Every finding on record at Montgomery General Elderly Care

Based on observation, record review, and staff interview the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This failed practice was a random opportunity for discovery and had the potential to effect all residents currently residing in the facility during the Long-Term Care Survey Process. Facility Census: 57. Findings Include: a) Dining room Continuous observation of the dining room on [DATE] from 11:30 AM to 12:01 PM, revealed that at 12:01 PM, (3) three residents at the round table were served their lunch meal. During the continuous observation no hand hygiene was offered and/or performed with the residents in the dining room area. During an interview on [DATE] at 12:03 PM, Nursing Assistant (NA) # 4 stated, They are supposed to lay them wet ones on the table, and nope they are not there today. Further observation of the lunch meal showed, NA #16 served and set up a resident's tray and then grabbed another tray to set up another resident's. NA# 16 stated, Oh, I forgot. b) Enhanced barrier protections On [DATE] at 9:30 AM while walking around the facility, there were multiple rooms (6 out of 20) observed with EBP signs on doors, but no dot on name plates to designate who the EBP applied to. They were all missing the pink dot. The facility used different color dots to signify different issues the residents may have. During an interview on [DATE] at 9:32 AM with Housekeeping #61. They stated, I don't know what each color is exactly but they have a list somewhere here. When asked where the list for the colors was: Housekeeper #61 stated, There isn't one (dot list) in every janitor's closet and not sure exactly where they had seen one before, but knew they had a few hanging up. They thought maybe the dirty utility room. While interviewing LPN #72 on [DATE] at 9:35 AM the LPN stated, The Dot on the residents name plates each have meaning, each is something different. There is a color chart in the dirty utility room. I believe PINK is the EBP dot color. LPN #72 took this surveyor to the dirty utility room on [DATE] at 9:40 AM to show me the dot list. Taped to the wall was a list with multiple color dot stickers with explanations of each color, PINK was denoted to mean EBP. Record review showed a copy of the EBP policy that stated the facility will ensure regular weekly rounds for accuracy. There was an in-service completed on [DATE] with signatures from all employees, this included a breakdown of all the color dots that the facility used. Of note the in-service training did not include the pink color dot in the training. The facility has a dot policy that uses color coded dots added to the residents name plates to ensure privacy as well as alert staff to what a resident's medical need or status maybe; EBP, fall, CPR, DNR etc. The Administrator stated during an interview on [DATE] at 11:50 AM when they were shown the different signs that were used in the in-service versus the sign that was in the dirty utility room. They will ensure another in-service with the correct information is done, and soon. c) Resident #9 Resident #9 and Resident #4 are roommates. Resident #9 was admitted on [DATE] for rehab, following discharge from acute care facility. Upon admission, resident had primary diagnosis of Severe Sepsis without Septic Shock, and had a PEG (Percutaneous Endoscopic Gastrostomy) tube. The resident had an on-going order dated [DATE] for Enhanced Barrier Precautions due to feeding tube and history of Sepsis. During the initial visit with the resident on [DATE] at approximately 1:20 PM, there was no signage on the residents' door for Enhanced Barrier Precautions. Surveyor at 1:30 PM, asked the NHA to accompany her to the residents' door. When asked about signage for enhanced barrier precautions, she responded that she was not aware that being on a feeding tube required Enhanced Barrier Precautions. Surveyor pointed out that both residents had orders for Enhanced Barrier Precautions. Surveyor suggested a consultation with the facility's policy for Enhanced Barrier Precautions. NHA said she would immediately ask nursing to get a sign posted on the door for Enhanced Barrier Precautions. An observation on [DATE] at approximately 11:00 AM, Enhanced Barrier signage had been placed on residents' door. d) Resident #4 Resident #4 and Resident #9 are roommates at the facility. Resident #4 had an order for Enhanced Barrier Precautions due to a history of ESBL (Extended Spectrum Beta Lactamase), a multi-drug-resistant bacteria. During the initial visit with the resident on [DATE] at approximately 1:20 PM, there was no signage on the residents' door for Enhanced Barrier Precautions. Surveyor at 1:30 PM, asked the NHA to accompany her to the residents' door. When asked about signage for enhanced barrier precautions, she responded that she was not aware that being on a feeding tube required Enhanced Barrier Precautions. Surveyor pointed out that both residents had orders for Enhanced Barrier Precautions. Surveyor suggested we consult the facility's policy for Enhanced Barrier Precautions. NHA said she would immediately ask nursing to get a sign posted on the door for Enhanced Barrier Precautions An observation on [DATE] at approximately 11:00 AM, Enhanced Barrier signage had been placed on residents' door. The facility's policy on Enhanced Barrier Precautions calls for Enhanced Barrier Precautions to be used when there is an indwelling medical device, as well as pan-resistant organisms. Based upon the physician orders and the facility's policy, Enhanced Barrier Precautions were to be used with both residents. A sign on the door served as a reminder for visitors, staff and residents on the importance of hand hygiene and adherence to facility infection control policies.

Based on observation and staff interview the facility failed to maintain a safe, clean, comfortable, and homelike environment by not providing a clean privacy curtain for Resident #27, and ensuring the residents' shower area for B Bath did not have paint peeling, missing caulking and rust on a shower caddy. These failed practices had the potential to affect more than a limited number of residents. Resident Identifier: #27. Facility Census: 57.Findings included: a) On 11/24/2025 at 12:45 Pm, The B Bath shower room was investigated. Peeling paint in the shower area and the bathroom floor area were observed including around the toilet by the state surveyors. The Administrator in Training reported the shower rooms are addressed yearly. On 11/25/2025 at 08:12 AM, the B Bath shower room was observed. The following observations were observed: paint peeling and missing on a large portion of the shower room's floor, caulking was missing around the toilet and in the shower area, large ring of missing paint and brownish substance was around the toilet, and paint was missing from the base of the walls, and rust was on a shower rack/caddy. These areas were confirmed by Nursing Assistant #19. Findings include: b) Resident number 27 On 11/24/25 at 12:06 PM an observation of Resident #27s privacy curtain found the curtain was soiled with a brown dried matter. During time of observation House Keeper #60 confirmed the curtain was dirty and required replacement.

Based on record review and staff interview the facility failed to provide care and services in accordance with current standards of practices by not following its policy and physicians orders related to weights. This failed practice was found true for (3) three of (6) six residents reviewed for nutrition during the Long-Term Care Survey Process. Resident identifiers: #55, #9, and #11. Facility Census: 57. Findings Include: a) Weight monitoring policy A review on 11/25/25 at 10:30 AM, of the policy titled {Weight Monitoring}, Section 2, C, reads: If there is a noticeable discrepancy in the current weight vs previous weight, the resident shall be re-weighted and the charge nurse shall follow-up accordingly. b) Resident #55 A record review on 11/24/25 at 2:32 PM, revealed that on 11/05/25 Resident #55 weighted 173 pounds (lbs.), and weighed 183 lbs. on 11/10/25. She was not reweighed for the weight discrepancy until 11/18/25 in which she weighed 173.5 lbs. Further record review for Resident #55, revealed an order that read as follows: Obtain a weekly weight. Once a day. On Tuesday at 12:30. Weights which are obtained above, shows that Resident #55 was not weighed weekly per Physicians order. During an interview on 11/25/25 at 11:06 AM, The Assistant Director of Nursing (ADON) confirmed that Resident #55 had not been weighed weekly per physicians order, and the policy had no been followed. c) Resident #11 Review of Resident #11's medical records revealed on 09/09/2025 the resident weighed 160 pounds (lbs). On 10/07/2025, the resident weighed 144 lbs. This is a 10 percent (%) weight loss in approximately four (4) weeks. Resident #11 was weighed again on 10/14/25 and weighed 143.6 pounds (lbs). On 11/25/2025 at 11:42 AM, the Certified Dietary Manager confirmed Resident #11 was not reweighed when a noticable discrepancy occurred between the weight on 10/07/25 and the previous weight on 09/09/25. He confirmed the resident had been reweighed a week after the noticable discrepancy occurred. No further information was provided through the completion of the survey process. d) Resident #9 Resident #9 was a new admission to the facility. She was admitted on [DATE] for rehab, following discharge from acute care facility. Upon discharge from hospital, the resident weighed 184.3 (83.6 kg). Upon entrance to the nursing home, her weight was recorded to be 183 lbs. Her discharge documentation from the acute care facility reported the resident was not tolerating her tube feeding well, and had been having nausea and vomiting. Upon admission, resident had primary diagnosis of Severe Sepsis without Septic Shock, and had a PEG (Percutaneous Endoscopic Gastrostomy) tube in place. Upon admission to the long term care facility, the Resident had the following orders regarding nutrition: Dietary Order NPO (Nothing by mouth)11/04/2025 Open Ended Dietary General Vital 1.5 bolus 327 ml Four Times A Day06:00 AM, 12:00 PM, 06:00 PM, 12:00 AM General Obtain Weekly WeightOnce A Day on Tue12:30 PM 11/05/2025 Resident is NPO (nothing by mouth). A Dietary Assessment was completed by the Dietary Manager (DM) on 11/11/25. The Resident was scored with a nutritional risk indicator as 14, which was High Risk. Progress Notes from the DM Resident is currently NPO-Vital 1.5 AC Bolus Tube Feeding 4x Day 237 cc each feeding . A history and physical was obtained on the resident on 11/11/25 by the admitting physician. A care plan was developed for the resident. The Resident's care plan for nutrition states, Potential for nutritional problem R/T (related to) resident is NPO with a PEG tube for feedings. Her goal was to maintain adequate nutritional status AEB: maintaining stable weight within 5% every 30 days . Some of the approaches to reach her goal were: Before taking away tray, ask if she has had enough to eat. Offer a substitute if < 50% of food is consumed. {Surveyor note: RESIDENT NPO} Follow Dietician recommendations for PEG feedings Observe, document, report to physician prn signs and symptoms of malnutrition (cachexia, weight loss, muscle wasting) significant weight loss (< 5% in one month, 10% in 6 months) The Resident's weight declined from the time period of 11/05/25 (admission) to survey entrance date of 11/24/25 by 13.66% or a total of 25 pounds. Her weights were recorded in the medical record as follows: On 11/05/25 weighed 183 lbs On 11/17/25 weighed 165.5 lbs On 11/18/25 weighed 158.0 lbs The electronic health system utilized by the facility is a software program by Matrix. Matrix had flagged the weights on 11/17/25 and 11/18/25 as being out of range, and in red ink. The Registered Dietician (RD) entered a progress note on the resident on 11/13/25, with a note to say the progress note was from 11/11/25, it did not save. RD recommended changing her order to Vital 1.5 AC 237 ml QID at 60 ml. per hour. A Progress note by an LPN on 11/18/25 stated resident had just been cleaned up and linens changed, as resident had vomited and was still experiencing nausea. LPN stated in her progress notes that she was going to hold the 6 am feeding for a little while to see how resident felt. The RD recorded this progress note on 11/20/25: Spoke to nurse today via phone regarding residents elevated blood sugars and feeding tolerance. Resident has not had episodes of vomiting since changing the rate of enteral feeding administration. BS levels have increased and medications are being adjusted. With the formula being an elemental feeding, high blood sugars are not uncommon. It was discussed to increase the rate to 70 ml per hour to give more down time; tolerance will be monitored by staff, Will continue to monitor for change via facility staff. There were no notes in the progress notes where the physician had been notified of the resident's significant weight loss. On 11/25/25, at approximately 1:15 PM, an interview was conducted with the Dietary Manager (DM) regarding the resident's weight loss. When asked what was being done to help control the weight loss on the resident, he replied let me pull up her medical record. He then pointed to a progress note and stated he had asked the Dietitian to review the resident. When asked if he knew if the physician had been informed of the significant weight loss he said he was not sure. On 11/26/2025 at 9:59 AM, an interview was conducted with the ADON about the resident's weight loss. When asked how the resident's weight was assessed upon admission, the ADON responded in the case of this resident, they used a Hoyer lift to weigh her. When asked if they always weigh residents at admission, the ADON responded yes. Weights are obtained in various ways depending upon what is best for the resident. The surveyor reviewed the section of the care plan on nutrition with the ADON, noting the resident was NPO. The ADON acknowledged the approach to Before taking away tray, ask if she (resident) has had enough to eat, Offer a substitute if < 50% of food was consumed was not appropriate for the resident. The surveyor explained the care plan was not personalized for the resident. When asked about a reason the resident has had such a significant weight loss in this short of a time period, the ADON responded the resident was not tolerating her feeding bolus, was vomiting. ADON responded, since we changed her feedings, she has had less vomiting. The surveyor pointed out, yet the resident is continuing to lose weight. When asked if the physician had been contacted about the weight loss, the ADON responded, The DM usually monitors the weight. I am not sure if he did. When asked about why there was no weight obtained per physician order on 11/25/25, she stated she would check on this and get back with me. A few minutes later, the ADON returned with a post it note stating, The resident was weighed on 11/25/25 by a restorative aide. Her Weight was 160. When asked why this was not documented in the medical record, she responded, The aide puts the weight in a log book, and the Dietary Manager then transfers it into the electronic medical record.

Based on Observation, Interviews and record review the facility failed to ensure residents private and confidential information was kept safe. This was a random opportunity for discovery during the long term care survey process with the potential to affect more than a minimal number of residents. Facility census: 57 On 11/25/2025 at 9:20 AM while conducting rounds this surveyor observed a medication cart and computer left unlocked and screen open while the nurse went to get medication from the med room. A resident's name and information was left on screen and easily viewable to anyone who passed by. The cart left approx. three min unattended.On 11/25/25 at 9:26 AM in an interview with LPN #72 stated that they had to get a med the resident needed to complete a med pass. I was only gone for a minute. During record review on 11/25/2025 at 2:00 PM of the New employee/Med cart and Resident Privacy policy's, It states that all carts and computers shall be locked and secured before stepping away for any length of time. The Administrator stated during an interview on 11/25/2025 at 2:12 PM they all know the policy and know better. Thank you for bringing it to my attention.

Based on record reviews and staff interviews the facility failed to ensure medical records were accurate for Resident #11 regarding DNR (do not Resuscitate) POST (Physician Orders for Scope of Treatment) and Resident #45 orders to offer thin liquids if refused thicken liquids. These failed practices were random opportunities for discovery and had the potential to affect more than a minimal number of residents residing in the long term care facility. Resident identifier: #11 and #45 Facility Census: 58 a) Resident #45 During record review of Resident #45's orders, revealed the following Diet order Start date: 11/04/25- End Date: Open Ended Description: REGULAR, MILDLY THICK LIQUIDS, PUREE Further [NAME] review of Resident #45's care plan revealed the following; Problem- start date 07/07/2022 Category: Nutritional status: Potential for nutritional problem related to resident requires mechanically altered diet due to difficulty chewing and thickened liquids due to difficulty swallowing (dysphagia), also has vitamin deficiency, hyperlipidemia(High Cholesterol), anemia in chronic kidney disease, gastro-esophageal reflux disease, and diabetes. Goal- Long Term Goal Target Date: 01/15/2025: Residents will maintain adequate nutritional status as evidenced by maintaining stable weight within 5% every 30 days. Approach: Start Date: 11/01/2024: Provide as serve diet as orderedL Pure, with mildly thickened liquids, offer the thickened liquids, if she (Resident #45) will not take them, then it is ok to give her regular, POA (Power of Attorney) wants us to try first with thickened prior to giving thin, but overall, she just wants her to stay hydrated. May have bread and cake.: On 11/26/25 at approximately 10:00 AM the administrator confirmed the Order should be updated, and stated, We will get this clarified with the Doctor now. b) Resident #11 Review of Resident #11's physician's orders showed an order written on 09/22/25 for Do Not Resuscitate (DNR), meaning the resident was not to have cardio-pulmonary resuscitation in the event of a cardiac or respiratory arrest. Resident #11's medical record showed a Physician Orders for Scope of Treatment (POST) form which was signed by the resident's Medical Power of Attorney (MPOA) on 04/07/25. This date was prior to the resident's admission to the facility. The POST form indicated the resident was to have resuscitation in the event of a cardiac or respiratory arrest. On 11/24/25 at 2:42 PM, the Administrator stated the resident's MPOA had stated he wanted the resident to be DNR in September 2025 due to the resident's decline in condition. The MPOA stated he had already completed a POST form, which was at his home. The MPOA brought in the POST form, which was the one now in the medical record. However, no one at the facility noticed the POST form indicated the resident was to be resuscitated. The Administrator stated the MPOA would be contacted to complete a DNR POST form. No further information was provided through the completion of the survey process.

Based on observations, staff interview and policy review this facility failed to store food in accordance with professional standards for food service safety. This failed practice was a random opportunity of discovery during the Long Term Care survey process. Facility Census: 57 Findings includea) During observation with kitchen inspection on 11/24/25 at 10:55 AM, noted the following items in the walk-in with label and dating missing and/or outdated.Container of pineapples- no label or use by dateContainer with slice of cake- no label or use by datePan of mashed potatoes- no label or use by dateContainer of chocolate pudding- no label or use by dateContainer of lettuce with expired use by date of 11/16/25Container of potato salad with expired use by date of 11/17/25Container of peas and carrots with expired use by date of 11/21/25Container of pasta salad with expired use by date of 11/21/25Container of sliced cheese -no label or use by date. During an interview on 11/24/25 at 11:15AM , [NAME] # 4 confirmed the above findings. During an interview on 11/25/25 at 2:56 PM, the Certified Dietary Manager (CDM) confirmed, the out-of-date food and some missing labels.The CDM further stated, It depends on the product but most generally we toss after 7 days. A review of policy on 11/25/25 at 3:00PM, titled[ Refrigeration/Freezing/storage of food.], under Procedure B reads as follows Cooks will check food storage daily and remove items that are past the appropriate used by date.

Based on record interview and staff interview, this facility failed to ensure all kitchen staff were up to date with their food handler cards. This failed practice was a random opportunity for discovery during the Long Term Care survey process. Employee identifiers: #4, #48, #55. Facility census: 57.Findings include: a) Food handler cards A record review on 11/25/25 at 1:45 PM of all dietary staff and up to date food handler cards revealed: Cook/aide #4 hire date was 03/17/23 with food handler card dated as completed on 11/24/25. Cook/aide #48 hire date of 08/26/23 with food handler card dated as completed on 11/25/25. Cook/aide #55 had an expired card as of 05/10/25. During interview with Certified Dietary Manager (CDM) on 11/25/25 at 2:00pm, he confirmed the hire dates and expiration dates

Based upon Observation, Interviews and record review the facility failed to ensure the facility remains free from accident hazards due to a medication cart and computer being left unlocked and in the main hallway A. This was a random opportunity for discovery during a long-term survey. Census: 57 Findings include: a) On 11/25/25 at 9:20 AM while conducting rounds this surveyor observed a medication cart and computer left unlocked while the Licensed Practical Nurse (LPN) went to get medication from the med room. A resident's name and information were left on screen, and the med cart was unlocked, and drawers were able to be opened. The cart was left approximately three (3) minutes unattended.On 11/25/25 at 9:26 AM in an interview with LPN #72 the LPN stated that they had to get a medication the resident needed to complete a medication pass. LPN #72 said, I was only gone for a minute. During record review on 11/25/2025 at 2:00 PM of the Med cart and Resident Privacy policy's, it states that all carts and computers shall be locked and secured before stepping away for any length of time. The Administrator stated during an interview on 11/25/2025 at 2:12 PM, They all know the policy and know better. Thank you for bringing it to my attention.

Based on record review and staff interview, the facility failed to document the resident's Medical Power of Attorney was notified when the resident experienced significant weight loss. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of nutrition. Resident identifier: #11. Facility census: 57. a) Resident #11 The facility's policy and procedure titled Weight Monitoring with effective date January 2004 and most recent revision date April 2016 stated the Power of Attorney (POA) or legal representative would be notified when the resident experienced significant weight loss. Review of Resident #11's medical records revealed on 09/09/25 the resident weighed 160 pounds (lbs). On 10/07/25, the resident weighed 144 lbs. This is a 10 percent (%) weight loss in approximately four (4) weeks. The resident continued to lose weight, weighing 141 lbs on 11/17/25. Further review of Resident #11's medical records showed no documentation the resident's POA was notified when the resident was found to have significant weight loss on 10/07/25. On 11/25/25 at 11:05 AM, the Assistant Director of Nursing (ADON) stated Resident #11's POA attends care plan conferences,but the resident has not had a care plan conference since the resident lost weight. The ADON stated Resident #11's POA frequently visited the resident. However, she was unable to locate documentation that Resident #11's POA had been notified when the resident lost weight. No further information was provided through the completion of the survey process.

The facility failed to ensure residents' comprehensive care plans were revised when changes occurred to the residents' interventions and residents' behaviors. This deficient practice had the potential to affect two (2) of 20 residents reviewed during the long-term care survey process. Resident Identifiers: #11 and #2. Facility census: 57. Findings included:a) Resident #11Resident #11's comprehensive care plan had a focus for a potential for nutritional problem. An intervention was initiated for 07/15/25 for monthly weights to be obtained. On 09/09/25, Resident #11 weighed 160 pounds (lbs). On 10/07/2025, the resident weighed 144 lbs. This was a 10 percent (%) weight loss in four (4) weeks. On 10/10/25, an order was written for weekly weights. Prior to this, the resident was weighed monthly. The resident's care plan was not updated when the resident's frequency to be weighed was changed from weekly to monthly. On 11/25/25 at 11:05 AM, the Assistant Director of Nursing (ADON) confirmed Resident #11's care plan was not revised when the resident was ordered to be weighed weekly instead of monthly. No further information was provided through the completion of the survey process. b) Resident #2 Review of Resident #2's comprehensive care plan showed the following focus related to the resident's behaviors: Has been known to take things from other residents. Will sometimes try to say that they gave them to her. Will also manipulate others or make them feel sorry for her in attempt to get what she wants from them. Can also be manipulative by crying at any given moment that she is asked about something or being redirected. Resident #11's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 11/04/25 coded the following behaviors: physical behavioral symptoms directed toward others four (4) to six (6) days during the look-back period, verbal behavioral symptoms directed toward others four (4) to six (6) days during the look-back period, other behavioral symptoms not directed toward others four (4) to six (6) days during the look-back period, and wandering daily during the look-back period. The following nursing progress documented behaviors: 10/24/25 at 12:28 PM - Resident refused am medications . 10/25/25 at 4:30 PM - Resident wandering and entering other residents rooms on A hall. Redirected numerous times. Refusing to leave one residents room. Assisted resident out of that room. Resident cursing this nurse. You son on of a bitch. Redirected. 10/28/25 at 9:29 AM - .resident was observed pulling at other residents shirt in a non-aggressive way. Writing nurse tried to redirect resident. Resident became verbally aggressive and attempted to grab this nurse by the hair. Redirection attempted, ineffective. Resident left activity room cussing and angry . 10/31/25 at 12:28 AM - Went into resident's room to give her medication, she said I'm not taking that medication it's not mine, give it to some of the poor people around here that cannot afford medication. Educated this resident that this medication belongs to her and it was ordered by the physician. She took the medication and pulled one pill out (neurotin) and told this nurse she wasn't taking anything else, when I tried to educate her about the medication, she proceeds to start cursing me and saying I needed to get the hell out of her room, I didn't know what the hell I was talking about. While passing medication on down the hallway this resident was found beside her roommates bed while the roommate was trying to sleep, she had clothes all over the bed and told me to get the hell out of her room and to close the door, when I tried to explain that the door could not be closed due to alarms she continued to curse. This resident came out of the room and was going into other resident's rooms, when she was redirected she again started to curse and say you leave me the hell alone and then would go into another resident's room, this continued for sometime. This resident is now 12:30 am up in her room with things all over her bed and gets very mad and aggressive if you try to talk to her about anything. 10/31/25 at 2:51 PM - Resident has been cursing at staff . 11/01/25 at 12:22 PM - Resident combative during care. Hitting, kicking, cursing. Resident has soiled herself multiple times this shift and resistant to care. Resident has been educated by recording nurse that she has risks of skin breaking down and infections. Resident has been getting into her roommate's belongings and taking them. Unable to be redirected today. Food, drink, and activities offered. 11/02/25 at 6:24 AM - Resident has refused care this shift. Aggressive. cursing, resistant to all care . 11/02/25 at 2:16 PM - Resident up several time during the night going into other resident's rooms. Resident was up at approximately 5 am saying she was going to visit a friend, educated this resident of the time and that most of the residents are still sleeping. Resident was shown where her room was, when this nurse went to give her medication, she told me to just leave it she would take it later, educated resident that this nurse could not leave medication in room, explained what it was for and she became very mad and told me that she knew what everyone was doing and no doctor had ordered medication for her, she held onto medication, had to convince resident that I had to have it if she was not going to take it. Resident then was mad, then proceeds to go up and down the halls in her wheelchair. This resident has been very combative, not wanting to take medication, going into others room and taking their belongings. She will be very mad one minute and then have a completely different attitude the next. 11/04/25 at 5:11 AM - Resident has been up ambulating via wheelchair around facility all shift. Unable to redirect resident to bed despite multiple attempts. Resident has not complained of any pain or discomfort. Residents states she is just up trying to help people. 11/8/25 at 10:09 AM - Resident refused breakfast time meal. Continues pacing halls in wheelchair, entering several residents rooms 11/8/25 at 6:23 PM - Resident continues pacing hallways in wheelchair. Being verbally aggressive with staff. Refusing incontinence care. Redirected several times from being in other residents rooms 11/14/25 at 4:26 PM - Resident refusing to walk with restorative therapy for multiple days. Resident difficult to redirect . 11/22/25 at 11:05 PM - Resident refused all HS [bedtime] meds. Attempted to give medications x3 [three times]. Education was provided. Resident still refused all medications but agreed to take her Gabapentin. Afterwards resident proceeded to continually ambulate multiple times around the facility . (All notes were typed as written in the medical records.) When this surveyor asked for the copy of the care plan on 11/25/25, it had been revised on 11/25/2025 to include the following problem focus, Resident has verbal behavioral symptoms toward staff at times. Resident also refuses medications at times and frequently roams into other residents [sic] rooms. Interventions for these behaviors had been added. On 11/25/2025 at 3:13 PM, the Assistant Director of Nursing confirmed Resident #2's behaviors of wandering, verbal aggression, and medication refusals had not been included in the comprehensive care plan until 11/25/25.

Based on observation and staff interview, the facility failed to treat a resident with respect and dignity during the dining experience by referring to the resident's adaptive spoon as a baby spoon. This failed practice had the potential to affect a limited number of residents and was a random opportunity for discovery. Resident Identifier: #8. Facility Census: 57. Findings included: a) Resident #8 On 11/25/25 at 12:10 PM, the State Surveyor was observing the dining room lunch meal service. Nursing Assistant (NA) #31 yelled across the room to the dietary window and told the staff to Throw me a baby spoon. NA #21 confirmed the spoon asked for by NA #31 was a baby spoon and that the resident sometimes eats with her fingers. The resident's diet order stated, NAS (No Added Salt), PUREE Special Instructions: Color suction lip plate, small color coated spoon. On 11/25/25 at 01:46 PM, the Administrator in Training reported they did not have a policy and procedure for dignity, but that they follow the state guidelines for dignity. The facility's Dining Program Policy and Procedure stated, the Purpose was to provide Skilled/ICF residents with a fine dining experience that is close to home dining as possible.

Based on record review, staff interview, and resident interview, the facility failed to provide Activities of Daily Living (ADL) care related to showers for dependent residents. This failed practice was found to be true for one (1) of three (3) residents reviewed for ADL care during the long term care survey process. Resident identifier:#27 Facility Census: 57 Resident identifier #27 Facility census #57.Findings include:a) Resident #27 On 11/25/25 at 4:00 pm record review shows the following:According to the shower schedule provided by the facility resident #27 is scheduled for showers on Tuesdays and Thursdays on day shift.Resident #27 was scheduled/received showers on the following days:10/28/25 - received no shower 10/30/25 - received no shower11/04/25 - received shower11/06/25 - received shower11/11/25 - received shower11/13/25 - received shower11/18/25 - received no shower11/20/25 - received no showerRecord review completed on 11/25/25 revealed Resident #27 is an extensive total dependence with one person assisting for showers.Further record review on 11/25/25 of Resident #27's care plan revealed Resident #27 requires moderate to max assist with activities of daily living due to diagnosis of Dementia/Alzheimer's. Resident is dependent on staff for bathing, transfers, and hygieneOn 11/25/25 at 4:23 the Administrator confirmed resident #27 had not received showers as required. No other documentation was provided prior to exit of this survey.

Based on record review and staff interview, the facility failed to ensure residents' care was supervised by a physician. The facility failed to document the physician was aware of Resident #11's significant weight loss. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of nutrition. Resident Identifier: #11. Facility Census: 57. Findings included: a) Resident #11 The facility's policy and procedure titled Weight Monitoring with effective date January 2004 and most recent revision date April 2016 stated the attending physician would be notified when the resident experienced significant weight loss. Review of Resident #11's medical records revealed on 09/09/2025 the resident weighed 160 pounds (lbs). On 10/07/2025, the resident weighed 144 lbs. This is a 10 percent (%) weight loss in approximately four (4) weeks. The resident continued to lose weight, weighing 141 lbs on 11/17/25. Further review of Resident #11's medical records showed no documentation the resident's attending physician was notified when the resident was found to have significant weight loss on 10/07/25. Resident #11 was evaluated by the physician on 11/24/25. The resident's weight loss was not mentioned in the physician evaluation progress note. On 11/25/25 at 11:05 AM, the Assistant Director of Nursing (ADON) stated she was unable to locate documentation that Resident #11's physician had been notified when the resident lost weight or that the physician was aware of the resident's weight loss. No further information was provided through the completion of the survey process.

Based on record review, resident interview and staff interview, the facility failed to implement the facility Abuse policy and procedure. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey Process. Resident identifiers: Resident #158, Resident #30 and Resident #15. Facility census: 58. Findings include: a) a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses: 1. Hallucinations 2. Vascular Dementia with other behavioral disturbance 3. Alzheimer's disease 4. Major depressive disorder recurrent, 5. Delusional disorders 6. Anxiety Medications: 1. Xanax 0.5 milligrams (mg) 1/2 tablet by mouth twice a day 2.Lamictal 200 mg 1 tablet by mouth at bedtime 3. Zyprexa 2.5 mg 1 tablet by mouth once a day 4. Mirtazapine 7.5mg 1 tablet by mouth at bedtime In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing not read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA/Daughter notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 am medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase zyprexa to 5mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to Barh for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN (LPN name) notified Dr. of continued behaviors and an order was obtained for resident to be transported to (local hospital ED) for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at local hospital facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. Jan Care called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in local hospital ED. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for phsych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back via BLS and they were pulling out of the facility at 6:23 am. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psychiatric Evaluation was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 pm and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to TMH ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitiled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Cheif Executive Officer (CEO) or designee and to other officals in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 pm, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurance on 11/08/23 had not been reported or investigated. b) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. The resident reported LPN #73 made derogatory statements such as calling her fat, telling her we are afraid to leave any food around you, and telling her a list a mile long of people who Resident #15 has been mean to, and threatening to send her up the river. The resident thought LPN #73 was implying she had a rap sheet and she would be sent to another facility. The FRI states, Resident does get her feelings hurt easily and is very child like with how she thinks but that is normal for her. The FRI, also, stated, Victim does not have capacity. (Name of Resident #15) BIMS (Brief Interview for Mental Status) is a 12 which is moderately impaired. No medical intervention was necessary. (Name of Resident #15) has been emotional distress all day and her roommate said she also had cried through the night the night before. (Typed as written.) An interview, with no date or time, during the facility investigation was held with Resident #15's roommate, Resident #45. Resident #45 confirmed the resident and LPN #73 were arguing and she thought they were going to fist fight. Resident #45 stated she couldn't remember details of what was said. The following witness statements were obtained from the staff: An interview was held with Nurse Aide (NA) #67. There was no specific date or time noted on the witness statement. Nurse Aide (NA) #67 stated, LPN #73 wanted to give the resident her breathing treatment. However, the resident was watching TV and did not want to miss it. NA #67 wanted to give Resident #15 her breathing treatment early due to getting off and there would only be one nurse there. NA #67 stated, the resident became upset and started yelling and cussing .calling the staff names. A witness statement with no date or time noted was obtained from NA #40. NA #40 stated, Heard (Name of LPN #73) talking down to (Name of Resident #15) going back to her room. (Name of Resident #15) was testy over what was on TV. (Name of LPN #73) intensified (Name of Resident #15) mood that's how she does. Told (Name of Resident #15) no one cares what (Name of Resident #15) has to say anyway. When NA #40 heard that she went to other end of hall to avoid hearing the rest of the conversation. Feel that if she intervened it would have made things worse for (Name of Resident #15). Treatment of people is unkind. Reminds her of another nurse that was awful she worked with before. Off Sat (Saturday), Friday she worked. (Typed as written.) A witness statement with the date of 09/19/24 but no time noted, NA #7 stated, I was in the dining room when (Name of Resident #15) was crying she said that (Name of LPN #73) .she stated she hated (Name of LPN #73) and when she got up and was leaving the dining room she said to me that she was going to get (Name of LPN #73) fired. A witness statement was obtained from Activities Director #70. The statement is as follows: Resident (Name of Resident #15) came into the activity room on Monday, September 16th at 10:30 AM and ask if she could speak to me about something private. She said Nurse (Name of LPN #73) came in her room fussing at her. She said (Name of LPN #73) really hurt her because she was making fun of her being fat. She said (Name of LPN #73) said she was afraid of leaving food on a plate around her. She said (Name of LPN #73) said she was so overweight. She said (Name of LPN #73) was yelling at her and saying mean things to her. I asked (Name of Resident #15) what was said she couldn't remember what all was said. She expressed that (Name of LPN #73) hurt her so badly she would like if I told (Name of LPN #73) not to come in her room anymore. She said (Name of LPN #73) told her she has had enough on her to send her away up the river. She said (Name of LPN #73) speaks to her roommate (Name of Resident #45) nicely but doesn't speak nice to her. I asked why and she said she feels like (Name of LPN #73) hates her. She said (Name of LPN #73) told her she has a wrap sheet a mile long and its enough to get her transferred to another facility. I expressed to (Name of Resident #15) that (Name of LPN #73) didn't have the authority to send her anywhere and (Name of Resident #15) said well according to her she does. (Name of LPN #73) told her she was mean to the other residents, her roommate and staff members. (Name of Resident #15) also was upset that (Name of LPN #73) made her leave the TV lounge to take her breathing treatments. She said (Name of LPN #73) told her she needed to take the treatment but could come back after she finished but (Name of Resident #15) doesn't want to walk to her room and then walk back. I told (Name of Resident #15) she needed to talk to the social worker about what happened and she said she was going to speak to her. (Name of Resident #15) said she just didn't want (Name of LPN #73) to be her nurse anymore. (Typed as written.) An additional witness statement was obtained from the Administrative Assistant #46. The written statement does not include a date or time. The witness statement states the following: (Name of Resident #15) and (Name of Resident #45) both came into the office and wanted to talk to (Name of Social Services #30). At the time, she was busy with someone in her office, so (Name of Resident #15) and (Name of Resident #45) asked if they could talk to me. (Name of Resident #15) appeared visibly upset so I let them sit by my desk and talk. (Name of Resident #15) said that she was upset with how (Name of LPN #73) had treated her and that she didn't want (Name of LPN #73) in her room or around her anymore. (Name of Resident #15) referenced an instance where (Name of LPN #73) either directly or indirectly made an offhand comment about (Name of Resident #15)'s weight, as well as making a comment about not being able to leave food on a plate around (Name of Resident #15). (Name of Resident #45) seemed to corroborate at least some, if not all, of what had happened. (Name of Resident #15) also mentioned that (Name of LPN #73) said she had a rap sheet on her this long. I also recall (Name of Resident #15) mentioning that someone said she was mean to (Name of Resident #45), (Name of Resident #45) refuted. On 10/21/24 at 2:15 PM, the five (5) day follow-up investigation dated 09/20/24 at 9:06 AM, was reviewed. The five (5) day follow-up states,No additional outcomes were found. Initial report was made regarding abuse, due to comments allegedly made by (Name of LPN #73), towards resident regarding her weight and sending her out of the facility. (Name of LPN #73 denies making any of the statements, she stated that she witnessed (Name of Resident #15) kicking her roommates walker and overheard (Name of Resident #15) calling her roommate a bitch when she intervened and explained to (Name of Resident #15) that she can't kick her roommate's walker because she or someone else could get hurt. The charge nurse responsible for oversight was not in the vicinity of the location where the incident allegedly occurred. Multiple staff members reiterated that (Name of Resident #15) can throw tantrums when she doesn't get her way. One staff member mentioned (Name of Resident #15) had mentioned prior to the incident that she was planning to get (Name of LPN #73) fired. Interviews and statements from staff and roommate were inconclusive. Most staff members heard (Name of Resident #15) get upset in the lounge when asked to return to her room and take a breathing treatment, but no staff members were around to see or hear the alleged incident take place. The allegation was inconclusive due to a lack of witnesses and evidence. (Typed as written.) On 10/21/24 at 4:15 PM, Resident #15 was interviewed regarding the allegation of verbal abuse. Resident #15 stated, she hollered at me at the top of her lungs, called me fat, and told me I was going to have to go to another place to live. During the interview, Resident #15 was visibly upset. She began to cry, wring her hands and shake. Resident #15 stated, I hate when I hear her voice .I can't get over it no matter how hard I try. The resident stated her roommate heard everything. She said she has talked with staff members about the incident with LPN #73 but continues to be upset. On 10/21/24 at approximately 5:00 PM, Resident 15's roommate at the time, was interviewed regarding the incident. Resident #45 was asked, do you remember an incident with (Name of Resident #15) and a staff member? Resident #45 stated, the nurse screamed at her .she was loud and was reprimanding her as if she were a child. Resident #45 was asked, do you think this was appropriate for a staff member to do? Resident #45 stated, no it was not appropriate I remember it happened I just can't remember all the exact words that were said. On 10/23/24 at 10:49 AM, an interview was held with Social Services #30 and Activities Coordinator #70. Both staff members were asked about the statements by witnesses and the interview which was held with Resident #15. Social Services #30 stated, Because, of . we went through all of the statements. I was ready to substantiate initially. We also got statements that (Name of Resident #15) says I am going to get her fired. The Social Services #30 was asked, was the resident not believed because of documented behaviors and angry statements the resident made? Social Services #30 stated, the staff was suspended. On 10/23/24 at 10:53 AM, the facility Administrator walked into the conference room. The Administrator was told of the previous conversation with Social Services #30 and Activities Coordinator #70. On 10/23/24 at 10:57 AM, the Administrator stated, The statements were reflective of what the resident stated, not what actually happened. I did feel she (LPN #73) was aggressive toward the resident. But based on the statements, I am not sure what happened. I feel the staff pushed the situation by being to loud. She (LPN #73 ) could not tell me exactly what was said but that she was loud. On 10/23/24 at 10:58 AM, the Administrator stated, I was out at a conference at this event, I was handling things over the phone. On 10/23/24 at 10:59 AM, Social Services #30 stated, This was a really tough one we went back and forth with this one. On 10/23/24 at 11:00 AM, the Administrator stated, I felt as if her escalating the situation required action . I feel that the resident saying she called her fat and the accusation that we could not substantiate. We feel like it is our job to protect residents, APS (Adult Protective Services) told us they were not interested in investigating, this is what helped lead us to our decision. The Administrator was asked, what would have convinced you this allegation of verbal abuse occurred? The Administrator stated, Another witness to collaborate what was said. NA #42 did not collaborate what she said, because she walked away .the resident is known to tell falsehoods and she had threatened to get the LPN fired. At this time, the written statement by NA #42 was reviewed with the Administrator. The Administrator stated, I do not recall her specific statement, but I do agree with you .the LPN was immediately suspended and upon return to work she was given a Last Chance Agreement. The Last Chance Agreement dated 09/20/24 stated, .It has been brought to the facility's attention that (Name of LPN #73) has previously engaged in inappropriate behavior by escalating situations with aggressive or difficult residents. Despite previous education and guidance on managing such situations with tact and professionalism, the issue persists. Effective immediately, this is the final written warning regarding her conduct. Any future incidents where (Name of LPN #73) raises her voice aggressively or acts in a manner that escalates conflict with residents will result in immediate termination of employment . The Administrator was asked, why was LPN #73 given this Last Chance Agreement? Did you feel the alleged verbal abuse occurred? The Administrator stated, I know she was loud .but I could not verify what actually took place. On 10/23/24 at 11:03 AM, Social Services #30 stated, I have talked to her (Resident #15) many times about the situation. But I do not have notes about this particular situation. I am not sure If I have formally talked to them (Resident #15 and Resident #45) about the situation. On 10/23/24 at 11:20 AM, the Administrator was asked, do you realize the resident remains upset regarding this allegation of verbal abuse .the resident continues to be visibly upset, such as crying and wringing her hands. The Administrator stated, She has been referred to our psych doctor. She comes once a week on Tuesdays. I will see if she has seen her. On 10/23/24 at approximately 12:15 PM, the Administrator was asked, why didn't LPN #73 follow the care plan intervention under the focus area of behavioral symptoms .which is when resident becomes physically abusive, STOP and try task later. Do not force task and Maintain a calm environment and approach to the resident. (Typed as written.) The Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior. 50552

Based on record review, resident interview and staff interview, the facility failed to provide an environment free from abuse. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey process. Resident identifiers: Resident #158, #30, #15. Facility census: 58. Findings included: a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident (FRI) revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses: 1. Hallucinations 2. Vascular Dementia with other behavioral disturbance 3. Alzheimer's disease 4. Major depressive disorder recurrent, 5. Delusional disorders 6. Anxiety Medications: 1. Xanax 0.5 milligrams (mg) 1/2 tablet by mouth twice a day 2. Lamictal 200 mg 1 tablet by mouth at bedtime 3. Zyprexa 2.5 mg 1 tablet by mouth once a day 4. Mirtazapine 7.5 mg 1 tablet by mouth at bedtime In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing note read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 am medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase Zyprexa to 5 mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to (Name of local hospital) for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN (LPN name) notified Dr. of continued behaviors and an order was obtained for resident to be transported to (area hospital ED) for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at area hospital facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. Jan Care called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in BARH ER. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for psych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back via BLS and they were pulling out of the facility at 6:23 am. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psych Eval was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 PM and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to TMH ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5 mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Chief Executive Officer (CEO) or designee and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 PM, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurrence on 11/08/23 had not been reported or investigated. b) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. The resident reported LPN #73 made derogatory statements such as calling her fat, telling her we are afraid to leave any food around you, and telling her a list a mile long of people who Resident #15 has been mean to, and threatening to send her up the river. The resident thought LPN #73 was implying she had a rap sheet and she would be sent to another facility. The FRI states, Resident does get her feelings hurt easily and is very child like with how she thinks but that is normal for her. The FRI, also, stated, Victim does not have capacity. (Name of Resident #15) BIMS (Brief Interview for Mental Status) is a 12 which is moderately impaired. No medical intervention was necessary. (Name of Resident #15) has been emotional distress all day and her roommate said she also had cried through the night the night before. (Typed as written.) An interview, with no date or time, during the facility investigation was held with Resident #15's roommate, Resident #45. Resident #45 confirmed the resident and LPN #73 were arguing and she thought they were going to fist fight. Resident #45 stated she couldn't remember details of what was said. The following witness statements were obtained from the staff: An interview was held with Nurse Aide (NA) #67. There was no specific date or time noted on the witness statement. Nurse Aide (NA) #67 stated, LPN #73 wanted to give the resident her breathing treatment. However, the resident was watching TV and did not want to miss it. NA #67 wanted to give Resident #15 her breathing treatment early due to getting off and there would only be one nurse there. NA #67 stated, the resident became upset and started yelling and cussing .calling the staff names. A witness statement with no date or time noted was obtained from NA #40. NA #40 stated, Heard (Name of LPN #73) talking down to (Name of Resident #15) going back to her room. (Name of Resident #15) was testy over what was on TV. (Name of LPN #73) intensified (Name of Resident #15) mood that's how she does. Told (Name of Resident #15) no one cares what (Name of Resident #15) has to say anyway. When NA #40 heard that she went to other end of hall to avoid hearing the rest of the conversation. Feel that if she intervened it would have made things worse for (Name of Resident #15). Treatment of people is unkind. Reminds her of another nurse that was awful she worked with before. Off Sat (Saturday), Friday she worked. (Typed as written.) A witness statement with the date of 09/19/24 but no time noted, NA #7 stated, I was in the dining room when (Name of Resident #15) was crying she said that (Name of LPN #73) .she stated she hated (Name of LPN #73) and when she got up and was leaving the dining room she said to me that she was going to get (Name of LPN #73) fired. A witness statement was obtained from Activities Director #70. The statement is as follows: Resident (Name of Resident #15) came into the activity room on Monday, September 16th at 10:30 AM and ask if she could speak to me about something private. She said Nurse (Name of LPN #73) came in her room fussing at her. She said (Name of LPN #73) really hurt her because she was making fun of her being fat. She said (Name of LPN #73) said she was afraid of leaving food on a plate around her. She said (Name of LPN #73) she was so overweight. She said (Name of LPN #73) was yelling at her and saying mean things to her. I asked (Name of Resident #15) what was said she couldn't remember what all was said. She expressed that (Name of LPN #73) hurt her so badly she would like if I told (Name of LPN #73) not to come in her room anymore. She said (Name of LPN #73) told her she has had enough on her to send her away up the river. She said (Name of LPN #73) speaks to her roommate (Name of Resident #45) nicely but doesn't speak nice to her. I asked why and she said she feels like (Name of LPN #73) hates her. She said (Name of LPN #73) told her she has a wrap sheet a mile long and its enough to get her transferred to another facility. I expressed to (Name of Resident #15) that (Name of LPN #73) didn't have the authority to send her anywhere and (Name of Resident #15) said well according to her she does. (Name of LPN #73) told her she was mean to the other residents, her roommate and staff members. (Name of Resident #15) also was upset that (Name of LPN #73) made her leave the TV lounge to take her breathing treatments. She said (Name of LPN #73) told her she needed to take the treatment but could come back after she finished but (Name of Resident #15) doesn't want to walk to her room and then walk back. I told (Name of Resident #15) she needed to talk to the social worker about what happened and she said she was going to speak to her. (Name of Resident #15) said she just didn't want (Name of LPN #73) to be her nurse anymore. (Typed as written.) An additional witness statement was obtained from the Administrative Assistant #46. The written statement does not include a date or time. The witness statement states the following: (Name of Resident #15) and (Name of Resident #45) both came into the office and wanted to talk to (Name of Social Services #30). At the time, she was busy with someone in her office, so (Name of Resident #15) and (Name of Resident #45) asked if they could talk to me. (Name of Resident #15) appeared visibly upset so I let them sit by my desk and talk. (Name of Resident #15) said that she was upset with how (Name of LPN #73) had treated her and that she didn't want (Name of LPN #73) in her room or around her anymore. (Name of Resident #15) referenced an instance where (Name of LPN #73) either directly or indirectly made an offhand comment about (Name of Resident #15)'s weight, as well as making a comment about not being able to leave food on a plate around (Name of Resident #15). (Name of Resident #45) seemed to corroborate at least some, if not all, of what had happened. (Name of Resident #15) also mentioned that (Name of LPN #73) said she had a rap sheet on her this long. I also recall (Name of Resident #15) mentioning that someone said she was mean to (Name of Resident #45), (Name of Resident #45) refuted. On 10/21/24 at 2:15 PM, the five (5) day follow-up investigation dated 09/20/24 at 9:06 AM, was reviewed. The five (5) day follow-up states,No additional outcomes were found. Initial report was made regarding abuse, due to comments allegedly made by (Name of LPN #73), towards resident regarding her weight and sending her out of the facility. (Name of LPN #73 denies making any of the statements, she stated that she witnessed (Name of Resident #15) kicking her roommates walker and overheard (Name of Resident #15) calling her roommate a bitch when she intervened and explained to (Name of Resident #15) that she can't kick her roommate's walker because she or someone else could get hurt. The charge nurse responsible for oversight was not in the vicinity of the location where the incident allegedly occurred. Multiple staff members reiterated that (Name of Resident #15) can throw tantrums when she doesn't get her way. One staff member mentioned (Name of Resident #15) had mentioned prior to the incident that she was planning to get (Name of LPN #73) fired. Interviews and statements from staff and roommate were inconclusive. Most staff members heard (Name of Resident #15) get upset in the lounge when asked to return to her room and take a breathing treatment, but no staff members were around to see or hear the alleged incident take place. The allegation was inconclusive due to a lack of witnesses and evidence. (Typed as written.) On 10/21/24 at 4:15 PM, Resident #15 was interviewed regarding the allegation of verbal abuse. Resident #15 stated, she hollered at me at the top of her lungs, called me fat, and told me I was going to have to go to another place to live. During the interview, Resident #15 was visibly upset. She began to cry, wring her hands and shake. Resident #15 stated, I hate when I hear her voice .I can't get over it no matter how hard I try. The resident stated her roommate heard everything. She said she has talked with staff members about the incident with LPN #73 but continues to be upset. On 10/21/24 at approximately 5:00 PM, Resident 15's roommate at the time, was interviewed regarding the incident. Resident #45 was asked, do you remember an incident with (Name of Resident #15) and a staff member? Resident #45 stated, the nurse screamed at her .she was loud and was reprimanding her as if she were a child. Resident #45 was asked, do you think this was appropriate for a staff member to do? Resident #45 stated, no it was not appropriate I remember it happened I just can't remember all the exact words that were said. On 10/23/24 at 10:49 AM, an interview was held with Social Services #30 and Activities Coordinator #70. Both staff members were asked about the statements by witnesses and the interview which was held with Resident #15. Social Services #30 stated, Because, of . we went through all of the statements. I was ready to substantiate initially. We also got statements that (Name of Resident #15) says I am going to get her fired. The Social Services #30 was asked, was the resident not believed because of documented behaviors and angry statements the resident made? Social Services #30 stated, the staff was suspended. On 10/23/24 at 10:53 AM, the facility Administrator walked into the conference room. The Administrator was told of the previous conversation with Social Services #30 and Activities Coordinator #70. On 10/23/24 at 10:57 AM, the Administrator stated, The statements were reflective of what the resident stated, not what actually happened. I did feel she (LPN #73) was aggressive toward the resident. But based on the statements, I am not sure what happened. I feel the staff pushed the situation by being to loud. She (LPN #73 ) could not tell me exactly what was said but that she was loud. On 10/23/24 at 10:58 AM, the Administrator stated, I was out at a conference at this event, I was handling things over the phone. On 10/23/24 at 10:59 AM, Social Services #30 stated, This was a really tough one we went back and forth with this one. On 10/23/24 at 11:00 AM, the Administrator stated, I felt as if her escalating the situation required action . I feel that the resident saying she called her fat and the accusation that we could not substantiate. We feel like it is our job to protect residents, APS (Adult Protective Services) told us they were not interested in investigating, this is what helped lead us to our decision. The Administrator was asked, what would have convinced you this allegation of verbal abuse occurred? The Administrator stated, Another witness to collaborate what was said. NA #42 did not collaborate what she said, because she walked away .the resident is known to tell falsehoods and she had threatened to get the LPN fired. At this time, the written statement by NA #42 was reviewed with the Administrator. The Administrator stated, I do not recall her specific statement, but I do agree with you .the LPN was immediately suspended and upon return to work she was given a Last Chance Agreement. The Last Chance Agreement dated 09/20/24 stated, .It has been brought to the facility's attention that (Name of LPN #73) has previously engaged in inappropriate behavior by escalating situations with aggressive or difficult residents. Despite previous education and guidance on managing such situations with tact and professionalism, the issue persists. Effective immediately, this is the final written warning regarding her conduct. Any future incidents where (Name of LPN #73) raises her voice aggressively or acts in a manner that escalates conflict with residents will result in immediate termination of employment . The Administrator was asked, why was LPN #73 given this Last Chance Agreement? Did you feel the alleged verbal abuse occurred? The Administrator stated, I know she was loud .but I could not verify what actually took place. On 10/23/24 at 11:03 AM, Social Services #30 stated, I have talked to her (Resident #15) many times about the situation. But I do not have notes about this particular situation. I am not sure If I have formally talked to them (Resident #15 and Resident #45) about the situation. On 10/23/24 at 11:20 AM, the Administrator was asked, do you realize the resident remains upset regarding this allegation of verbal abuse .the resident continues to be visibly upset, such as crying and wringing her hands. The Administrator stated, She has been referred to our psych doctor. She comes once a week on Tuesdays. I will see if she has seen her. On 10/23/24 at approximately 12:15 PM, the Administrator was asked, why didn't LPN #73 follow the care plan intervention under the focus area of behavioral symptoms .which is when resident becomes physically abusive, STOP and try task later. Do not force task and Maintain a calm environment and approach to the resident. (Typed as written.) The Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior. 50552

49465 Based on record review and staff interview, the facility failed to ensure all allegations of abuse and or neglect were reported to appropriate state agencies as required. This was true for two (2) of four (4) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #4 and #158. Facility Census: 58. Findings Include: a) Resident #4 A review of the facilities grievance and concerns on 10/22/24 at 5:38 PM, revealed a concern that reads as follows: (Resident #4 named) wanted put in bed during mealtime and two staff have to put her in bed and most staff were feeding other residents and told her soon as they could put her to bed they would. Resident stated that a nurse said Poor Thing to her because she was ready to go to bed and stated her hips were hurting from the wheelchair. The staff that made the comment received verbal disciplinary action. During an interview on 10/22/24 at 5:41 PM, the Administrator stated, I remember the incident. The original person she said it was, was not who it was. We found it was a (Nurse Aide) NA. The NA said that she did not mean that in a derogatory way, she meant it as a sweet gesture. The administrator additionally stated, We will report it now. b) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses included Hallucinations, Vascular Dementia with other behavioral disturbance, Alzheimer's disease, Major depressive disorder recurrent, Delusional disorders and Anxiety. In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing not read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 AM medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase Zyprexa to 5 mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to (name of local hospital) for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN (Name of LPN) notified Dr. of continued behaviors and an order was obtained for resident to be transported to (name of local hospital) ER for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at (name of local hospital) facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. (Ambulance Company name) called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in (name of local hospital) ER. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for psych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back via BLS and they were pulling out of the facility at 6:23 am. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psychiatric Evaluation was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 PM and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to (local hospital name) ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5 mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Chief Executive Officer (CEO) or designee and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 PM, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurrence on 11/08/23 had not been reported or investigated. 50552

Based on record review, resident interview, observation and staff interview, the facility failed to complete a through and complete investigation regarding allegations of verbal abuse for Resident #15 and physical abuse for Resident #158. This was true for two (2) of four (4) residents reviewed under the care area of abuse. Resident Identifiers: #15 and #158. Facility Census: 58. Findings Include: a) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. The resident reported LPN #73 made derogatory statements such as calling her fat, telling her we are afraid to leave any food around you, and telling her a list a mile long of people who Resident #15 has been mean to, and threatening to send her up the river. The resident thought LPN #73 was implying she had a rap sheet and she would be sent to another facility. The FRI states, Resident does get her feelings hurt easily and is very child like with how she thinks but that is normal for her. The FRI, also, stated, Victim does not have capacity. (Name of Resident #15) BIMS (Brief Interview for Mental Status) is a 12 which is moderately impaired. No medical intervention was necessary. (Name of Resident #15) has been emotional distress all day and her roommate said she also had cried through the night the night before. (Typed as written.) An interview, with no date or time, during the facility investigation was held with Resident #15's roommate, Resident #45. Resident #45 confirmed the resident and LPN #73 were arguing and she thought they were going to fist fight. Resident #45 stated she couldn't remember details of what was said. The following witness statements were obtained from the staff: An interview was held with Nurse Aide (NA) #67. There was no specific date or time noted on the witness statement. Nurse Aide (NA) #67 stated, LPN #73 wanted to give the resident her breathing treatment. However, the resident was watching TV and did not want to miss it. NA #67 wanted to give Resident #15 her breathing treatment early due to getting off and there would only be one nurse there. NA #67 stated, the resident became upset and started yelling and cussing .calling the staff names. A witness statement with no date or time noted was obtained from NA #40. NA #40 stated, Heard (Name of LPN #73) talking down to (Name of Resident #15) going back to her room. (Name of Resident #15) was testy over what was on TV. (Name of LPN #73) intensified (Name of Resident #15) mood that's how she does. Told (Name of Resident #15) no one cares what (Name of Resident #15) has to say anyway. When NA #40 heard that she went to other end of hall to avoid hearing the rest of the conversation. Feel that if she intervened it would have made things worse for (Name of Resident #15). Treatment of people is unkind. Reminds her of another nurse that was awful she worked with before. Off Sat (Saturday), Friday she worked. (Typed as written.) A witness statement with the date of 09/19/24 but no time noted, NA #7 stated, I was in the dining room when (Name of Resident #15) was crying she said that (Name of LPN #73) .she stated she hated (Name of LPN #73) and when she got up and was leaving the dining room she said to me that she was going to get (Name of LPN #73) fired. A witness statement was obtained from Activities Director #70. The statement is as follows: Resident (Name of Resident #15) came into the activity room on Monday, September 16th at 10:30 AM and ask if she could speak to me about something private. She said Nurse (Name of LPN #73) came in her room fussing at her. She said (Name of LPN #73) really hurt her because she was making fun of her being fat. She said (Name of LPN #73) said she was afraid of leaving food on a plate around her. She said (Name of LPN #73) said she was so overweight. She said (Name of LPN #73) was yelling at her and saying mean things to her. I asked (Name of Resident #15) what was said she couldn't remember what all was said. She expressed that (Name of LPN #73) hurt her so badly she would like if I told (Name of LPN #73) not to come in her room anymore. She said (Name of LPN #73) told her she has had enough on her to send her away up the river. She said (Name of LPN #73) speaks to her roommate (Name of Resident #45) nicely but doesn't speak nice to her. I asked why and she said she feels like (Name of LPN #73) hates her. She said (Name of LPN #73) told her she has a wrap sheet a mile long and its enough to get her transferred to another facility. I expressed to (Name of Resident #15) that (Name of LPN #73) didn't have the authority to send her anywhere and (Name of Resident #15) said well according to her she does. (Name of LPN #73) told her she was mean to the other residents, her roommate and staff members. (Name of Resident #15) also was upset that (Name of LPN #73) made her leave the TV lounge to take her breathing treatments. She said (Name of LPN #73) told her she needed to take the treatment but could come back after she finished but (Name of Resident #15) doesn't want to walk to her room and then walk back. I told (Name of Resident #15) she needed to talk to the social worker about what happened and she said she was going to speak to her. (Name of Resident #15) said she just didn't want (Name of LPN #73) to be her nurse anymore. (Typed as written.) An additional witness statement was obtained from the Administrative Assistant #46. The written statement does not include a date or time. The witness statement states the following: (Name of Resident #15) and (Name of Resident #45) both came into the office and wanted to talk to (Name of Social Services #30). At the time, she was busy with someone in her office, so (Name of Resident #15) and (Name of Resident #45) asked if they could talk to me. (Name of Resident #15) appeared visibly upset so I let them sit by my desk and talk. (Name of Resident #15) said that she was upset with how (Name of LPN #73) had treated her and that she didn't want (Name of LPN #73) in her room or around her anymore. (Name of Resident #15) referenced an instance where (Name of LPN #73) either directly or indirectly made an offhand comment about (Name of Resident #15)'s weight, as well as making a comment about not being able to leave food on a plate around (Name of Resident #15). (Name of Resident #45) seemed to corroborate at least some, if not all, of what had happened. (Name of Resident #15) also mentioned that (Name of LPN #73) said she had a rap sheet on her this long. I also recall (Name of Resident #15) mentioning that someone said she was mean to (Name of Resident #45), (Name of Resident #45) refuted. On 10/21/24 at 2:15 PM, the five (5) day follow-up investigation dated 09/20/24 at 9:06 AM, was reviewed. The five (5) day follow-up states,No additional outcomes were found. Initial report was made regarding abuse, due to comments allegedly made by (Name of LPN #73), towards resident regarding her weight and sending her out of the facility. (Name of LPN #73 denies making any of the statements, she stated that she witnessed (Name of Resident #15) kicking her roommates walker and overheard (Name of Resident #15) calling her roommate a bitch when she intervened and explained to (Name of Resident #15) that she can't kick her roommate's walker because she or someone else could get hurt. The charge nurse responsible for oversight was not in the vicinity of the location where the incident allegedly occurred. Multiple staff members reiterated that (Name of Resident #15) can throw tantrums when she doesn't get her way. One staff member mentioned (Name of Resident #15) had mentioned prior to the incident that she was planning to get (Name of LPN #73) fired. Interviews and statements from staff and roommate were inconclusive. Most staff members heard (Name of Resident #15) get upset in the lounge when asked to return to her room and take a breathing treatment, but no staff members were around to see or hear the alleged incident take place. The allegation was inconclusive due to a lack of witnesses and evidence. (Typed as written.) On 10/21/24 at 4:15 PM, Resident #15 was interviewed regarding the allegation of verbal abuse. Resident #15 stated, she hollered at me at the top of her lungs, called me fat, and told me I was going to have to go to another place to live. During the interview, Resident #15 was visibly upset. She began to cry, wring her hands and shake. Resident #15 stated, I hate when I hear her voice .I can't get over it no matter how hard I try. The resident stated her roommate heard everything. She said she has talked with staff members about the incident with LPN #73 but continues to be upset. On 10/21/24 at approximately 5:00 PM, Resident 15's roommate at the time, was interviewed regarding the incident. Resident #45 was asked, do you remember an incident with (Name of Resident #15) and a staff member? Resident #45 stated, the nurse screamed at her .she was loud and was reprimanding her as if she were a child. Resident #45 was asked, do you think this was appropriate for a staff member to do? Resident #45 stated, no it was not appropriate I remember it happened I just can't remember all the exact words that were said. On 10/23/24 at 10:49 AM, an interview was held with Social Services #30 and Activities Coordinator #70. Both staff members were asked about the statements by witnesses and the interview which was held with Resident #15. Social Services #30 stated, Because, of . we went through all of the statements. I was ready to substantiate initially. We also got statements that (Name of Resident #15) says I am going to get her fired. The Social Services #30 was asked, was the resident not believed because of documented behaviors and angry statements the resident made? Social Services #30 stated, the staff was suspended. On 10/23/24 at 10:53 AM, the facility Administrator walked into the conference room. The Administrator was told of the previous conversation with Social Services #30 and Activities Coordinator #70. On 10/23/24 at 10:57 AM, the Administrator stated, The statements were reflective of what the resident stated, not what actually happened. I did feel she (LPN #73) was aggressive toward the resident. But based on the statements, I am not sure what happened. I feel the staff pushed the situation by being to loud. She (LPN #73 ) could not tell me exactly what was said but that she was loud. On 10/23/24 at 10:58 AM, the Administrator stated, I was out at a conference at this event, I was handling things over the phone. On 10/23/24 at 10:59 AM, Social Services #30 stated, This was a really tough one we went back and forth with this one. On 10/23/24 at 11:00 AM, the Administrator stated, I felt as if her escalating the situation required action . I feel that the resident saying she called her fat and the accusation that we could not substantiate. We feel like it is our job to protect residents, APS (Adult Protective Services) told us they were not interested in investigating, this is what helped lead us to our decision. The Administrator was asked, what would have convinced you this allegation of verbal abuse occurred? The Administrator stated, Another witness to collaborate what was said. NA #42 did not collaborate what she said, because she walked away .the resident is known to tell falsehoods and she had threatened to get the LPN fired. At this time, the written statement by NA #42 was reviewed with the Administrator. The Administrator stated, I do not recall her specific statement, but I do agree with you .the LPN was immediately suspended and upon return to work she was given a Last Chance Agreement. The Last Chance Agreement dated 09/20/24 stated, .It has been brought to the facility's attention that (Name of LPN #73) has previously engaged in inappropriate behavior by escalating situations with aggressive or difficult residents. Despite previous education and guidance on managing such situations with tact and professionalism, the issue persists. Effective immediately, this is the final written warning regarding her conduct. Any future incidents where (Name of LPN #73) raises her voice aggressively or acts in a manner that escalates conflict with residents will result in immediate termination of employment . The Administrator was asked, why was LPN #73 given this Last Chance Agreement? Did you feel the alleged verbal abuse occurred? The Administrator stated, I know she was loud .but I could not verify what actually took place. On 10/23/24 at 11:03 AM, Social Services #30 stated, I have talked to her (Resident #15) many times about the situation. But I do not have notes about this particular situation. I am not sure If I have formally talked to them (Resident #15 and Resident #45) about the situation. On 10/23/24 at 11:20 AM, the Administrator was asked, do you realize the resident remains upset regarding this allegation of verbal abuse .the resident continues to be visibly upset, such as crying and wringing her hands. The Administrator stated, She has been referred to our psych doctor. She comes once a week on Tuesdays. I will see if she has seen her. On 10/23/24 at approximately 12:15 PM, the Administrator was asked, why didn't LPN #73 follow the care plan intervention under the focus area of behavioral symptoms .which is when resident becomes physically abusive, STOP and try task later. Do not force task and Maintain a calm environment and approach to the resident. (Typed as written.) The Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior. b) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses included Hallucinations, Vascular Dementia with other behavioral disturbance, Alzheimer's disease, Major depressive disorder recurrent, Delusional disorders, and Anxiety. In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing not read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA/Daughter notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 am medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase Zyprexa to 5 mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to (name of local hospital) for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN R. [NAME] notified Dr. of continued behaviors and an order was obtained for resident to be transported to (name of local hospital) ER for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at (name of local hospital) facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. (Name of local ambulance service) called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in (name of local hospital) ER. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for psych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back and they were pulling out of the facility at 6:23 AM. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psych Eval was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 PM and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to (name of local hospital) ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5 mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Chief Executive Officer (CEO) or designee and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 PM, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurrence on 11/08/23 had not been reported or investigated. 50552

Based on record review and staff interview, the facility failed to provide treatment and care in accordance with professional standards of practice. Resident #23 refuses all AM and PM medications and has had no physician intervention since 05/24. In addition the facility failed to offer hospice to Resident #158. This failed practice was found true for (2) two of 18 sample residents reviewed during the long term care survey process. Resident identifier: #23 and #158. Facility Census 58. Finding Included: a) Resident #23 A record review on 10/21/24 at 2:06 PM, revealed Resident #23 had multiple notes from 05/24 to present of refusing AM and PM medications. The notes also revealed Resident #23 was educated on the risk of refusing the medications; however Resident #23's Brief Interview for Mental Status (BIMS) score is 99. Further record review revealed Resident #23 was ordered the following medications: Famotidine 20 Milligrams (mg) one time a day at 9:00 AM. Levothyroxine 112 mcg one time a day at 9:00 AM. Lipitor 10 mg one time a day at 9:00 PM. Metoprolol tartrate 25 mg every 12 hours at 9:00 AM and 9:00 PM. A review of Resident #23's care plan on 10/22/24 at 3:15 PM, revealed the following care plan for refusal of medications: Focus: Wanders in/out of other residents rooms at times. Says Oh Lord frequently. Occasionally will take others' belongings. Also frequently refuses medications and is verbally and physically abusive with care. The only intervention related to refusing medications reads as follows: Encourage to take medications. Explain importance of taking medications. May mask taste in ice cream or applesauce or food/drink if necessary. Implemented on 07/10/2024. An interview on 10/22/24 at 2:45 PM, Licensed Practical Nurse (LPN) #58 stated, I crush her meds in applesauce. She just refuses them. A record review on 10/22/24 at 3:00 PM revealed Resident #23's blood pressure had been high 44 times since 06/01/24. No physician intervention was noted. Further record review revealed the only physician note addressing the refusal of medications is from 05/20/24 reads as follows: (Doctor named) notified of resident refusing medications. He stated to continue to attempt to give medications and to document when resident refuses them. Risk and benefits explained to the resident of the medications and importance of taking them. POA also notified of resident refusing medications. Further record review of Resident #23's Medication Administration Records (MAR) from 06/2024 to present revealed Resident #23 had refused her medications everyday. During an interview on 10/22/24 at 3:56 PM, the Assistant Director of Nursing (ADON) agreed there are no notes in the chart to say what we are doing about resident refusing meds for a long period of time. She then stated, Let me see if I can find anything else. No further evidence was provided by the end of the survey. b) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses included Hallucinations, Vascular Dementia with other behavioral disturbance, Alzheimer's disease, Major depressive disorder recurrent, Delusional disorders, and Anxiety. In addition to the following documentation: 12/18/2023 4:20 PM New order received from Dr. for Roxanol 0.25 mg sublingual Chirrs for pain, medication is currently on order from pharmacy, resident previously taking Tramadol 50 mg BID for pain this does not appear to be controlling residents pain as exhibited by resident hollering out more frequently as well as moaning/facial grimacing when being transferred or repositioned in bed. MPOA made aware and is in agreement with this change in patients plan of care. Tramadol to be discontinued once Roxanol is received from pharmacy. 12/19/2023 4:25 PM Resident continues on Cephalexin for UTI. Resident tolerates the medication without difficulty. no adverse reaction noted at this time. fluids are frequently offered and encouraged. Resident has had no c/o pain or discomfort from recent fall. Resident is currently resting in bed. call light and fluids are within reach. Nursing 12/20/2023 1:55 AM Resident continues on Cephalexin for UTI. No adverse reactions noted this shift. Resident has been yelling out this shift. Has been receiving Roxanol as scheduled is somewhat effective. Spit out most of hs medication. 12/20/2023 7:59 AM Spoke with Dr about increasing Roxanol from Q4 to Q2, Dr . agreed POA notified 12/21/2023 9:16 AM Res. unable to take her medications. Dr. notified. New order to d/c meds except for Ativan and Roxanol. 12/21/2023 12:17 PM Resident moaning out and restless in bed, family at bedside and spoke with LPN (LPN name) about resident being uncomfortable . Last administration of Morphine Concentrate 0.25 ml less than an hour. Dr. notified and new order to increase dose to 0.5 ml. Family aware of change. 12/22/2023 8:21 PM Resident continues on Roxanol every 2 hours. Resident noted to be restless and sitting up in her bed this morning during 8 am dose. PT/TO in the resident's room with the recording nurse when resident stated she wanted to get up in wheelchair. Prior to getting up in wheelchair resident drank one cup of coffee, one cup of water, and ate a container to applesauce without difficulty. PT/TO assisted the resident up to wheelchair. Resident helped by standing when transferring to wheelchair. Resident self-propelling some while up in wheelchair. Resident place backed to bed after a few hours. Resident rested well after being up. Roxanol seems to be controlling the resident's pain and discomfort. Resident currently resting in bed with family at bedside. 12/22/2023 10:45 PM Resident continues on Roxanol every 2 hours. Resident noted to be restless but calmed after a position change in bed. Roxanol seems to be controlling the resident's pain and discomfort. Resident currently resting in bed with family members at bedside. 12/23/2023 10:38 PM Roxanol 0.5mls continues as ordered q 2 hrs. Resident seems comfortable. Family was at bedside earlier. 12/25/2023 5:02 PM Called to room by family, resident noted to be absent of vital signs, auscultation revealed no breath sounds or heart sounds, Dr. notified, time of death 1658, family remains at bedside. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed which revealed the following care plan: PROBLEM: Code status GOAL: Residents wishes will be followed during stay. INTERVENTIONS: Allergies: ASA, PCN, Sulfa, Cipro, Ciprodex Does not have decision making capacity Limited Additional interventions IVF for defined trail period of 10 days. No tube feeding. No further documentation of a care plan addressing end of life care was identified. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At time, the DON acknowledged: 1. The facility has no policy and procedure related to the provision of Hospice services. 2. While the facility does have a contract with a local hospice provider, the facility failed to inform Resident #158 of this service. 3. Resident #158 was not offered hospice services. 4. No further documentation of end of life care was provided. 50552

Based on observations and resident council interviews, the facility failed to uphold residents' rights to voice grievances freely, without fear of reprisal, as required by CMS standards. This deficiency poses a potential risk to more than a limited number of who currently reside in the facility by creating an environment where individuals may hesitate to utilize the grievance process. Faiclity Census: 58. Findings Included: a) Resident Council Meeting On 10/22/24 at 2:04 PM, a special resident council meeting was held in the facility's main dining room, attended by the activities coordinator (permitted by the residents) and this surveyor. The meeting followed a standard agenda to review ongoing and new matters. During the meeting, the surveyor asked residents if they understood how to file an official grievance. After a brief pause, only Resident #7, identified as the council president, responded, indicating the location of the grievance folder. Other residents were silent, with several displaying hesitant or reserved body language. The surveyor then posed a follow-up question about whether residents feared reprisal for filing grievances. In response, multiple residents were observed exhibiting signs of apprehension, including crossing arms, nodding affirmatively, or verbally confirming a fear of staff retaliation. This observed reluctance and collective unease suggest that residents may not feel safe or supported in expressing concerns, potentially undermining the efficacy of the facility's grievance process. The residents' visible discomfort and hesitation to voice concerns indicate a potential systemic failure by the facility to maintain an open, supportive environment for grievance reporting, as mandated by CMS guidelines. This omission directly impacts the facility's responsibility to foster a transparent culture for resident feedback, increasing the risk that resident needs or grievances may go unaddressed, thereby compromising overall resident well-being.

Based on record review and staff interview, the facility failed to develop the care plan which includes all diagnoses for Resident #54, Resident #15 and Resident #16; and implement the care plan for Resident #15 and Resident #29. This was true for four (4) of 18 residents reviewed during the survey process. Resident Identifiers: #54, #15, #16 and #29. Facility Census: 58. Findings Included: a) Resident #54 On 10/22/24 at 1:00 PM, the care plan was reviewed for Resident #54. The care plan did not include the following diagnoses: --Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. --Pain, unspecified --Shortness of Breath --Hyperlipidemia, unspecified --Hypomagnesemia --Hypokalemia --Other peripheral vertigo, unspecified ear --Hypertensive heart and heart failure --Chronic Kidney Disease --Unspecified Atrial Fibrillation --Gastro-esophageal reflux disease without esophagitis On 10/22/24 at 1:25 PM, Registered Nurse (RN) #66 stated, I don't use big words .it has to be simple and easy to understand .I don't always add the diagnosis usually a description. On 10/22/24 at 3:15 PM, the Administrator was notified regarding the care plan not including specific diagnoses. The Administrator stated, I understand what you are telling me. b1) Resident #15 On 10/22/24 at 1:45 PM, the care plan was reviewed for Resident #15. The care plan did not include the following diagnoses: --Constipation, unspecified --Hypothyroidism, unspecified --Chronic Obstructive Pulmonary Disease (COPD), unspecified --Hyperlipidemia --Unspecified systolic (congestive) heart failure --Obstructive sleep apnea --Methicilin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere (History of ) --Non-ST elevation (NSTEMI) myocardial infarction On 10/22/24 at 3:15 PM, the Administrator was notified regarding the care plan not including specific diagnoses. The Administrator stated, I understand what you are telling me. b2) Resident #15 On 10/22/24 at 1:45 PM, the care plan was reviewed for Resident #15. One (1) of the care plan interventions under the focus area of behavioral symptoms was not followed. A documented event happened between 09/13/24-09/15/24 which was reported to all State agencies on 09/16/24. Resident #15 became upset verbally and physically. Licensed Practical Nurse (LPN) #73 did not follow the interventions of maintain a calm environment and approach to the resident and when the resident becomes physically abusive, STOP and try task later. Do not force to do task. On 10/23/24 at 1:15 PM, the Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior. c) Resident #16 On 10/22/24 at 2:00 PM, the care plan was reviewed for Resident #16. The care plan did not include the following diagnoses: --Unspecified systolic (congestive) heart failure --Iron deficiency anemia secondary to blood loss (chronic) --Chronic atrial fibrillation, unspecified --Arteriosclerotic heart disease of native coronary artery without angina pectoris --Peripheral vascular disease, unspecified --Chronic Obstructive Pulmonary Disease, unspecified --Hyperlipidemia, unspecified --Hypothyroidism, unspecified --Pain, unspecified --Gastro-esophageal reflux disease without esophagitis --Hypokalemia --Solitary pulmonary nodule --Constipation, unspecified --Methicillin resistant Staphylococcus aureus infection, unspecified site (History of) --Non-ST elevation (NSTEMI) myocardial infarction (History of) On 10/22/24 at 3:15 PM, the Administrator was notified regarding the care plan not including specific diagnoses. The Administrator stated, I understand what you are telling me. d) Resident #29 During the initial observation on 10/21/24 at 12:29 PM, there was found to be a white board in Resident #29's room. Written on the white board was Moon boots on at all times Further observation of Resident #29 lying in bed revealed she did not have her moon boots on. A record review on 10/21/24 at 1:30 PM, revealed a care plan for Resident #29 that read as follows: Focus: At risk for pressure ulcers related to requiring assistance with bed mobility and incontinence of bladder and bowel. [NAME] score shows risk for skin breakdown. History of an unstageable pressure ulcer on right heel. Intervention: Moon boots to be worn at all times. Remove for bathing. An observation of 10/21/24 at 1:55 PM, showed Resident #29 up to a Geri chair, being assisted with lunch. Resident #29 was not wearing moon boots. During an interview on 10/21/24 at 1:57 PM, Nurse Aide (NA) #24 stated, Yes she should have them on. I don't even know where they are. Let me look in her closet. 49465

Based on record review, staff interview and resident interview, the facility failed to provide sufficient protection to prevent resident to resident abuse. Resident #32, #50 and #10 all suffered actual harm because of Resident #6's physically abusive behavior. Resident #32 suffered actual harm when Resident #6 threw a glass of water at her because she wandered into his room. This caused Resident #32 to suffer a puncture wound to the top her head which was bleeding. She also had red marks on her back and side. Resident #50 suffered actual harm after Resident #6 hit her and ran over her foot. She had broken skin to the top of her foot. Resident #50 was immediately limping after the incident. Resident #10 suffered no physical harm because of the abuse she was however physically abused by Resident #6 who hit her with a water pitcher and then voiced satisfaction about hitting her. Resident #6 was able to recall the incidents mentioned above to the surveyor and provided names of the residents he did not like. Resident #6 indicated he does not like the other residents wandering into his personal space. He voiced to the surveyor the wandering of other residents makes him very angry. This was true for three (3) residents who were identified as the victims of Resident #6 during a complaint survey. Three (3) residents including Resident #6 were reviewed for behavioral problems during a complaint survey. Resident identifiers: #32, #50, #10 and #6. Facility census: 58. Findings included: a) Resident #32 A review of Resident #32's medical record found the following progress note: 05/23/23 at 12:48 AM, Resident was wheeling around in her wheelchair and went into (room number of Resident #6) we all heard someone yelling and LPN (Name of LPN #21) went running to that room along with several aides to find this resident from (Resident #6 & #39's room number) threw a glass of water on this resident, after getting her out of the room we checked her over and she has puncture wound in the top of her head that was bleeding, and red marks on her back and side, resident appears to be doing ok, she was given Tylenol was just recently put in bed where she is now resting, call lights and fluids all within reach. A review of Resident #6's medical record found the following progress notes related to this incident: 05/22/23 at 10:17 PM, written by LPN #21, &;This nurse heard yelling in (name of resident''s) room, when I went in room, a female confused residents arm was out of her shirt, the shirt was wet, I asked (name of resident) what happened, he said, She hit me. 05/22/23 at 11:18 PM, written by LPN #18, When this nurse went into room to see why he threw water all over resident from (room number of resident) which my conversation was witnessed by (name of nurse aide #19), he said she keeps coming in my fucking room and bothering me, I said you can't continue to throw water on people and hit other resident with stuff, he had his remote in his hand to the TV, and said keep her out of my fucking room, I said (name of resident) was not going to hurt you if you would have hit your light someone would have gotten her out, he said fuck you to this nurse and threw the remote across the room and hit the wall, he then started to call this nurse a fat fucking whore, numerous times, along with other vulgar things, I walked out of the room and he continued to yell things, when the paramedics came to get him after doing what he did to the EMT (name of ambulance attendant) pushing the table onto her saying I am not going any fucking where, also calling her a fucking fat whore on his way out of the building he started yelling to this nurse I hope you die and I hope you guts fall out, holding up his arms and yelling 'later bitches.' He made the comment that he had stories to tell at the hospital of all the crack head nurses that work here. 05/23/23 at 6:35 PM When this nurse and other nurse staff were completing readmission skin check on resident other nurse staff (name of the other staff member LPN #20) explained to resident new care plan orders. During this resident said, You bitches just wait- every channel will be here for all you bitches! I will kill all you bitches! Resident then threw entire dinner tray and drink at this nurse. Resident continuously Said, fuck you bitches, I don't give a fuck. (Name of staff member-LPN #20) gave resident his call light and resident said fuck it too and threw call light off the side of the bed. Resident still in room yelling profanity and threats to staff and other residents. Safety precautions in place. b) Resident #10 A review of Resident #6's medical record found the following notes pertaining to an incident involving Resident #10: 05/07/23 at 02:18 AM, Resident got agitated due to resident (room number) walking past his room in the hallway. Resident turned TV to maximum volume. Resident got extremely agitated when staff asked him to turn his TV down so surrounding residents could sleep. Called CNA a fat a** wh*re and also stated Your wife is a wh*re too! When attempting to redirect this resident he threw his TV remote against the wall. 05/05/23 at 11:00 PM, [Recorded as Late Entry on 05/06/2023 02:22 AM]: Resident had TV volume set to max volume. Multiple residents in surrounding rooms complaining of noise. Resident (room number) stating he wanted to call the police; over the noise. When this resident was asked to turn down the volume he became very agitated and started yelling and cursing at staff. Resident started making very disturbing and derogatory statements and threats toward resident (room number of the other resident) who was nowhere near the room at this time. Multiple unsuccessful attempts to redirect resident were made. Resident is resting in bed at this time with call light in reach. 04/10/23 at 2:25 AM Resident threw a water pitcher at resident in (room number of Resident #10.) States I got her that time to (Name of nursing aide #22.) This LPN ( #23) spoke to Resident about incident states I don't want the bitch in here. c) Resident #50 A review of Resident #50's medical record found the following progress note related to an incident with Resident #6: Resident was ambulating in the hallway and touched the back of male Resident #39's wheelchair. Male resident then hit this resident with his fist and hit her with his wheelchair twice, running over her right foot in the process. Resident observed to have broken skin and redness to top outer side of right foot. No swelling noted at this time, however resident was limping immediately following injury. Resident is currently ambulating in hallway without difficulty at this time, no limping observed. Physician and (Name of power of attorney) POA, notified. Will continue to monitor. A review of Resident #6's medical record found the following related to the incident with Resident #50: 01/15/23 at 4:18 PM, Resident was propelling himself in the service hallway near the kitchen and laundry when resident (room number) touched the back of his wheelchair. (Name of Resident #6) then hit (room number of other Resident #50) on the right side of her body with his left fist proceeded to chase after her trying to knock her down twice. He ran over her right foot causing injury while doing this. He continued to follow her as she was trying to get away from him. This event was witnessed by (Name of nurse aide) Incident was reviewed on camera. This event happened at 3:44 PM. On call APS (adult protective service worker) called to send message to (Name of APS worker) social worker about resident's transfer to (name of hospital) for incident. Doctor provided orders to send to (name of hospital) for psychiatric evaluation. Wound vac disconnected and threatening to pull his g-tube out. 01/15/23 at 4:40 PM, "This recording nurse along with (name of another nurse LPN #20) witnessed the resident stating that he was going to cause more harm to resident (room number of Resident #50.) He stated. I am going to kill that whore, I hope that she goes to straight to hell. Resident also stated, I am going to rip my feeding tube and catheter out. Staff attempted to redirect but was unsuccessful. Resident has not caused any self-harm at this time. Resident is being closely monitored for safety. c) Resident #6 Record review found the [AGE] year-old Resident was admitted to the facility on [DATE]. Current diagnoses included: Bipolar Disorder, Anxiety disorder due toknown physiological condition, Intellectual Disabilities, and Paraplegia. Further review of the medical record found a progress annual note, dated 04/14/23. The resident had a BIMS (Brief Interview for Mental Status) score of 12. A score of 12 indicated the resident's cognition is moderately impaired. The Resident had a Health Care Surrogate appointed to make medical decisions as he has been determined to lack capacity to make his own medical decisions. An interview with the Social Worker (SW) #23 on 05/30/23 at 11:42 AM, revealed the following information when asked what the facility was doing to address Resident #6's physically abusive behaviors toward other residents: We are trying to get the Psychiatric facility to admit him. On 05/23/23 we sent him to 2 different Psychiatric hospitals, both of them did not admit him. We called his psychiatrist and he said he would get him a bed at the one facility. So far, they said they have no empty beds. I just called again on 05/26/23 and was told, still no beds. I have called other nursing homes and they don't want him either. As soon as you send his notes over they say they have no beds. She said she had just received some information about homes in the state that accept residents with developmental delays and she was going to call some of them. The social worker did not indicate the facility was doing any interventions while waiting on a bed to open up which would keep Resident #6 from physically abusing other residents. An interview with the administrator on the morning of 05/30/23 found she repeated the information provided by the social worker adding we are trying to find placement somewhere else but no one will take him. We just can't dump him somewhere. I have told the psychiatric hospital we will take him back if they would just admit him and try to get his behaviors under control. The administrator said the Resident was sent to the Psychiatric hospital when the 01/15/23 incident occurred but they refused to admit him at that time. The Administrator named no interventions which were in place to prevent Resident #6 from abusing other residents while waiting for placement at another facility. Resident #6 was interviewed in his room at 12:45 PM on 5/30/23. He provided the following information: I'm trying to be good. I haven't done anything for 3 days. I hatepeople wandering into my room. (Name of Resident #50) is the worst. When people get in my room I just go off. When I go off it's bad. I can't control myself. Now that my door is closed it isn't so bad. I have nothing to do here. I don't want to go to that hospital in (Name of town.) I don't like it and I don't like the one in (Name of another town.) I like my roommate and I like other Residents here. Like the old lady across the hallway. She is a sweetheart, I talk to her every day, she comes over to visit The Resident was able to provide the names of the Residents he did not like and had altercations with. He stated he did not like these residents because they get in his space and when that happens, he gets angry and wants to hurt them. He verbalized the Residents were confused and did not know any better, but he says staff need to keep these Residents away from him and then he wouldn't do the things he does. The Resident said he was paralyzed from the waist down because a woman pushed him off a cliff about 2 years ago when he lived in the community. He said his parents were dead, and his sister could not take care of him. When asked about the staff, the Resident named three (3) staff members he doesn't like but when asked why, he could not provide specifics. The Resident said several staff members are my friends. He said he wished he could get his own apartment and just get out of here. Resident #6 said the higher ups have taken his cell phone and television remote control and that's all I have to do. When asked why, the Resident said, Because I threw them. I broke my television, but I have a new one now but I can't watch it because I don't know where the remote control is. The resident said he rarely attends activities at the facility. The activities are more for the older people and not things he wants to do. When asked what he likes to do, he said watch TV, talk on my cell phone and I would like to play games like on an X-Box. Review of the current care plan found the following problem, start date 04/7/22, edited on 05/23/23: Resident has behavioral symptoms toward others (e.g., throwing things at others, cursing at staff and other residents). Also refuses various care (feeding, turning and repositioning, appts., care at times). Has made statements of going to kill himself, was sent for eval and treatment, tells psych that he did not say that and tells staff that he did not mean it. Has been known to make sexually inappropriate comments. The goal associated with the problem, edited: 05/01/23: Resident will not harm self or others secondary to physically abusive behavior. Approaches included: Is not to have anything within reach that can be used as a weapon. Have call light within reach so that he can call for assistance when he needs something. May not have tv remote or cell phone within reach (these items must be used with supervision and then taken back from him when he is done). Also may not have a soda can. Drink must be poured into a plastic cup. Keep curtain pulled in the center of the room between the two residents, created on 05/23/23. Verbally redirect from sexually inappropriate comments. Alert staff if resident acts out in any way sexually, created on 11/10/22. Educate resident that if an unwanted wandering visitor enters room, to use call light so staff can remove the res. from that room. Also, if staff see that another res. enters room, they can remove the wandering resident. Place stop sign across the doorway in attempts to deter other wandering residents, created on 05/23/23. Take all expressions of harming self seriously. If res. Makes these statements, send to psychiatric hospital for evaluation and treatment, created on 06/20/22. If resident has behaviors that endanger others, send out to psych hospital, created on 06/13/22. Divert resident's behavior by conversation, verbal redirection, music, tv., edited on 07/15/22. Encourage to participate in care. Remind/educate why not to refuse, created on 04/27/22. Assess whether the behavior endangers the resident and/or others. Intervene if necessary, created on 04/27/22. When resident becomes physically abusive, STOP, and try task later. Do not force to do task, created on 04/07/22. At 3:20 PM on 05/30/23, the Resident's two (2) nursing assistants (#9 and #16) were interviewed after leaving the Resident's room. Neither of the NAs knew where the remote control for the television or the cell phone was located. They said the resident used them to throw at staff and he actually broke his own television when he threw the remote control at the TV screen. Both NA's said if the Resident was angry they just stop care and come back later. They were aware the Resident did not like confused residents who go into his room and both said they try to keep these residents out of the room if they see them. After reviewing the progress notes in the electronic medical record, Social Worker (SW) #23 documented a telephone call to one (1) nursing home on [DATE] who said they had no beds. The Director of Nursing made a note on 05/24/23 documenting another nursing facility was called and they would not take the resident due to a behavior risk. The medical record indicated the facility had attempted to obtain placement at a psychiatric hospital after the 01/11/23 incident and two (2) psychiatric hospitals refused to admit the resident after the05/23/23 incident. The Resident had two (2) visits to the psychiatrist: 11/03/22 and 01/26/23. On the morning of 05/31/23 at approximately 9:30 AM, the administrator said the facility had called many different places, but she realized all the efforts to find alternative placement were not documented in the medical record. The administrator was asked about sending the resident to a psychiatric facility as a means to correct the Resident #6& #39;s behavior and protect other residents, however; this plan had not happened. She was asked, what are the other alternatives? She said, We really don't have other alternatives. The administrator said the ombudsman had been involved but the ombudsman said other residents have the right to wander about in the facility. The administrator said a private firm had been contracted to help them with behavior care plans coordinated by a psychiatrist for residents with known problems. The administrator said, They will be here next month. No other information about efforts to prevent Resident #6 from physically abusing residents was provided.

Based on record review, staff interview, and resident interview the facility failed to protect Residents from mental, physical, and sexual abuse resulting in actual harm, including physical pain, mental anguish and psychosocial harm to multiple residents, as perpetrated by Resident #49's ongoing pattern of irrational and aggressive behaviors. This was true for seven (7) of 58 residents. Two (2) residents had to be sent to the hospital for physical harm resulting from Resident #49's actions. Several residents complained of living in fear of Resident #49 which is psychosocial harm. Resident #49 was found in another residents room in their bed completely nude and touching the other resident which is a form of sexual abuse. Resident identifiers: Resident #49, Resident #31, Resident #27, Resident #52, Resident #16, Resident #20, Resident #44 and Resident # 54. Facility census: 58. Findings Included: a) Policy Review A review of the facility policy titled Resident Abuse/Neglect reads as follows: I. POLICY: .to ensure that residents are not subjected to abuse by staff, other residents, consultants, volunteers, staff or other individuals. II. PURPOSE: It is the purpose of this policy to define forms of abuse and neglect in order to facilitate education, recognition and reporting III. DEFINITIONS: Abuse- willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish . Sexual Abuse-includes, but limited to sexual harassment, sexual coercion, or sexual assault. Physical Abuse-includes hitting, slapping, pinching, kicking, pushing, pulling hair, handling rough, angry manner and other related acts against a person. Mental Abuse- includes such actions as humiliation, harassment, threats of punishment or deprivation and so on. .V. Reporting -It is the responsibility of the facility to ensure that all staff are aware of the reporting requirements and support an environment in which covered individuals report a reasonable suspicion of a crime and staff and others report all alleged violations of mistreatment, exploitation, neglect or abuse, including injuries of unknown source, and misappropriate of resident property. -If the events that caused the allegation involved abuse, neglect or result in serious bodily injury, a report is made not later two (2) hours after the center is notified of the allegation VI. Resident to Resident altercations-resident to resident altercations must be reported in accordance with regulations include any willful action that results in a physical injury, mental anguish or pain. VII. Investigation upon the report or discovery of any circumstance noted above the facility, under the direction of the administrator will investigate the concern including observation, interviews, document reviews and all means to determine the events and credibility of the report. The facility will protect residents from harm during the investigation. b) Resident #49 During a record review on 12/13/22 Resident #49 medical record revealed the following progress notes: -10/18/2022 at 6:57 AM Typed as writtenResident went into room A11-2. Scratched resident in bed 11-2 on arm. Resident redirected back into own room. -10/13/22 at 2:33 PM typed as written Resident has been going in resident rooms on b hall. These residents have yelled at her to get out. Some resident's are scared of her. Resident is very difficult to redirect -10/09/22 at 3:43 PM typed as written RESIDENT WAS ROAMING FROM ROOM TO ROOM , PICKING UP PERSONAL BELONGINGS, COMBATIVE WHILE TRYING TO REDIRECT , RESIDENT WAS PUSHING ANOTHER RESIDENT IN ROOMA12/1 AND RESIDENT WAS YELLING BECAUSE SHE WAS SCARED OF HER, CNA (Name Redacted to ensure privacy) INTERVENED TRIED TO GET HER TO STOP -10/07/2022 at 12:11 AM Typed as WrittenResident has been very combative and noncompliant this shift. Has been wandering in and out of numerous residents rooms and taking their belongings- in doing so, multiple residents have become upset and making complaints. Resident becomes combative and yells at staff when redirection is attempted. Resident attempted to pull resident from A17-1 out of bed- resident A17-1 began hollering for help. When this nurse attempted to intervene, resident (Last name of Resident #49) hit nurse in face with a stolen shoe. At another time, resident was trying to push resident B19-1 in her WC, resident was trying to get away but could not. Resident B19-1 then stood up from WC to get away, lost balance, and hit her head against the wall- nurses sent resident B19-1 to local ER for evaluation. (Resident #49's name) was attempting to get resident B19-1 up from ground when she fell - resident B19-1 began yelling for help and yelling at resident (Name of Resident #49) to go away. Event caught on camera. -09/16/22 at 6:20 PM typed as written resident took coke from another resident and threw it on the other resident resident was not easy to redirect was hitting cna. -08/16/2022 at 6:30 PM typed as written Resident took the drink cart at suppertime from the end of the B hall at supper time. Resident was pushing it towards the back of a resident sitting in the hallway. Recording nurse attempted to redirect the resident who had a hard grip on the cart. Let go of the cart and walked by recording nurse then turned around and beat recording nurse on the back several times open palmed. -08/16/22 at 11:57 PM typed as written Resident had found a dirty brief out of a trash bag and was rubbing it on A15-2. Resident gave dirty brief with encouragement began pushing recording nurse who had the trash bag into the soiled room. Resident was taking the thermometer off of the vital machine. Took hand sanitizer off of the med cart. -07/01/22 at 3:30 AM typed as written Resident smacked resident A12-2 in face. This occurred because, Resident A12-2 didn't want to be pushed in wheel chair and told this resident to stop. Redirected resident. -05/23/22 at 6:49 PM typed as written Resident hit resident A17-2 in the face during activities this evening. Resident was trying to take A17-2 resident's walker and bag. Staff separated the residents. Resident was redirected by staff. resident is currently up walking facility. safety precautions are in place. will continue to monitor. -05/16/22 at 11:38 PM typed as written This nurse and CNA responded to yelling from (resident #35's name). Upon entry we see (resident #49's name) ripping blankets off the bed and throwing items from the bedside tables. (Resident # 49's name) was hitting and kicking staff. We escorted (Resident #49's name) out of the room. In the hallway resident lifted her feet and this nurse and CNA had to sit resident into the floor. Resident then began to crawl around whispering to the floor. Currently up roaming the facility. Will continue to monitor behaviors. -04/27/22 at 6:22 PM typed as written Resident hit resident room A12-1 upside the head for being in her way. Staff quickly redirected residents. Will continue to monitor. -04/15/22 at 9:45 PM typed as written Resident was found in room A1 above resident in bed B ( a Male Resident) of that room completely nude, touching and grabbing on resident. When CNA tried to redirect resident out of room and get resident dressed resident became combative with staff. Staff finally got resident dressed and assisted her out of the room. Resident then wandered around facility going in and out of other residents room. Redirection was used as needed. Will continue to monitor and inform on coming nurse of this situation. During an interview on 12/14/22 at 11:14 AM the Social Worker stated these incidents are not abuse, she does not have capacity and does not know what she is doing. During an interview on 12/14/22 at 11:15 AM, the Director of Nursing (DON) stated, I knew some of this was going on. The DON then asked the surveyor for advice on what to do with Resident #49. During an interview on 12/14/22 at 11:16 AM, the Administrator stated the resident is demented and combative. It's not abuse because she is demented. What else do you want us to do, we have tried everything. We have sent her for psychiatric evaluation and has appointment this month. Done 1:1 with her. While leaving the room the Administrator stated It's worth the dumping tag just to get rid of her. An additional review of Resident #49's medical record on 12/13/22 found the following psychiatric consults for Resident #49: -On 04/25/22 the consult had the following medications suggestions ~lower Citalopram 10mg daily ~increase Klonopin 0. 5mg three times a day (TID) ~increase Seroquel 50mg TID ~Add Aircept 5mg daily ~Add Depakote 250 mg twice a day (BID) A review of Resident #49's physician orders revealed no order for the Aircept, no increase of klonopin, and no decrease of citalopram as recommended by the psychiatrist. The administrator also stated, We have tried 1:1 but it didn't work. However the facility was unable to show any evidence to prove they did 1:1 observations with Resident #49. An interview on 12/14/22 at 12:36 PM, with the consulting Pharmacist, found he is in the facility monthly. I send my recommendations within a week or two. I meet with the Administrator, Director of Nursing and we review anyone that has behaviors. Resident #49's name has not came up in the last month. I look at the Psychiatrist consult if they are scanned into the chart. I look at Psychiatrist recommendations and talk to our facility physician about the recommendation and see why he think its not needed. The doctor does not want the residents on Aircept due to side effects like weight loss. c) Resident #31 During a review on 12/13/22 at 4:20 PM, Resident #31's medical records revealed a fall on 10/06/22. The event report on 10/06/22 at 8:40 PM type as written read: At approximately 8:5mg, resident let out a shout and began hollering for help. (Name of Nurse Aide) informed this nurse that resident was in the floor on A hall. Resident was found laying on left side and holding her head on the left side. Red knot noted to top of residents head on left side. Pupils round and reactive. Alert with confusion per baseline. ROM (range of motion) x (times) 4 WNL (within normal limits), but has been holding left hip and c/o (complaints of) pain to area. Resident assisted to WC (Wheelchair). Cameras replayed, resident got up from WC attempting to get away from resident in room A7-2 and lost balance, hitting left side of head directly against wall. Resident then landed on left side of body. Ice pack applied to bump on head x20 mins. Dr notified. Orders to send to (Name of local hospital) for evaluation. POA (Power of Attorney) notified. A review of the local hospital discharge summary on 10/06/22 revealed Resident #31 had a closed head injury and contusion of the scalp. d) Resident #27 During a review on 12/13/22 Resident #27's medical record revealed a fall on 09/18/22 at 9:14 PM. The event report on 09/18/22 typed as written read as follows: (Name of Nurse Aide (NA)) reported that (Name of Resident #27) was in the floor of another resident's room, she stated that she was in a room across the hall and observed resident lying on her back in the floor. Upon entering the room resident was observed still lying on her back on the floor. Resident reports that she hit her head and c/o pain in the back of her head, no bumps or knots noted at this time. Resident initially c/o back pain as well but then denied back pain prior to going to the ER (emergency room ) for evaluation. Resident VS(vital Signs) - BP (blood pressure): 138/78, R (respirations): 18, O2 (Oxygen): 97% on RA (Room Air), T(temperature): 97.3. (Name of Resident #27) reports that another resident had come into her room and took her belongings, she then followed her into another resident's room where (Name of Resident #27) states the (Resident #49) threw me in the floor;. Resident transferred to (Name of Local Hospital) for evaluation d/t (due to)hitting her head and c/o pain. No visible signs of injury observed at this time Dr.(doctor) and representative notified. A review of the local hospital discharge summary on 09/18/22 revealed an acute cervical myofascial strain, acute thoracic myofascial strain and acute lumbar myofascial strain. The CT (Computerized Tomography Scan) of the head, neck, thoracic spine and lumbar spine and bony pelvis did not show any acute fractures or dislocations. e) Resident Council Meeting and Interviews During the Resident Council meeting held 12/13/22 at 10:10 AM the group as a whole was asked the following question: Do you have anyone wandering in your rooms? Their responses included: -We have a few that wander into our room and run the hall ways all hours of the night. -We have one that steals your stuff (Resident #49's name). -(Resident #49's name) will get in bed with you , pull all the covers off your bed in the middle of the night while you are trying to sleep. - (Resident #49's name) I am afraid of her, she will hit people and slap them. -I am afraid of being hit by (Resident #49's Name). -I have never been hit or slapped by (Resident #49's Name), but I'm very afraid. I just try to stay my distance. - I am so scared of her, she has grabbed my arm. During an interview on 12/14/22 at 10:50 AM, Resident #54 stated, (Name of Resident #49) came into the room and took my roommates tissues and she chased after her. Then she was pushed by (Name of Resident #49). She hit her head and had to go to the hospital. I am afraid she will hit me, she comes into our room all the time. You just have to keep your distance to feel safe. During an interview on 12/14/22 at 10:55 AM, Resident #52 stated I am afraid of (Name of Resident #49) hitting me. During an interview on 12/14/22 at 10:56, AM, Resident #16 stated (Name of Resident #49) has grabbed me before, I am afraid of her. During an interview on 12/14/22 at 10:57 AM, Resident #20 stated (Name of Resident #49) will grab people, I am afraid she is going to hurt someone. During an interview on 12/14/22 at 10:58 AM, Resident #44 stated I am not afraid of (Name of Resident #49), if she ever hits me then I hit her back. I don't think she should be there, people don't feel safe. f) Resident #50 Review of Resident #50's medical records where Resident #49, went into his room causing behavioral issues: -- 05/14/2022 at 09:50 PM- Resident upset about(Name of Resident #49) coming into his room and waking him up and messing with his things. The resident stated, My cousin hid a gun in here and next time (Name of Resident #49) comes in here I am going to shoot her in the head. I also have some buddies coming to see me and they will kill her. -- 05/15/2022 at 12:20 AM: which read as follows: -Resident rang call light at approximately 12:00 am. Resident stated I need to talk to my nurse I've been having chest pains since about 7:30.The nurse entered the residents room he said You better call an ambulance my chest is hurting really bad and grabbed his left side I then asked how long his chest had been hurting he stated since about 7:30 this evening I then asked resident why he didn't tell me sooner he stated I was just too worked up about that bitch (Name of Resident #49) , coming into my room and forgot to say anything. Nurse let resident know that we would have to send him to the nearest hospital (across the street), we would call his aunt and I had to give him aspirin he agreed to this. We left the room to start the send out process. When I entered the room again taking to take the aspirin back to resident he stated I do not want to go anymore I called and talked to my aunt, and I feel better. She prayed for me.

Based on observations and staff interviews, it was determined the facility had not ensured each resident received care and services to assist the resident in attaining or maintaining the highest practicable level of well-being. A resident was given medications and fluids without having the head of her bed elevated sufficiently, there was no evidence a resident's family had been informed of the risks and benefits of refusing a therapeutic diet, and a resident was given beverages with straws although the physician had written an order for [REDACTED].#4, and #29. Facility census: 54. Findings include: a) Resident #47 On 09/14/10, at approximately 10:10 a.m., the nurse (Employee #12) prepared the resident's medications and went into the room to administer them. The resident's head and torso were only elevated to approximately 30 degrees while she took her medications and drank the [MEDICATION NAME] in water. On 09/14/10, at approximately 10:40 a.m., a nursing assistant (Employee #31) gave the resident a beverage to consume. The head of the resident's bed was still at approximately 30 degrees. b) Resident #4 Review of the resident's medical record found form entitled "Release and / or Refusal of Treatment" that had been signed on 08/06/10 at 1:15 p.m., by the resident's medical power of attorney (MPOA). "Refusing mech(ical) soft NCS diet (res wants reg.diet) allowed sweets also. (NCS stands for no concentrated sweets.) Review of the nursing entries, admission nursing assessment, social services notes, physician progress notes [REDACTED]. The resident's admission [DIAGNOSES REDACTED]. Review of her daily blood sugars revealed these had been gradually going up - in August, she had blood sugars in the 100+ range; in September - the first week's readings were all in the 200+ range, and from 09/09/10 through 09/16/10 - all readings were in the 300+ range. This was discussed with the dietary manager at approximately 12:45 p.m. on 09/16/10. She said the nurse said she had explained the risks and benefits, but nothing was found in the medical record to reflect this had occurred. c) Resident #29 Review of the resident's medical record found the speech therapist had evaluated the resident and had noted the resident should not use straws. The current physician's orders [REDACTED]. In the dining room, at lunch time on 09/16/10, the resident was observed sitting at a table with two (2) containers of thickened liquid, both with straws inserted into the containers. The dietary slip that was on the resident's tray was reviewed, but there was nothing about no straws for the resident. This was discussed with dietary manager at approximately 12:45 p.m. on 09/16/10. She said a staff member had recognized the resident should not have the straws when it was noted the surveyor was looking at this resident's tray. She offered that the staff member had just come back from vacation. .

Based on record review and staff interview, the facility failed to ensure one (1) of eleven (11) sampled residents received the care and services necessary to promote regular bowel elimination and prevent a fecal impaction. Record review revealed Resident #23 received at CT scan of her abdomen and pelvis on 03/11/10, in response to complaints of stomach pain projecting to her back. According to the radiology report dated 03/11/10, the CT scan revealed a "(l)arge amount of fecal material in the rectosigmoid portion of the colon with fecal impaction." Further review of the resident's medical record found she was assessed as having hypoactive bowel sounds during her admission nursing assessment on 02/09/10, with no follow-up assessment of her bowel sounds until she complained of abdominal pain on 02/24/10, at which time her bowel sounds were normal in three (3) quadrants and hyperactive in the upper left quadrant of her abdomen. No further assessments of her bowel sounds were documented after this finding, although she continued to complain of (and was medicated for) abdominal pain. A comparison of documentation of the resident's bowel movements (BMs), recorded in the plan of care kardex (kardex) and the bowel and bladder elimination pattern evaluation (B&B evaluation form) for the period of 03/01/10 through 03/31/10, found significantly conflicting information about the frequency at which she was having BMs, calling into question the accuracy of the BM monitoring upon which the facility staff based a determination of whether to administer medications to treat constipation. Even where the two (2) separate documents concurred that no BMs had occurred for three (3) consecutive days, the facility failed to administer medications to promote bowel elimination in accordance with the physician's standing orders. Resident identifier: #23. Facility census: 49. Findings include: a) Resident #23 1. Resident #23's medical record, when reviewed on 06/14/10 at approximately 2:00 p.m. and again on 06/15/10, disclosed this [AGE] year old female was admitted to the facility from a local hospital on [DATE], with [DIAGNOSES REDACTED]. -- 2. According to the admission nursing assessment completed at 4:25 p.m. on 02/09/10, the assessor noted, on a physical assessment of the resident's abdomen, that bowel sounds were present and "hypoactive". According to Medline Plus, a service of the U.S. National Library of Medicine and the National Institutes of Health, " ...Reduced (hypoactive) bowel sounds include a reduction in the loudness, tone, or regularity of the sounds. They indicate a slowing of intestinal activity. "Hypoactive bowel sounds are normal during sleep, and also occur normally for a short time after the use of certain medications and after abdominal surgery. Decreased or absent bowel sounds often indicate constipation. ..." (Source: <http://www.nlm.nih.gov/medlineplus/ency/article/ 7.htm>) Following this finding, there was no evidence of any further assessment of the resident's bowel sounds until the resident complained of stomach pain on 02/24/10. -- 3. A nursing note completed by the director of nursing (DON) on 02/24/10 at 4:25 p.m. stated, "(Arrow pointing upward) in geri chair @ (at) bedside states 'pain in stomach goes to back.' Unable to quantify or describe specifically in response to questions. Denies burning, stabbing, knife-like twisting pain. Abd (abdomen) flat, non-distended, normoactive BS (bowel sounds) x 3 quadrants /c (with) hyperactive sounds upper left quad on auscultation. Non-tender to palpation. Denies nausea. Reviewed BM record. Appetite good. Remains calm during assessment. Instructed med (medication) nurse to administer pain med. Skin warm and dry." Review of the February 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"C/O (complaint of) constipation." The next consecutive entry in the nursing progress notes was dated 10:40 a.m. on 03/02/10, indicating the completion of a dietary consult. This entry was followed by another entry at 5:00 p.m. on 03/02/10, noting receipt of orders for [MEDICATION NAME] 20 mg every day and a consult with Physician #2 (a [MEDICATION NAME]). The next consecutive entry in the nursing progress notes, dated 03/04/10 at 8:30 a.m., noted the resident's attending physician (Physician #1) visited the resident and ordered [MEDICATION NAME] 10 mg by mouth thirty (30) to sixty (60) minutes before meals at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. Review of the physician's progress note for this visit, dated 03/04/10, found the statement, "Abd (abdominal) pain unclear etiology." Review of the March 2010 MAR found a nurse administered MOM at 5:00 p.m. on 03/04/10 for "constipation". The next consecutive entry in the nursing progress notes, dated 03/08/10 at 8:30 a.m., noted Physician #2 visited the resident and gave orders for a CT scan of her abdomen and pelvis with oral and intravenous (IV) contrast, a chest x-ray and a urinalysis with culture and sensitivity all to be scheduled for 03/11/10. The next consecutive entry in the nursing progress notes, dated 03/10/10 at 4:40 p.m., noted that staff notified the resident's legal representative of the above ordered diagnostic procedures. The next consecutive entry in the nursing progress notes, dated 03/11/10 at 9:00 a.m., noted the resident was prepped for the CT scan. The next consecutive entry in the nursing progress notes, dated 03/11/10 at 10:40 a.m., indicated the resident had returned from the CT scan and had expelled a large amount of loose stool. The results of the CT scan were noted as having been received and communicated via facsimile to both Physicians #1 and #2 at 1:00 p.m. on 03/12/10. The radiology report, dated 03/11/10, stated, "Large amount of fecal material in the rectosigmoid portion of the colon with fecal impaction." At no time after the resident complained of stomach pain on 02/24/10 was there documentation of a nursing assessment of the resident's abdomen to include an assessment of the resident's bowel sounds, prior to the discovery of the fecal impaction on 03/11/10. -- 4. According to Medline Plus, "A fecal impaction is a large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This mass may be so hard that it cannot come out of the body. Watery stool from higher in the bowel may move around the mass and leak out, causing soiling or diarrhea." (Source: <http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm>) Also according to Medline Plus, "Constipation refers to infrequent or hard stools, or difficulty passing stools. Constipation may involve pain during the passage of a bowel movement, inability to pass a bowel movement after straining or pushing for more than 10 minutes, or no bowel movements after more than 3 days. ..." (Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm) -- 5. Review of Resident #23's medical record found a sheet of physician's standing orders, which included the following: "M.O.M. (Milk of Magnesia) 30ml (sic) with Cascara 10ml (sic) every 3 days by mouth as needed for residents with c/o (complaint of) constipation." "Check for impaction two times weekly if no bowel movement is recorded for three consecutive days. Fleets enema every day if needed after resident is checked for impaction." "[MEDICATION NAME] ([MEDICATION NAME]) 10mg suppository rectally once daily for constipation." -- 6. The nursing note, dated 02/24/10 at 4:25 p.m., indicated the assessing nurse had reviewed the resident's BM record. Record review revealed the nursing assistants recorded each resident's bowel elimination action on a monthly kardex. The instructions on the kardex directed staff to record both bowel and bladder elimination in the same section of the form for each shift daily; staff was supposed to record each BM by noting the size of the BM as follows: S = Small, M = Medium, L = Large, and D = Diarrhea. A review of the resident's February 2010 kardex found the nursing assistants recorded Resident #23 as having BMs daily from 02/15/10 through 02/28/10, on some days noting that BMs occurred on more than one (1) shift. According to the documentation on this kardex, at no time during this period did the resident have three (3) consecutive days with no BM, which would have triggered the need to administer MOM in accordance with the physician's standing orders. According to this record, there was no indication for the need to administer a dose of MOM on 02/24/10. A review of the resident's March 2010 kardex found the nursing assistants recorded Resident #23 as having BMs daily from 03/01/10 through 03/11/10 (the day she was found to have a fecal impaction). Again, on some days, staff even noted the resident had BMs on more than one (1) shift. According to documentation on this kardex, at no time during this period did the resident have three (3) consecutive days with no BM, which would have triggered the need to administer MOM in accordance with the physician's standing orders. According to this record, there was no indication for the need to administer a dose of MOM on 03/04/10. -- 7. Further record review revealed a B&B evaluation form for the period of 03/01/10 through 03/31/10. On this form staff was supposed to, on an hourly basis, circle "BL" if the resident were incontinent of bladder and circle "B" if the resident were incontinent of bowel. Additionally, each time the resident voids urine or has a BM, staff was to place a check mark in the corresponding column (for "Voided" or "BM") corresponding to this time it occurred. According to this record, Resident #23 did NOT have BMs on a daily basis in the days leading up to the discovery of the fecal impaction, as had been recorded on the kardex: 03/01/10 - BM at 10:00 a.m. 03/02/10 - BM at 7:00 a.m. 03/03/10 - No BM 03/04/10 - No BM 03/05/10 - BM at 3:00 a.m. 03/06/10 - No BM 03/07/10 - No BM 03/08/10 - BM at 4:00 p.m. 03/09/10 - BM at 8:00 a.m. 03/10/10 - BMs at 7:00 a.m., 11:00 a.m., and 2:00 p.m. In view of the sharp inconsistencies between the information recorded on the kardex and the B&B evaluation form for the same time frame (03/01/10 through 03/10/10), the surveyor could not ascertain which, if either, record accurately reflected Resident #23's bowel elimination activity in the days preceding the discovery, via CT scan, of the fecal impaction on 03/11/10. -- 8. In an interview on 06/16/10 at approximately 12:00 p.m., the DON and a registered nurse (RN - Employee #9) related their belief that staff had acted appropriately and timely by getting Resident #23 an appointment with a [MEDICATION NAME] and having the physician at the facility examine her. -- 9. Following the discovery of the fecal impaction on 03/11/10, review of the resident's bowel elimination activity throughout the remainder of March 2010 (as recorded on both the March 2010 kardex and the B&B evaluation form), found periods when the resident had no BM for three (3) consecutive days when no MOM (or other intervention to promote regular bowel elimination) was administered in accordance with the physician's standing orders: According to the March 2010 kardex, the resident had no BM following the afternoon shift on 03/12/10 until the night shift on 03/15/10 with no interventions (when she was noted to have a small BM), following the night shift on 03/15/10 until the afternoon shift on 03/19/10 (when she was noted to have an "XLG" BM), following the afternoon shift on 03/20/10 until the afternoon shift on 03/23/10 (when she was noted to have a small BM), and form the afternoon of 03/25/10 through 03/31/10 (with no BM being recorded on this kardex through the end of the month). According to the March 2010 B&B evaluation form, the resident had no BM from 1:00 p.m. on 03/11/10 until 3:00 a.m. on 03/15/10, from 6:00 a.m. on 03/15/10 until 3:00 p.m. on 03/22/10, and from 2:00 p.m. on 03/27/10 through 11:59 p.m. on 03/31/10, with no interventions. -- 10. Record review found staff did not accurately and completely fill out the kardex with respect to bowel actions for the months of February, March, April, and June 2010. Staff did not consistently document the number of BMs as they occurred, nor were they consistent in documenting the size of each BM in accordance with the instructions on the form. In an interview on the afternoon of 06/15/10, the DON confirmed the nursing assistants were not completing these forms as required. -- 11. Further review of the resident's record found a progress summary note, dated 05/24/10, indicating the resident again complained of abdominal pain. Review of the June 2010 kardex found the resident had no recorded BM from the afternoon of 06/06/10 through the afternoon of 06/15/10. Review of physician's telephone orders revealed an order, dated 06/04/10, for 4 ounces of prune juice to be delivered on the resident ' s breakfast tray everyday when available from dietary. There were no other bowel stimulating interventions provide. A review of the resident's medical record did not reveal any documentation pertaining to consumption of prune juice; therefore, the nursing staff had no way of determining whether the resident consumed the prune juice. The prune juice came with other fluids at the breakfast meal, and the documentation of the resident's consumption prune juice was combined with the total amount of all fluids consumed at any given meal. .

Based on medical record review, family interview, and staff interview, the facility failed to provide care and services in accordance with the resident's expressed advance directives to maintain proper hydration and health for one (1) of eleven (11) sampled residents. Resident #43 exhibited poor oral intake of food and fluids with a significant weight loss beginning in February 2010, and signs / symptoms of dehydration beginning in April 2010. The resident's physician orders [REDACTED]. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident identifier: #43. Facility census: 49. Findings include: a) Resident #43 1. Record review revealed Resident #43 was initially admitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an assessment reference date (ARD) of 05/03/08, she weighed 159# with a height of 60 inches, was receiving a therapeutic diet and a dietary supplement with no nutritional problems noted at that time, to include no chewing or swallowing problems, and she had experienced no significant weight change. She subsequently discharged to a private home on 05/16/08. Resident #43 was readmitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an ARD of 04/13/09, she weighed 149# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. She was subsequently discharged to a private home on 07/15/09 and was readmitted on [DATE]. According to her comprehensive admission assessment with an ARD of 08/29/09, she weighed 140# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. [DIAGNOSES REDACTED]. According to an abbreviated quarterly assessment with an ARD of 11/28/09, Resident #43 weighed 131# with a height of 60 and was receiving a therapeutic diet and a dietary supplement. The assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. Further record review revealed, on 12/07/09, the registered dietitian (RD) noted on her recommendation form to the physician that the resident had poor intake by mouth and a significant weight loss. At this time, the RD recommended 2 ounces of a sugar-free nutritional supplement three (3) times a day. Documentation in the resident's clinical record reflected the RD had seen Resident #43 after 12/07/09 but made no further recommendations. According to an abbreviated quarterly assessment with an ARD of 02/21/10, she weighed 126# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. At this time, the assessor indicated there was a significant weight loss, but no chewing or swallowing problems were noted. On 03/23/10, Resident #43 was started on nectar thickened liquids. On 04/04/10, a nurse documented that a nursing assistant reported Resident #43 was coughing and was observed drinking regular (not thickened) water from a sink. On 04/05/10, a nurse documented the resident was not eating. Resident #43 was sent to the hospital at 1:30 p.m. on 04/05/10, for evaluation of questionable stroke. The nursing transfer / discharge note stated, "Resident has a history of stroke, family concerned, stated they thought her mouth was drawn, physician was notified of transfer." Additional documentation in this note stated the resident had been exhibiting difficulty swallowing for several weeks. Resident #43 returned to the facility later that same evening (on 04/05/10 at 7:30 p.m.) with [DIAGNOSES REDACTED]. On 04/06/10, a nurse documented the resident was found drinking melted ice (not thickened) from the bucket holding a bottle of thickened liquid at bedside. Resident #43 was sent to the hospital on [DATE] for a modified [MEDICATION NAME] swallowing study. The impression from the swallowing study noted: "At this time patient displayed a functional oro-pharyngeal phase swallow." The recommendations from the swallowing study were: "1. Consider continuation of a regular diet with regular thin liquids. "2. Full upright position with all oral intake and remain upright for 30 minutes following. "3. Monitor pt. (patient) for signs of aspiration. "4. May consider beginning each meal with ice or lemon swab to stimulate swallow or 'wake up' swallow. "5. Clinical correlation is recommended." On 04/08/10, Resident #43 was taken off of thickened liquids, put back on regular thin liquids, and ordered sugar-free ice cream to stimulate swallow instead of ice as recommended. Nursing documentation, dated 04/21/10, noted Resident #43 refused breakfast and was spitting it out. An RD progress note, dated 04/27/10, noted various lab values that had been obtained, including the following elevated values: serum glucose - 143 (normal range is 64 to 128); blood-urea-nitrogen (BUN) - 41 (normal range is 7 - 20); and creatinine - 1.9 (normal range is 0.8 - 1.4); the elevated BUN and creatinine levels are indicative of impaired renal function, and the elevated BUN, creatinine, and serum glucose levels can also be indicative of dehydration. In the same note, the RD stated the physician was notified of lab values. The RD made no recommendations at this time. On 05/01/10, a nurse documented Resident #43 "drools food at times pushes tongue forward when eating." On 05/04/10, a nurse documented Resident #43 got choked at dinner and " ... was able to cough and clear throat (sic) must have been liquid because resident never coughed anything up." On 05/06/10, a nurse noted the resident was observed "sticking tongue to the end of her mouth and pushing food out, holding food before swallowing, letting fluids drool out the sides of her mouth." On 05/07/10, a nurse documented Resident #43 got "strangled" twice on water. On 05/15/10, a nurse recorded the nursing assistant observed Resident #43 was spitting her food out and coughing. According to the next consecutive assessment, a comprehensive assessment addressing a significant change in status with an ARD of 05/23/10, the resident weighed 113# with a height of 60 inches and was now receiving a mechanically altered diet, a therapeutic diet, and a dietary supplement. The assessor indicated there was a significant weight loss, she left twenty-five percent (25%) or more of her food uneaten at most meals, she was on a planned weight change program, and she now had both chewing and swallowing problems. A nursing note, dated 06/04/10 at 10:00 a.m., stated, "Unable to get sippy cup to mouth. Resident dehydrated, poor skin turgor." A physician's telephone order was obtained to send the resident to the hospital emergency room for evaluation, and the resident's responsible party was notified at 9:55 a.m. on 06/04/10. The nursing transfer / discharge note, dated 06/04/10 at 10:00 a.m., in the section on the transfer / discharge summary where the nurse briefly describes events leading to transfer, the nurse recorded: "Decrease in blood pressure, decrease level of consciousness, decrease in cognition, and very dehydrated." She had also written, "Resident intake poor." On 06/04/10, she transferred to an acute care hospital, where she was admitted with provisional [DIAGNOSES REDACTED]. Hospital documentation also noted her lab values included elevated chloride, serum glucose, and serum sodium levels, all of which can be indicative of hypovolemia. According to her resident assessment instruments, Resident #43, and she returned to the nursing facility on 06/08/10. Her Medicare 5-Day assessment, with and ARD of 06/15/10, indicated she now weighed 115# with a height of 59 inches, and the assessor also noted she had chewing and swallowing problems, she had experienced a significant weight loss, and she had been receiving nutrition fluid via a feeding tube and intravenously (IV). Resident #43 remained on IV fluids until the insertion of a feeding tube on 06/15/10. -- 2. Review of Resident #43's physician orders [REDACTED]. The POST form was updated on 08/19/09, with the same wishes specified. -- 3. During a telephone interview beginning at 1:00 p.m. on 06/15/10, Resident #43's MPOA indicated she felt good about the care Resident #43 related to her hygiene needs. She said she was not satisfied as far as the care of her health needs; she felt Resident #43's health was continuing to decline. The MPOA stated she had called the facility and spoken with the social worker (Employee #66). She questioned whether Resident #43 had had another stroke, and she asked Employee #66 to have the physician call her to discuss the resident's change in condition. The physician did not contact the MPOA as requested. The MPOA stated no one at the facility had ever discussed the need for a feeding tube until 06/09/10, when she came to a care conference at the facility. -- 4. During an interview with the social worker (Employee #66) on 06/15/10 at 2:00 p.m., she stated she had contacted the physician regarding a feeding tube on 05/22/10, due to the resident's weight loss and poor intake. She said the physician wanted to first try [MEDICATION NAME] to stimulate her appetite before consulting about a feeding tube. According the Employee #66, she contacted the physician again regarding a feeding tube on 06/09/10, and the physician told the social worker to contact the MPOA regarding consult for a feeding tube. .

Based on medical record review, family interview, and staff interview, the facility failed to provide care and services in accordance with the resident's expressed advance directives to maintain adequate parameters of nutrition and health for one (1) of eleven (11) sampled residents. Resident #43 exhibited poor oral intake of food and fluids with a significant weight loss beginning in February 2010, and signs / symptoms of dehydration beginning in April 2010. The resident's physician orders [REDACTED]. According to weight records, Resident #43 weighed 146.8# on 08/19/09; on 06/09/10, she weighed 107#. This represented a 39.8# weight loss over a ten (10) month period. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident identifier: #43. Facility census: 49. Findings include: a) Resident #43 1. Record review revealed Resident #43 was initially admitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an assessment reference date (ARD) of 05/03/08, she weighed 159# with a height of 60 inches, was receiving a therapeutic diet and a dietary supplement with no nutritional problems noted at that time, to include no chewing or swallowing problems, and she had experienced no significant weight change. She subsequently discharged to a private home on 05/16/08. Resident #43 was readmitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an ARD of 04/13/09, she weighed 149# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. She was subsequently discharged to a private home on 07/15/09 and was readmitted on [DATE]. According to her comprehensive admission assessment with an ARD of 08/29/09, she weighed 140# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. [DIAGNOSES REDACTED]. According to an abbreviated quarterly assessment with an ARD of 11/28/09, Resident #43 weighed 131# with a height of 60 and was receiving a therapeutic diet and a dietary supplement. The assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. Further record review revealed, on 12/07/09, the registered dietitian (RD) noted on her recommendation form to the physician that the resident had poor intake by mouth and a significant weight loss. At this time, the RD recommended 2 ounces of a sugar-free nutritional supplement three (3) times a day. Documentation in the resident's clinical record reflected the RD had seen Resident #43 after 12/07/09 but made no further recommendations with respect to her weight loss. According to an abbreviated quarterly assessment with an ARD of 02/21/10, she weighed 126# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. At this time, the assessor indicated there was a significant weight loss, but no chewing or swallowing problems were noted. On 03/23/10, Resident #43 was started on nectar thickened liquids. On 04/05/10, a nurse documented the resident was not eating. Resident #43 was sent to the hospital at 1:30 p.m. on 04/05/10, for evaluation of questionable stroke. The nursing transfer / discharge note stated, "Resident has a history of stroke, family concerned, stated they thought her mouth was drawn, physician was notified of transfer." Additional documentation in this note stated the resident had been exhibiting difficulty swallowing for several weeks. Resident #43 returned to the facility later that same evening (on 04/05/10 at 7:30 p.m.) with [DIAGNOSES REDACTED]. Resident #43 was sent to the hospital on [DATE] for a modified [MEDICATION NAME] swallowing study. The impression from the swallowing study noted: "At this time patient displayed a functional oro-pharyngeal phase swallow." The recommendations from the swallowing study were: "1. Consider continuation of a regular diet with regular thin liquids. "2. Full upright position with all oral intake and remain upright for 30 minutes following. "3. Monitor pt. (patient) for signs of aspiration. "4. May consider beginning each meal with ice or lemon swab to stimulate swallow or 'wake up' swallow. "5. Clinical correlation is recommended." On 04/08/10, Resident #43 was taken off of thickened liquids, put back on regular thin liquids, and ordered sugar-free ice cream to stimulate swallow instead of ice as recommended. Nursing documentation, dated 04/21/10, noted Resident #43 refused breakfast and was spitting it out. On 05/01/10, a nurse documented Resident #43 "drools food at times pushes tongue forward when eating." On 05/06/10, a nurse noted the resident was observed "sticking tongue to the end of her mouth and pushing food out, holding food before swallowing, letting fluids drool out the sides of her mouth." On 05/15/10, a nurse recorded the nursing assistant observed Resident #43 spitting her food out and coughing. According to the next consecutive assessment, a comprehensive assessment addressing a significant change in status with an ARD of 05/23/10, the resident weighed 113# with a height of 60 inches and was now receiving a mechanically altered diet, a therapeutic diet, and a dietary supplement. The assessor indicated there was a significant weight loss, she left twenty-five percent (25%) or more of her food uneaten at most meals, she was on a planned weight change program, and she now had both chewing and swallowing problems. A nursing note, dated 06/04/10 at 10:00 a.m., stated, "Unable to get sippy cup to mouth. Resident dehydrated, poor skin turgor." A physician's telephone order was obtained to send the resident to the hospital emergency room for evaluation, and the resident's responsible party was notified at 9:55 a.m. on 06/04/10. The nursing transfer / discharge note, dated 06/04/10 at 10:00 a.m., in the section on the transfer / discharge summary where the nurse briefly describes events leading to transfer, the nurse recorded: "Decrease in blood pressure, decrease level of consciousness, decrease in cognition, and very dehydrated." She had also written, "Resident intake poor." On 06/04/10, she transferred to an acute care hospital, where she was admitted with provisional [DIAGNOSES REDACTED]. Hospital documentation also noted her lab values included elevated chloride, serum glucose, and serum sodium levels, all of which can be indicative of hypovolemia. (See also citation at F327.) Resident #43 returned to the nursing facility on 06/08/10. Her Medicare 5-Day assessment, with and ARD of 06/15/10, indicated she weighed 115# with a height of 59 inches, and the assessor noted she had chewing and swallowing problems, she had experienced a significant weight loss, and she had been receiving nutrition fluid via a feeding tube and intravenously (IV). Resident #43 remained on IV fluids until the insertion of a feeding tube on 06/15/10. -- 2. Review of the resident's weight records, during her stay from 08/19/09 through 06/09/10, revealed the following: 08/19/09 - 146.8# 08/24/09 - 140.0# 09/07/09 - 136.0# 10/06/09 - 135.7# 11/03/09 - 131.1# 12/08/09 - 133.1# 01/04/10 - 126.1# 02/08/10 - 125.6# 03/09/10 - 123.4# 04/05/10 - 118.1# 05/03/10 - 113.0# 05/24/10 - 106.1# 05/30/10 - 105.4# 06/09/10 - 107.0# -- 3. Review of Resident #43's physician orders [REDACTED]. The POST form was updated on 08/19/09, with the same wishes specified. -- 4. During a telephone interview beginning at 1:00 p.m. on 06/15/10, Resident #43's MPOA indicated she felt good about the care Resident #43 related to her hygiene needs. She said she was not satisfied as far as the care of her health needs; she felt Resident #43's health was continuing to decline. The MPOA stated she had called the facility and spoken with the social worker (Employee #66). She questioned whether Resident #43 had had another stroke, and she asked Employee #66 to have the physician call her to discuss the resident's change in condition. The physician did not contact the MPOA as requested. The MPOA stated no one at the facility had discussed with her the need for a feeding tube until 06/09/10, when she attended a care conference at the facility. -- 5. During an interview with the social worker (Employee #66) on 06/15/10 at 2:00 p.m., she stated she had first contacted the physician regarding a feeding tube on 05/22/10, due to the resident's weight loss and poor intake. She said the physician wanted to first try [MEDICATION NAME] to stimulate her appetite before consulting about a feeding tube for a defined period. According to her weight records, Resident #43 weighed 113# on 05/03/10, when the social worker approached the physician about a feeding tube. (By this time, the resident had already experienced a weight loss of 27# (19%) in an eight (8) month period.) According the Employee #66, she contacted the physician again regarding a feeding tube on 06/09/10, and the physician told the social worker to contact the MPOA regarding obtaining a consult for a feeding tube. .