resident continued to participate with RNA program; occasionally refused to participate; and will continue to encourage participation on different days and times. An NP (nurse practitioner) note dated July 20, 2022 revealed the resident reported pain to the right shoulder and was encouraged to increase activities and be out of bed to chair. Another NP note dated July 21, 2022 included resident was alert and oriented x3. Assessment included deconditioning and plan was for PT/OT to evaluate and treat. Review of the clinical record revealed that resident #57 was sent to the hospital for a critical laboratory result on July 23, 2022; and, was readmitted back at the facility on July 25, 2022. The daily skilled note dated July 29, 2022 documented observations of ROM and AROM for assistive device use. Per the clinical record, the order for AROM on BUE and BLE with bike, weights and resistance bands was discontinued on August 1, 2022. The PT encounter note dated August 9, 2022 revealed RNA training was performed with demonstration of all activities, donning and doffing prosthetic, transfers and standing in parallel bars. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADL care plan was revised on August 23, 2022 to include an intervention of RNA to perform AROM BUE/BLE therapeutic exercises to maintain and improve strength 3x/week as tolerated to manage and prevent contractures and minimize pain. However, review of the RNA documentation for resident #57 from August 24, 2022 through September 15, 2022, revealed that RNA services for 15 minutes were provided only on the following dates: August 24, September 6, 13, and 14. It also included the resident refused on the following dates: August 26, 27, September 3 and 5, 2022. Further review of the report included revealed there was no RNA offered/provided on the week August 28 through September 3. The restorative note dated September 10, 2022 included the resident only worked out once that week; and that, the resident refused or did not get up for RNA services. Despite documentation of resident refusal, there was no evidence found in the clinical record that attempts were made to implement the RNA program; and, revise interventions to address the resident's refusal. Further review of the clinical record revealed no evidence the physician was notified of the resident's refusal and RNA not followed as ordered. In an interview conducted on September 12, 2022 at 10:04 a.m., resident #57 stated that he used to receive limited physical therapy and had received only approximately 20 therapy visits. He stated he currently receives RNA services; however, the RNA staff providing the services, does not have the strength to move him around. Resident #57 further stated that the RNA services he receives was not consistently provided. An interview was conducted on September 15, 2022 at 12:48 p.m. with a Restorative Nurse Assistant (RNA/staff# 73) who stated that resident #57 was supposed to have RNA services three times a week; and, supposed to do sit, stand, prosthetic and bike exercises. However, resident refuse everything but the bike. She also said that RNA encounters are documented on the RNA progress report and log; however, there was also a paper log in the RNA book located in the gym. Review of the documentation provided to the survey team and the documentation found in the RNA book was conducted with staff #73 who stated there was another person providing RNA services to the residents. She stated that person could have provided the RNA but did not document the encounters and/or refusals. Staff #73 stated that person was no longer employed at the facility. An interview was conducted on September 15, 2022 at 1:24 p.m. with the Director of Nursing (DON/staff #135) who stated the Assistant Director of Nursing (ADON) was helping significantly with RNA program. The DON stated that RNA services should be provided as ordered; and staff are expected to document appropriately in progress notes, including noncompliance of residents with the RNA. During the interview, a review of the clinical record was conducted with the DON who stated that based on the documentation, RNA services were provided or offered only on August 24, September 6, 13, and 14, 2022. The DON stated if the order directed for RNA services to be provided three times a week, then there should be documentation for each of those encounters on a weekly basis. A policy titled Restorative Care reviewed on July 2021 revealed that it is their policy that restorative care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. It also included that any therapeutic interventions, including restorative interventions will be provided under physician orders. Further, the policy included that restorative nursing programs may include dining, ADLs, ROM and/or ambulation. The facility policy on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, clinical record review, and family and staff interviews, the facility failed to provide care and treatment for one (#2) of two sampled residents with routine foot care, which resulted in an infection to the resident's toe. The facility census was 99. Findings include: Resident #2 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A care plan for alteration in skin due to mobility limitations dated (MONTH) 2, (YEAR) included a goal that the resident would be free from additional skin breakdown/irritation. An approach included .Podiatry consult and treatment as indicated . A significant change MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR) revealed the resident's BIMS (Brief Interview for Mental Status) score was 13, indicating intact cognition. The MDS further revealed the resident required extensive assistance of one person with personal hygiene. Review of the Comprehensive CNA (certified nursing assistant) Shower Reviews dated (MONTH) 3, 22 and 26, (YEAR), (MONTH) 12 and 19, 2019, and (MONTH) 6, 13, 26 and 20, 2019 revealed the following: .Does the resident need his toenails cut? Yes . The Shower Reviews were signed by a licensed nurse. However, there was no clinical record documentation that the resident's toenails were cut from (MONTH) (YEAR) through (MONTH) 2019. Review of a Comprehensive CNA Shower Review dated (MONTH) 2, 2019 revealed .Does the resident need his toenails cut? Yes. Right big toenail is coming off. The Shower Review sheet was signed by a licensed nurse. There was no clinical record documentation that the resident's right toenail had been addressed on (MONTH) 2 or 3 or on (MONTH) 4, 2019, prior to 2:07 p.m. An interview was conducted on (MONTH) 4, 2019 at 2:07 p.m., with the resident and a family member. The family member stated that podiatry care had been requested, but they were informed that the podiatrist was just at the facility or the resident was not on the podiatry list. The resident's family member stated that the resident's toenails are long and needed to be cut. The resident's family member then proceeded to take the resident's socks off. The resident's toenails were observed to be approximately 1/4 inch past the tips of his toes and the right great toe was red and swollen. The family member immediately notified a RN (registered nurse/staff #107). An assessment of the resident's right great toe was conducted on (MONTH) 4, 2019 at 3:08 p.m., by the wound nurse. Per the Wound Assessment Note the following was documented: Resident seen today as report of right great toe possibly infected. Resident's nail on right great toe lifted, area below nail red and warm, blanchable at this time. Reported to primary doctor. New orders received for daily dressing change using [MEDICATION NAME] and Kerlix. Also orders for antibiotic therapy for five days. Podiatrist contacted with permission from family and primary doctor. Toenails were trimmed during this visit but needs a podiatry visit. A Physician's Note dated (MONTH) 4, 2019 included .Right great toe redness with discharge .Right great toe infection concerning for underlying infection, placed on [MEDICATION NAME] (antibiotic) 100 milligrams twice a day for five days . A physician's orders [REDACTED]. A Podiatry Note dated (MONTH) 5, 2019 documented .Patient seen for examination and care of feet and nails. Seen for follow-up care of feet and nails .Nails painful and uncomfortable. Patient unable to cut own toenails .Nurses state patient jammed right foot and great toenail is loose .Nails elongated 1 - 5 bilaterally. Thickened, yellow, dystrophic painful nails 1-5 left and 1-5 right. Lytic (infection) right first toenail. Localized [DIAGNOSES REDACTED] and serosanguinous drainage. Subungual hematoma. Tender to palpation .Pitting [MEDICAL CONDITION] bilaterally 2/4 or greater .Reduced nails 1-5 bilaterally, manual and mechanical debridement .Elevate legs throughout the day as much as possible to reduce swelling. Nail removed following cleansing area with alcohol pad .[MEDICATION NAME] and Band-Aid applied to be changed every day for 5 days. Notify if any increased signs of infection occur, including but not limited to purulence, swelling, redness and streaking . Another physician's orders [REDACTED]. Pat dry. Apply [MEDICATION NAME] (antibiotic ointment) and Band-Aid daily times seven days. Monitor for signs of infection. A Nurse's Note dated (MONTH) 5, 2019 documented Patient on oral [MEDICATION NAME] for right great (toe) infection. First dose started today. Podiatrist in facility today to treat patient's toes. Dressing change daily with [MEDICATION NAME] . An interview was conducted with a CNA (staff #66) on (MONTH) 6, 2019 at 1:51 p.m. Staff #66 stated that if she noticed that a resident's toenails were long she would document it on the Shower Review sheet, and then the licensed nurses are supposed to cut the resident's toenails. The CNA stated that she had noticed that the resident's toenails were long. An interview was conducted with a LPN (licensed practical nurse/staff #118) on (MONTH) 7, 2019 at 9:31 a.m. Staff #118 stated that if a CNA documented on the Shower Review sheet that a resident needed their toenails cut, she would assess the resident and cut the toenails if needed. An interview was conducted with a RN (staff #107) on (MONTH) 7, 2019 at 10:19 a.m. Staff #107 stated that when she signs the Shower Review sheets, she is just acknowledging that the resident received a shower. Staff #107 stated that the resident's toenails were very hard and he needed a podiatrist to trim his nails. Staff #107 stated the resident has been at the facility for almost two years, but she did not know if the resident had ever been seen by the podiatrist. Staff #107 further stated that she had asked the resident why he didn't tell her that he needed his toe nails cut. An interview was conducted with the DON (Director of Nursing/staff #84) on (MONTH) 7, 2019 at 10:34 a.m. Staff #84 stated that if anything new is documented on the Shower Review sheets, the licensed nurses should assess the resident. Staff #84 stated that if the resident is diabetic or the licensed nurse was unable to cut the resident's toenails, the licensed nurse should write a consult for podiatry care. Another interview was conducted with staff #84 on (MONTH) 7, 2019 at 11:40 a.m. Staff #84 stated that the facility did not have a policy regarding foot care, but it was a standard of practice.

Based on clinical record review, staff interviews and facility and hospital documentation, the facility failed to ensure that adequate supervision was provided to one (#193) of two sampled residents during care, resulting in a fall with a fracture. The resident census was 99. Findings include: Resident #193 was admitted to the facility on (MONTH) 11, 2014, with [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 1, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment. In Section G, Functional Status, the resident was assessed to require the assistance of two or more with bed mobility. A care plan included the resident had a self care deficit, as evidenced by maximum assist for most ADL's (activities of daily living) related to muscle weakness with additional risk related to orthostatic [MEDICAL CONDITION] . The goals were Will participate to ability .Will be washed, dressed . Approaches included Setup, cue and assist as needed for ADLs. Encourage participation to ability. Task segmentation as needed .Provide assist as needed for completion of ADL cares . The care plan did not include that the resident required the assistance of two or more with bed mobility. A Nurse's Note dated (MONTH) 18, (YEAR) documented .total care with ADLs, bed mobility and transfers. Another Nurse's Note dated (MONTH) 29, (YEAR) documented the resident was total care with ADLs, bed mobility and Hoyer lift for transfers. A Medicare Note dated (MONTH) 28, (YEAR) included .was changing the patient in bed. Patient fell out of bed and onto the floor .Patient was still in pain at time of transfer but was alert again and able to answer some questions appropriately but still had a noticeable change in mentation. A written statement by a RN (registered nurse/staff #110) dated (MONTH) 28, (YEAR) documented the supervisor (staff #110) was notified that the resident was involved in a fall. The CNA (certified nursing assistant/staff #136) reported that he was cleaning the patient in bed without the assistance of another CNA. Per the statement, he had the resident roll on his side with the resident's body facing toward him. The CNA reported that the resident began to roll into his body and off the bed and that he attempted to break the patient's fall with his body, but the resident ultimately fell to the ground. The CNA was asked how hard the resident had hit the floor and the CNA responded with some force. The CNA was asked if the resident hit his head and he responded no. The floor nurse reported that he entered the room to find the resident on the floor face down. When supervisor entered the room, the resident was already placed back in bed. Supervisor assessed the resident. His face was pale and he had a dazed look in his eyes. Pupils were sluggish to react. Resident was asked if he was feeling any pain and stated that he had a headache which he rated at a 7 out of 10, with 10 being the worst pain he ever felt. Also noted a 12 centimeter circular skin tear to the right arm. When asking the resident if he was experiencing any pain in his arm, he stopped responding to questions. His head fell back onto the pillow and he seemed to lose consciousness. MD was notified. He advised to send the resident to the emergency department for assessment. Hospital documentation dated (MONTH) 28, (YEAR) included the following: .A CNA was attempting to wash the patient while on his bed. The bed was raised at the time with no safety rails as the CNA rolled the patient to wash his back. The patient fell off his bed and on to the ground. The patient hit his head resulting in loss of consciousness .Stable small presumed left frontal subdural hygroma without mass effect .Stable low-density 8 millimeter left frontal potential subdural hygroma without significant interval change .There is a mildly impacted [MEDICAL CONDITION] humeral neck . A Nurse's Note dated (MONTH) 29, (YEAR) revealed Late entry (MONTH) 28, (YEAR). Patient fell out of bed during patient care by CNA. Assessment done and charge nurse during shift notified .Patient sent out to .hospital. Review of the facility's Reportable Event Record Report dated (MONTH) 2, (YEAR) revealed .At approximately 6:00 a.m. on (MONTH) 28, (YEAR), the CNA was performing bed bath/linen change on resident .when resident appeared to no longer participate and subsequently rolled out of the bed. Immediate assessment following the fall concluded significant symptomatic [MEDICAL CONDITION]. Resident .was transported to (name of hospital) and admitted for symptomatic [MEDICAL CONDITION]. On (MONTH) 29, (YEAR), per hospital records, x-rays of bilateral shoulder and bilateral hand/wrists were obtained and conclusive for positive [MEDICAL CONDITION] shoulder . Further review of the clinical record revealed the resident was readmitted to the facility on (MONTH) 3, (YEAR) and was enrolled in hospice services. A Change in Condition Note dated (MONTH) 9, (YEAR) documented Late entry (MONTH) 8, (YEAR) .Time of death called .at 7:07 p.m . An interview was conducted with a RN (staff #110) on (MONTH) 6, 2019 at 9:13 a.m. Staff #110 stated that a CNA (staff #136) was caring for the resident at the time of the fall. Staff #110 said the CNA rolled the resident toward himself to provide care and the resident stiffened and fell out of bed. Staff #110 stated the resident's bed was at the normal height and that the resident only required one person for cares while in bed. Multiple attempts were made to contact staff #136 by telephone on (MONTH) 6 and 7, 2019, however were unsuccessful. An interview was conducted with the Therapy Director (staff #11) on (MONTH) 7, 2019 at 9:54 a.m. Staff #11 stated that if a resident required maximum assistance for bed mobility it would mean that one or two staff were required to assist the resident. An interview was conducted with the MDS coordinator (staff #64) on (MONTH) 7, 2019 at 10:45 a.m. Staff #64 stated that the resident was a big guy and should of had two staff for bed mobility. An interview was conducted with a CNA (staff #58) on (MONTH) 7, 2019 at 11:15 a.m. Staff #58 stated that if he was unsure if a resident required one or two staff for bed mobility and cares, he would check with a nurse. An interview was conducted with the DON (Director of Nursing/staff #84) on (MONTH) 7, 2019 at 11:21 a.m. Staff #84 stated that the facility only initiated a two person assist for bed mobility after a fall, or if a resident had a large abdominal girth, which would put the resident at risk with turning in a bed. Staff #84 stated the facility's Smart Charting (CNA charting tool) is updated by the MDS. Staff #84 stated that she was unable to review how much assistance the resident required at the time of this fall, as the resident was readmitted to the facility and she was only able to review the most recent admission. Staff #84 stated that if the MDS included that the resident required a two person physical assist for bed mobility, this information should have auto-populated to the Smart Charting.