Every finding on record at PruittHealth - Lilburn

Based on observations, staff interviews, and review of the facility's policy titled, Labeling, Dating, and Storage, the facility failed to properly store, label, date, and discard food items. These deficiencies created a potential risk for 124 out of 129 residents who received an oral diet from the kitchen, increasing their risk of foodborne illnesses.Findings Include:Review of facility's policy titled, Labeling, Dating, and Storage dated November 11, 2022, documented in Procedures 1. Food and beverage items will have an identifying label as well as a received date and open date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc.During the initial kitchen tour on 07/26/2026 at 11:20 AM, revealed in the dry storage area one 24 (ounce) oz. package of gravy mix with an expiration date of 07/25/2026. The walk-in freezer revealed one box of six yellow frying corn 160 count with expiration date 07/12/2026. The walk-in cooler/refrigerator revealed eight 20 oz. loaves of honey wheat bread with expiration date 07/25/2026. One box of (22) 1 oz. cup cream cheese with expiration date 07/05/2026. One box of 27 eight oz. lactose free/fat free milk with expiration date 06/22/2026. During a follow up observation of the kitchen on 07/27/2026 at 11:08 AM, located near the countertop and small appliances, revealed sitting on a serving tray, 40 six oz. prepared bowls of cereal with lids that were not labeled or dated, three granola, 16 corn flakes, 11 fruit loops, one cheerio, and nine frosted flakes. During inspection, the Regional Environmental Director pointed out dates on a brown sheet of paper that revealed an expiration date of 07/15/2026. Upon further observation during the lunch meal tray pass, several plates were found stacked in the plate warmer, which had been placed on the tray line by the cook and dietary supervisor, and were wet. The Dietary Manager randomly selected plates from the right side of the two-holder plate warmer and discovered eight plates that had a wet substance on them.On 07/27/2026, at 1:30 PM, an interview was held with Dietary Aide (DA) GG, who stated that she was not aware of the term used to describe the presence of wet substances (wet nesting) on dishes intended for preparation, although she recognized that it could lead to contamination. DA GG mentioned that she had numerous tasks to complete that day and had overlooked the issue. Additionally, DA GG noted that she had prepared the 40 cereal bowls found without a label or date the previous day.On 07/29/2026, at 11:46 AM, an interview with the Dietary Manager indicated that all staff members are required to verify food is labeled including, open and discard dates. The Dietary Manager stated that she conducts these checks every morning; however, she was unable to do so on the morning of the initial tour due to numerous responsibilities, which caused her to forget. She expressed concern that this oversight could potentially lead to someone becoming ill, particularly as DA GG was hurrying to prepare trays for the residents. The Dietary Manager stated she had not yet conducted an in-service training on 'wet nesting' since it had not previously been an issue.

Based on observations, record review, staff interviews and review of facility policy titled, Care Plans the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 51 sampled residents (R) (R136) reviewed for baseline care planning. This had the potential to result in unaddressed or delayed intervention for R136 not having a documented plan addressing his fall risk, malnutrition risk, and non-ambulatory status. Findings include:Review of the facility's policy titled, Care Plans, revised on [DATE], revealed the baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission.Review of R136's Electronic Health Record (EHR) revealed he was admitted on [DATE] with diagnoses including, but not limited to, acute on chronic systolic (congestive) heart failure, chronic right heart failure, nonrheumatic mitral valve insufficiency, dysphagia (oral phase), cognitive communication deficit, difficulty walking, generalized muscle weakness, other lack of coordination, type 2 diabetes mellitus without complications, and mixed hyperlipidemia.Record review of R136's Minimum Data Set (MDS) assessment, type and date [DATE] (Death in Facility), revealed the assessment was not fully completed due to R136 residing in the facility fewer than 14 days. Section A (Identification Information) documented R136 was admitted to the facility from a short stay hospital and expired in the facility, a total of seven days.Review of R136's admission Observation, completed [DATE] at 8:29 PM through 8:44 PM, revealed the following: R136 required a Stand Assist Lift for all transfers and was not ambulatory; R136 had bruising to both upper extremities and redness to the coccyx on skin assessment; R136 scored 8 on the Malnutrition Screen, indicating he was at risk of malnutrition; and R136 scored 55 on the Morse Fall Scale, indicating he was at high risk for falls, with a documented history of falling.Review of R136's care plan revealed a baseline care plan was not fully completed. Documentation in the record stated, No evidence of a 48 Hour base care plan was found.Review of a Care Conference Acknowledgement Form dated [DATE] at 2:24 PM through 2:25 PM revealed the baseline care plan and admission physician order forms were reviewed with R136 and R136's resident representative, and a copy was provided to R136's resident representative. This form did not contain evidence that the substantive content of a baseline care plan, addressing R136's individualized risks and needs, had been developed.Interview conducted on [DATE] at 8:50 AM with Minimum Data Set Director (MDSD) revealed nurses are responsible for the baseline care plan, specifically the nurse who admits the resident. MDSD stated the baseline care plan is required to be completed within 48 hours of admission. Review of R136's care plan on MDSD computer confirmed the baseline care plan was not completed. MDSD stated R136 was in the facility for 7 days and his baseline care plan should have been completed within that time. She stated an incomplete baseline care plan can negatively affect the resident's plan of care going forward and stated that if the admitting nurse is unable to complete the baseline care plan, it should be reported to the next shift for completion.Interview conducted on [DATE] at 1:12 PM with the Director of Health Services (DHS), revealed the baseline care plan should be completed within 48 hours of admission and that the admitting nurse is responsible for completing it. The DHS confirmed upon review that R136's baseline care plan was not fully completed. The DHS stated she expected that staff would follow established policies and procedures. She identified the potential negative outcome of an incomplete baseline care plan as compromised resident care.Interview conducted on [DATE] at 1:53 PM with the Administrator revealed the baseline care plan should be completed immediately upon admission, within 24 hours. The Administrator confirmed upon observation that R136's baseline care plan was not fully completed. The Administrator stated her expectation is that the baseline care plan be completed in a timely manner by nurse leadership and reviewed/checked by the receiving nurse, and stated unit managers are typically responsible for completing the baseline care plan. The Administrator identified the potential negative outcome as the possibility that R136 had a condition that went untreated or unaddressed because required assessment questions were not completed, which could have been detrimental to him.

Based on observations, record review, staff interviews, and review of the facility's policy Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, the facility failed to provide the necessary care and services for one of two residents (R) (R27) reviewed for hearing services by assessing whether the resident's hearing aids were in use and available, implementing physician orders, and notifying the physician when the hearing aids were unavailable. This deficient practice could result in impaired communication, decreased participation in care, and reduced quality of life.Findings include:Review of the facility's policy titled, Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, last updated December 6, 2022, revealed the following under Procedure: 1. Nursing partners shall encourage and assist the patient/resident in carrying out the specialty service physician recommendations and instructions.Findings include:R27 was admitted to the facility with diagnoses including bilateral hearing loss.A review of the audiologist note dated 12/02/2025 documented, The patient is an experienced hearing aid user with bilateral hearing aids. Hearing aids were purchased through the hearing aid company and were fit on 10/07/2025. The patient cares for the hearing aids and stores them in their room.A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section B (Hearing, Speech, and Vision) that the resident's hearing was assessed as adequate with the use of a hearing aid. A review of Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition.A review of R27's care plan revealed an active problem of bilateral hearing impairment (hard of hearing) and hearing aid use. The care plan documented that the resident was admitted with hearing aids and that the resident's son was to provide the hearing aid charger. Interventions included assisting the resident with charging the hearing aids as needed.Review of the physician's orders revealed an active order, initiated on 10/25/2025, to Place hearing AIDS in once daily at 9:00 am. A second active order, initiated on 10/07/2025, directed staff to remove the hearing aids at bedtime, open the battery door to turn them off, and store them in a safe, dry location.A review of R27's July 2026 Medication Administration Record (MAR) revealed the daily 9:00 AM order to place the resident's hearing aids was documented as completed through July 25, 2026. There was no documentation that the hearing aids were placed on July 26, 2026, or July 27, 2026.During a medication administration observation on 07/27/2026 at 8:00 AM, the surveyor observed R27 having difficulty hearing LPN AA and repeatedly asking the nurse to repeat what she was saying. LPN AA repeatedly informed the resident that she had brought her medications. After administering the medications, LPN AA left the room without asking the resident about her hearing aids, determining whether they were in place or available in the room, or addressing the physician's order related to hearing aid use.During an observation and interview with R27 on 07/27/2026 at 11:23 AM in her room, the surveyor asked whether she was using hearing aids. The resident repeatedly asked the surveyor to repeat the question and then stated that she did have hearing aids but was not sure where they were.During an interview on 07/27/2026 at 11:25 AM, Certified Nursing Assistant (CNA) FF stated that R27 does not hear well and uses hearing aids. She further stated that she speaks loudly and bends down to the resident's eye level to help the resident hear and understand her.During a joint interview with LPN DD and the Director of Health Services (DHS) on 07/27/2026 at 1:36 PM, LPN DD stated that she had not seen the resident's hearing aids for some time, which was why she had not been documenting the hearing aid order on the MAR. LPN DD acknowledged that she should have at least asked the resident about her hearing aids during the morning medication pass but did not. She further acknowledged that she should have notified the physician that the resident's hearing aids were unavailable.The DHS stated that nurses are expected to follow physician orders, assess residents as needed, document care promptly in the MAR, and notify the physician when physician orders cannot be carried out or when there is a change in the resident's condition.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Infection Prevention-Hand Hygiene, Infection Control: Glucometer Cleaning and Disinfecting, and Infection Control Prevention and Control Activities, the facility failed to perform hand hygiene and sanitize shared medical equipment while providing care to four residents during medication pass. The facility sample was 63 residents. This failure had the potential to increase the risk of infection transmission among residents and staff. Findings include: Review of the facility's policy titled, Infection Prevention-Hand Hygiene, updated 10/15/2024 revealed the Policy section included D. Indications Requiring Hand Wash or Hand Rub. 1. Before and after contact with the resident. 2. Before donning gloves, including sterile gloves 4. After contact with a resident's intact skin, (i.e., taking blood pressure, pulse, and lifting/turning a resident) .7. Immediately after removal of personal protective equipment (e.g., gloves, gown, facemasks). Review of the facility's policy titled Infection Control: Glucometer Cleaning and Disinfecting, updated 8/15/2024 revealed the Policy section included C 4. Glucometers that are shared must be cleaned and disinfected between each patient/resident use. D. Hand Hygiene and Gloves. 1. Perform hand hygiene immediately before donning gloves .4. Perform hand hygiene immediately after removing of gloves and before and before touching medical supplies intended for use on other patients/residents. E. Cleaning and Disinfection. Note: The Glucose Meter must be cleaned and disinfected after each patient/resident use to minimize the risk of transmission of blood-borne pathogens between patients/residents and healthcare professionals 4. Clean and disinfect the meter by using the EPA approved wipes Germicidal and Disinfectant Wipes. Wipe all external areas of the meter including both the front and back surfaces until visibly clean . Review of the facility's policy titled Infection Control Prevention and Control Activities, revised 2/1/2018 revealed the Policy section included Hand Washing. 1. Hands should be washed often. 2 Hands will be washed immediately after gloves are removed, between patient contact, equipment handling and when otherwise indicated to wash hands between tasks . Gloves: 1. Wash hands immediately to avoid transfer of microorganisms to other environments 4 .Hand washing, as per policy, is mandatory after glove removal .Occupational Health If applicable, tools are cleaned as outlined above when soiled and prior to leaving testing area. An observation on 5/13/2025 at 8:15 am revealed Registered Nurse (RN) AA performing a medication pass for Resident (R) 65. The RN pulled the medication cart to the room and began preparing medications without performing hand hygiene. In the middle of the task, he realized one medication was missing and went to the medication room to retrieve it. Upon returning, he resumed the task without performing any hand hygiene. RN AA was then interrupted by another staff member and briefly stepped into an adjacent resident's room after securing the medication cart. He returned shortly thereafter and resumed the medication pass, again without performing hand hygiene. He retrieved all prepared medications and entered the resident's room without sanitizing his hands. When administering eye drops, he donned gloves but did not perform hand hygiene before or after removing the gloves, or upon exiting the room. RN AA checked the resident's blood pressure, then returned the BP machine to the cart without cleaning it and proceeded to the next resident. He did not sanitize his hands upon leaving the room or before moving to the next resident. At the following resident's room, RN AA began preparing medications for R55 without sanitizing his hands. He also brought the previously used, uncleaned BP machine into the room, checked the resident's blood pressure, and administered medications. The RN neither sanitized the BP machine after use nor performed hand hygiene before proceeding to the third resident. Then RN AA rolled his cart to the third resident, R48. The RN failed to perform hand hygiene before starting the medication pass, as well as upon entering and exiting the third resident's room. Next, RN AA rolled his medication cart to the fourth resident, R426. RN AA failed to perform hand hygiene again before initiating the medication pass or upon entering the fourth resident's room. The RN proceeded to check the resident's blood pressure and blood glucose levels before administering medications. After completing the task, he returned the blood pressure cuff and glucometer to the medication cart and was observed sanitizing only the glucometer using a few small, square alcohol prep pads. He then sanitized his hands with hand sanitizer. When asked by the surveyor whether the blood pressure cuff should have been sanitized after being used on different residents, the RN responded that he did not believe it was necessary, as there was no risk of blood exposure, unlike with a glucometer. When further questioned about hand hygiene between residents during the med pass, the RN acknowledged that he should have sanitized his hands but failed to do so. Later that day, on 5/13/2025 at 3:00 pm, RN AA approached the surveyor and admitted he was mistaken and should have sanitized the blood pressure cuff between each resident's use. An interview with the Infection Control Nurse (IC) on 5/14/2025 at 2:05 pm revealed that her expectation is for staff to always sanitize their hands prior to entering a resident's room and before providing care. Using alcohol-based hand rub is appropriate if hands are not visibly soiled, but after three consecutive uses, hand washing is required. If providing care to more than one resident, hands must be sanitized between residents. Regarding cleaning of shared equipment, the IC nurse stated that it must be cleaned between each resident's use using Micro-Kill wipes. In an interview with the Director of Health Services (DHS) on 5/14/2025 at 2:15 pm, she stated that staff are expected to practice frequent hand hygiene, especially when providing resident care. She emphasized that staff must sanitize their hands prior to starting a med pass, upon entering a room, before administering medications, and upon leaving the room. Regarding shared equipment, the DHS stated that staff are expected to properly clean all shared equipment between resident use by using disinfectant wipes and allowing the equipment to completely dry. She noted that using small, square alcohol prep pads is not acceptable for cleaning shared equipment.

Based on observations, record review, staff interviews, and review of the facility policy, titled, Clean air filters, the facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters for one room [ROOM NUMBER] out of 18 rooms in B Hall. This deficient practice had the potential to compromise the health and safety of the residents by increasing the risk of infections. Findings Include: 1. A review of the facility's policy, titled Clean air filters, revealed the Steps section was, 2. Remove air filter and inspect for cleanliness. If filter is dirty either wash or replace depending on type of filter. If clean, reinstall filter. An observation on 5/12/2025 at 3:04 pm and 5/14/2025 at 4:42 pm, observed in room [ROOM NUMBER], PTAC filters with grey, fuzzy debris. Interview walking rounds on 5/15/2025 at 9:45 am with the Maintenance Director (MD) confirmed dirty PTAC unit. MD revealed the maintenance staff clean the filters monthly and they keep a log of this; however, they didn't get a chance due to other areas that needed his attention. MD stated his expectation was for environmental issues to be taken care of as soon as possible. He stated the staff report issues to maintenance via the maintenance logbook located at each nursing desk and they now have TELS system that the staff are becoming acclimated in its use. MD stated he was not aware of any Maintenance policy. The Administrator confirmed the facility does not have a Maintenance or Environmental policy. The Administrator asked the MD to immediately correct and address the area of concern. An interview conducted on 5/15/2025 at 3:43 pm, the Administrator stated the Maintenance Director and Housekeeping Director oversee cleaning the PTAC filters. She stated her expectations are for PTAC filters to be clean. The Administrator stated a possible negative outcome could be a resident could have an allergic reaction.

Based on observations, record review, and staff interviews the facility failed to document behavior monitoring for two resident(s) (R) (R10 and R56) of 63 sampled residents who required behavior monitoring for psychotropic medication use. Findings include: 1. admitted : 10/28/2016 with the following pertinent diagnoses: primary generalized (osteo)arthritis, type 2 diabetes mellitus without complications, essential (primary) hypertension, depression, unspecified, anxiety disorder, unspecified, active acute embolism and thrombosis of unspecified deep veins of left lower extremity, other idiopathic peripheral autonomic neuropathy, insomnia, unspecified, pain in left knee, pain in left hand, pain in unspecified knee, pain in left wrist, abrasion, left knee, sequela, and rheumatoid arthritis, unspecified. A review of the quarterly minimum data set (MDS) dated [DATE] revealed Section C - Brief Interview of Mental Status (BIMS) 12, indicating mild cognitive impairment. Section D: indicating mild depressive symptoms. Section E: No potential indicators for psychosis and no behaviors exhibited. A review of the Physician Orders for R10 documented: 1. Xanax (alprazolam) - Schedule IV tablet; 0.25mg; amt: 1 tablet; Quantity: 30; oral [DX: Anxiety disorder, unspecified] Once a Day - PRN; PRN 1 Side Effects: Falls, dizziness, or headaches; Subdued, sedated, lethargic, or withdrawn; Muscle/nonspecific pain or unexplained abnormal movement; Decline in physical functioning (e.g., mobility or activities of daily living (ADLs) Psychomotor agitation (restlessness, pacing, hand wringing); Psychomotor retardation (slowed speech, thinking, movement) 2. Zoloft (sertraline) tablet; 50 mg; amt: 3 tablet; oral [DX: Depression, unspecified] Once A Day; 09:00 am Trazodone tablet; 150 mg; amt: 1/2 tablet; oral 3. Buspirone tablet; 5 mg; amt: 1; oral [DX: Depression, unspecified] Three Times A Day; 9:00 am, 1:00 pm, 5:00 pm Side Effects: Subdued, sedated, lethargic, or withdrawn; Mental Status Changes Order Description: Monitor resident for s/s of Behaviors and Mood related to depression, anxiety and chronic pain secondary to rheumatoid arthritis Frequency: Every Shift Review of Behavior Monitoring revealed that the following dates have not been recorded: May-5/5(am), 5/10-5/12(pm), April-4/3(pm), 4/13(pm), 4/17(pm), 4/23(pm), 4/26(am+pm), 4/30(pm), 3/5(pm), 3/6(pm), 3/11(pm), 3/25(pm), Feb-2/5(pm), 2/11(pm), 2/16(pm), 2/18(pm), 2/19(pm), Jan-1/2(pm), 1/11(pm), 1/12(pm), 1/13(pm), 1/17(pm), 1/19(pm), 1/22(pm), 1/23(am+pm). Observation and interview on 5/15/2025 at 3:32 pm R10 was awake and alert watching television in her room. R10 revealed her pain gets bad sometimes, and she would like to take more pain medication, but she is fine right now and does not want any changes. R10 confirms that she does suffer from insomnia, and the pain interferes with her sleep at times, but is fine right now. 50272 2.A review of the Electronic Health Record (EHR) for R56 revealed she was admitted on [DATE] and has the following diagnosis but not limited to schizophrenia, post-traumatic stress syndrome (PTSD), bipolar disorder and depression. A review of R56's admission Minimum Data Set (MDS) dated [DATE] documented in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 12, indicating cognitively intact. A record review of R56's care plan with a start date of 2/19/2021 revealed R56 to be care planned for medications and behaviors (r/t) PTSD, major depressive disorder and mild anxiety disorder. The care plan stated R56's interventions are to report changes in mood and behaviors to nurse, physician, social worker, treat as per orders (every shift; days, evenings and nights). A record review of R56's physician orders revealed a prescription for five (5) milligrams (mg) of Abilify (atypical antipsychotic). The medication was prescribed for schizophrenia, psychotic disturbance, bipolar disorder and depression and is to be administered twice a day with a start date of 9/11/2024. Furthermore, a record review of R56's physician orders dated 11/18/2023, requires behavior monitoring to be documented every shift (days and nights). Behavior monitoring instructions to direct staff to chart on observed behaviors that include but not limited to sad mood/tearful, anxious mood/attention seeking, insomnia, physical aggression, sexually inappropriate, wanders and/or destroys property. Record review of R56's Medication Administration Record (MAR) for March, April, and May 2025 revealed the following days with no charting of behavior monitoring. Record review of R56's Medication Administration Record (MAR) for March, April, and May 2025 revealed the following days with no charting of behavior monitoring. March 2025 - behavior monitoring was not documented on the day shift for March 2, 5, 10, 13, 14, 18, 19, 24, and 28. On the night shift, documentation was missing for March 14, 18, 24, and 25. April 2025 - behavior monitoring was not documented on the day shift for April 2; April 7 through 11; April 13 and 14; April 16 through 18; April 21 through 24; and April 30. It appears April 16 was listed twice. On the night shift, documentation was missing for April 1, 9, 12, 21, and 23. May 2025 - behavior monitoring was not documented on the day shift for May 2 and from May 5 through May 7. An interview conducted on 5/15/2025 at 11:13 am, Licensed Practical Nurse (LPN) JJ explained it is the responsibility of the nurse assigned to each hall to complete behavior monitoring documentation for residents on their shift. LPN JJ reported having multiple residents with behavior monitoring orders that require documentation every shift. She revealed she knows the orders are present because they appear on the Medication Administration Record (MAR) and emphasized that there is no reason they should be missed. LPN JJ acknowledged that the expectation is for the nurse to document any behaviors observed during their shift. Interview on 5/15/2025 at 12:08 pm with the Director of Health Services (DHS) revealed the nurse scheduled for a shift is responsible for completing behavior monitoring documentation during that shift. The DHS stated that behavior monitoring is a physician's order and must be followed. She explained that failure to complete the required documentation may result in communication breakdowns and a lack of necessary follow-up and without proper documentation, staff are unable to respond effectively to resident needs. Interview on 5/15/2025 at 3:47 pm with the Administrator revealed that without proper monitoring and documentation, a resident who requires behavior oversight could be involved in an incident, could sustain injuries, could pose a risk to themselves or others.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Care Plans, the facility failed to follow care plan related to (r/t) allergy restrictions concerning chocolate for one resident (R) (R56) out of 63 sample residents. This failure had the potential to result in an adverse allergic reaction. Findings included: Review of the policy titled, Care Plans, dated 2022, indicated, Admission Comprehensive Plan of Care - 3. The comprehensive person -centered care plan is developed to include measurable goals and time frames to meet a patient/resident's medical, nursing and psychosocial needs the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. A review of the Electronic Health Record (EHR) for R56 revealed she was admitted on [DATE] and has the following diagnosis but not limited to schizophrenia, dementia, post-traumatic stress syndrome (PTSD), bipolar disorder and depression. Furthermore, R56's EHR documented a food allergy to chocolate dated 12/8/2020. A review of R56's admission Minimum Data Set (MDS) dated [DATE] documented in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 12, indicating cognitively intact. A record review of R56's care plan with a start date of 9/22/2023 revealed R56 to be care planned to have a food allergy to chocolate. The care plan documented that R56 will not receive food with allergy ingredients. An observation and interview conducted on 5/14/2025 at 12:59 pm, R56's bedside tray was observed to contain a wrapped piece of chocolate cake, untouched. Upon verifying the meal tray slip, it was documented twice that R56 had an allergy to chocolate, and it listed the chocolate cake as Black Forest Cake. When asked, R56 confirmed that she did not eat the cake because she is allergic to chocolate. An interview was conducted on 5/14/2025 at 1:02 pm, Registered Nurse (RN) DD explained that when staff retrieve trays from the cart, they are required to verify the tray slip to ensure accuracy and alignment with the resident's dietary needs, including allergies. She confirmed that R56 is known to have a chocolate allergy and should not have been served chocolate cake. RN DD emphasized that the expectation is for all staff to check the tray ticket for the correct name, food, and allergy information to prevent potential harm such as an anaphylactic reaction. An interview was conducted on 5/14/2025 at 1:05 pm, Certified Nursing Assistant (CNA) EE stated she has been employed at the facility for about five months and regularly passes meal trays on the hall where room [ROOM NUMBER] (R56) is located. She confirmed she checked the resident's name, informed them of the items on the tray, and assisted with setup. She stated she verifies that residents are not receiving incorrect food and confirmed that R56 is allergic to chocolate. She recognized the cake on the tray as chocolate but admitted she was unsure what Black Forest Cake meant and did not realize it contained chocolate. An interview was conducted on 5/14/2025 at 1:28 pm, Dietary Aide (DA) FF stated she has worked in the facility for six years. She was on the tray line and said she follows the tray ticket instructions for portions and items to be included. DA FF acknowledged the possibility that she may have unintentionally placed an incorrect item on a tray. An interview was conducted on 5/14/2025 at 1:31 pm, Dietary Aide (DA) GG stated she has been working in the facility for nearly three years. Her role involves checking tray tickets and verifying that the correct meal components are included. She confirmed she added the chocolate cake to tray's and stated that if a resident has a chocolate allergy, they are typically given fruit instead. An interview was conducted on 5/14/2025 at 1:35 pm, Dietary Aide (DA) HH confirmed her responsibility was to add drinks, desserts, condiments, and silverware on the day in question. She stated she ensures the tray slip matches the items included but emphasized that DA GG was the last person verifying the trays before they were placed on the cart. An interview was conducted on 5/14/2025 at 1:39 pm, Dietary Aide (DA) II stated she had been employed at the facility for about a week. On the day in question, she stated she was stationed in the middle of the tray line serving beverages and desserts, including the cake. She confirmed that DA GG was responsible for final verification. DA II stated she checks the tray tickets but did not notice any residents listed with a chocolate allergy. An interview was conducted on 5/14/2025 at 1:43 pm, Dietary Kitchen Manager (DKM), who has served in her role for two years, explained the process: cooks plate the food per the tray ticket, and dietary aides add beverages, condiments, and desserts. She stated that dietary staff are trained to review tray slips, which include residents' allergies at the top and bottom. DKM confirmed that if a resident is allergic to chocolate, it should be visibly indicated, and substitutions such as fruit are expected. Observations and interviews were conducted on 5/14/2025 at 1:52 pm, in R56's room, DKM, DA FF, DA GG, DA HH observed and confirmed R56's tray to contain a piece of chocolate cake. DA GG stated she was sure she had removed the chocolate cake, but she could not confirm if another staff member placed it back. She mentioned she was aware that R56 is allergic to chocolate. Staff present collectively acknowledged that R56 is allergic to chocolate and should not have served it. The DKM stated her expectation is for all dietary staff to follow tray tickets carefully and the failure to adhere to these protocols has the potential to result in an allergic reaction and resident dissatisfaction. An interview was conducted on 5/15/2025 at 3:47 pm, The Administrator emphasized that the care plan must be followed consistently by all staff involved in meal service. Failure to do so may result in a resident receiving a food item they are allergic to, which could lead to a lot of medical issues.

Based on record reviews, staff interviews, and a review of the facility's policy titled, Care Plan the facility failed to update the care plan for resident (R) R30 to accurately reflect the resident's code status for one of 63 sampled residents. This failure had the potential to result in the provision of care that was not aligned with the resident's end-of-life wishes, potentially causing physical and emotional harm. Findings include: Review of the facility policy titled Care Plans, updated 7/27/2023 reveals under Policy .section 7 .Update care plan electronically. When applicable, write a new goal, discontinue approaches and /or add approaches Care Plan Review and Update: 1 .Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals, or approaches should be indicated directly on the care plan .Updates to the care plans should be made with any changes in condition at the time of change in condition occurred . A review of Resident's (R)30 electronic records revealed she was admitted on [DATE] with the following diagnoses: cerebrovascular accident (CVA), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right side, bedbound status, chronic obstructive pulmonary disease (COPD), heart failure, type 2 diabetes mellitus, essential hypertension, atherosclerotic heart disease, peripheral vascular disease, chronic kidney disease stage 3, thromboembolism, anemia, respiratory failure with hypoxia, neoplasms of soft tissue and skin, and localized swelling/mass/lump of the right upper limb. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of physician orders showed: 6/11/2024: Code status-DNR (Do Not Resuscitate). 3/19/2025: Do not hospitalize or send out for appointments per resident choice. 3/19/2025: Referral to [Named Hospice Company] for evaluation and treatment. Review of the POLST (Physician Orders for Life-Sustaining Treatment), signed on 8/19/2024 by the physician and the resident, indicated that R30 elected to allow natural death (DNR). Review of the care plan for R30 showed a problem initiated on 7/27/2023 and last reviewed on 3/11/2025, which incorrectly documented the resident as a full code. In an interview conducted with Licensed Practical Nurse (LPN BB) on 5/14/2025 at 9:30 am, she stated that to verify a resident's code status, she can check multiple sources. In the computer system she would check the physician orders, the banner in the electronic record, and the resident's care plan. They also have the Advance Directive and Code Status Report on the crash cart and in the narcotic book on each medication. When the surveyor requested to review R30's care plan, LPN BB acknowledged that the advance directive was not correct and stated she would notify the Social Worker to fix it. She added that while nurses can make certain updates to care plans, advance directive changes are handled by either the Social Worker or MDS Coordinator. In an interview with the Social Work (SW) Director on 5/14/2025 at 9:40 am, she explained that upon admission, discussions regarding code status are conducted with the resident and/or responsible party, and the necessary documentation is completed. The POLST form is scanned into the system, and the code status is reviewed during the care plan meetings. She confirmed that resident R30 initially had full code status, which was later changed to DNR and hospice. She acknowledged that the care plan was inaccurate regarding the resident's current code status and should have been updated promptly at the time of the change to reflect this. The Social Work Director admitted she was unsure how the update was missed.

Based on observations, staff and resident interviews, record reviews, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to administer medications as per physician's orders for two residents of 63 sampled residents. This deficient practice may result in residents not receiving necessary treatment, posing a risk to their health and safety. Findings include: Review of the facility's policy titled: Medication Administration: General Guideline, reveals the Policy statement, Medications are administered as prescribed, in accordance with good nursing principles and practices an only by persons legally authorized to do so .Procedure: .2. Medications are administered in accordance with written orders of the attending physician .9 . The individual records the administration on the patient/resident's MAR at the time the medication is given. At the end of each medication pass, the person administering the medications review the paper MAR or the electronic version of e-MAR to ascertain that all necessary doses were administered, and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications .13. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .that dosage administration is initiated and circled and for facilities utilizing the e-MAR system for not administering medication at scheduled time. An explanatory note is entered on the reverse side of the record provided for PRN indication and general medication notes and for e-MAR the note can be typed into the appropriate space provided within the electronic system. If more than two consecutive doses of the vital medication are withheld or revised, the physician is notified. 1). A review of Resident's (R)57 Admission Record revealed that R57 was admitted to the facility in 2021 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease ( COPD), malignant neoplasm of the prostate, degenerative joint disease (DJD), venous insufficiency with deep vein thrombosis (DVT), anemia, Gastroesophageal Reflux disease ) GERD), chronic hepatitis C, peritoneal abscess, diverticulosis of the large intestine, and a history of alcohol dependence. Review of his most recent quarterly MDS indicates a BIMS score of 15, indicating intact cognition. On 3/5/2024, the resident was diagnosed with herpes zoster (shingles-viral disease characterized by a painful skin rash with blisters). Review of the physician orders reveals the following orders to treat shingles: Acyclovir cream 5%, to be applied twice daily to the rash on the right thigh, right lower leg, and right buttock from 3/7/2024 through 3/15/2024, and Acyclovir 400 mg tablets, to be taken orally five times per day for 10 days, starting 3/5/2024. The first oral dose on 3/5/2024 was not administered due to the medication being unavailable, as documented in the Medication Administration Record (MAR). The medication became available on 3/6/2024 and was administered as ordered by the physician, five times daily from 3/6/2024 through 3/16/2024, at 12:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Out of the 50 scheduled doses during this period, three were not signed as administered. R57 wrote a complaint to the state stating that staff not giving his shingles medications like the doctor scheduled for him to take them. In an interview with R57 on 5/12/2025 at 12:35 pm in his room, the surveyor conducted an in-depth interview with the resident regarding his complaint. The resident presented a personally created table documenting dates and times he believed he received the prescribed medication. On the resident-created medication table, several blanks were noted, suggesting missed doses. However, upon comparison of the resident-created table with the Medication Administration Record (MAR), the surveyor was able to verify that R57 was receiving medications consistently, with the exception of three instances: 3/6/2024 at 8:00 am; 3/10/2024 at 8:00 am; and 3/10/2024 at 9:00 am. In an interview conducted on 5/14/2025 at 2:00 pm., the Infection Control Nurse (IP) admitted that it is hard to determine whether the medication was actually given or simply not documented in those three instances where it was not checked off in the MAR. She further stated that during medication administration, nurses are not allowed to leave any blanks on the MAR In an interview with the Director of Health Services (DHS) on 5/14/2025 at 2:15 pm, she stated that her expectation is for staff to document all administered medications. If a medication is not given, it should still be signed off with a reason noted, such as medication not available or resident refused. 2. Review of Resident's 326 electronic medical record (EMR) revealed he was admitted to the facility on [DATE] post left fourth and fifth toes amputation and discharged against medical advice (AMA) on 7/21/2024 at 11:56 am. Review of the hospital rehabilitation physical therapy (PT) assessment dated [DATE] revealed that the patient demonstrated a high level of motivation and good cognitive function, orientation: oriented x4. Review of R 326 Physician Orders revealed the following orders: 7/20/2024 ceftazidime (ceftazidime 2 g/50 mL-D5% intravenous solution) every 8 hours (6 am, 2:00pm, 10:00 pm. Infusion Therapy FLUSH: 3mL 0.9% Normal Saline (NS) intravenous ( IV) before, between and after each infusion and 3 mL 0.9% NS IV every 8 hours to maintain patency. A complaint was submitted to the State Agency, alleging that the resident was admitted on the evening of Friday, July 19, 2024 for a six-week course of IV antibiotics to be administered every 8 hours via a Periferrally Inserted Central Cathether (PICC) line. However, the resident was not receiving any IV medications as ordered. Review of the hospital discharge documentation revealed a medication list indicating the medications the resident was to receive, including the date and time of the next scheduled dose. It was documented that the new medication, Ceftazidime 2 g/50 mL in D5% intravenous solution, was to be administered every 8 hours, with the next dose scheduled for 7/19/2024 at 6:00 pm. Review of the Medication Administration Record (MAR) revealed that the first dose of IV antibiotic Ceftazidime 2 g/50 mL was administered on 7/20/2024 at 10:00 pm, indicating that the resident was without the IV medication-ordered to be given every eight hours-for approximately 28 hours. The second dose of the antibiotic was administered on 7/21/2024 at 6:00 am. Shortly thereafter, the resident's family took the resident home against medical advice. During a medication pass observation conducted on 5/12/2025, from 8:00 am to 10:00 am, the surveyor observed RN AA administering medications. No blanks were noted on the MAR. When asked about proper documentation of medication administration, RN AA stated that nurses are not permitted to leave blanks and that he always documents the appropriate response, depending on the situation. In an interview with the DHS on 5/14/2025 at 2:15 PM, she stated that her expectation is for staff to document all administered medications. If a medication is not given, it must still be documented with a reason noted, such as medication not available or resident refused. She further explained that if the medication was not available from the pharmacy, staff have access to CUBE X or PYXIS, where emergency medications are stored, and could have obtained it from there. If the medication was not available in CUBE X, the nurse should have contacted the physician to inform them of the situation and request an alternative antibiotic that was available, to prevent a gap in essential treatment for the resident.

Based on observations, record review, and interviews with residents and staff, the facility failed to adhere to documented food preferences and allergy-related restrictions concerning chocolate for one resident (R56) out of 63 sample residents. The facility census was 86. This failure had the potential to result in an adverse allergic reaction, decline in the residents' trust in the facility's ability to meet their dietary needs, thereby impacting overall quality of care and resident safety Findings Include: The facility did not provide a policy related to (r/t) adhering to food preferences and allergy-related restrictions. A review of the Electronic Health Record (EHR) for R56 revealed she was admitted on [DATE] and has the following diagnosis but not limited to schizophrenia, dementia, post-traumatic stress syndrome (PTSD), bipolar disorder and depression. Furthermore, R56's EHR documented a food allergy to chocolate dated 12/8/2020. A review of R56's admission Minimum Data Set (MDS) dated [DATE] documented in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 12, indicating cognitively intact. A record review of R56's care plan with a start date of 12/8/2020 revealed R56 to be care planned to have a food allergy to chocolate with a start date of 9/22/2023. The care plan documented that R56 will not receive food with allergy ingredients. An observation and interview conducted on 5/12/2025 at 12:42 pm, R56's meal tray slip listed spaghetti with meat sauce; however, it was observed she received broccoli chicken rice casserole instead. R56's broccoli chicken rice casserole was observed untouched and when asked why she had not eaten her food she stated she disliked rice and that she sometimes receives the wrong meal. Furthermore, it was observed that rice was listed as dislikes on her food slip. Certified Nursing Assistant (CNA) CC confirmed that the meal was not spaghetti with sauce. An observation and interview conducted on 5/14/2025 at 12:59 am, R56's bedside tray was observed to contain a wrapped piece of chocolate cake, untouched. Upon verifying the meal tray slip, it was documented twice that R56 had an allergy to chocolate, and it listed the chocolate cake as Black Forest Cake. When asked, R56 confirmed that she did not eat the cake because she is allergic to chocolate. An interview was conducted on 5/14/2025 at 1:02 pm, Registered Nurse (RN) DD explained that when staff retrieve trays from the cart, they are required to verify the tray slip to ensure accuracy and alignment with the resident's dietary needs, including allergies. She confirmed that R56 is known to have a chocolate allergy and should not have been served chocolate cake. RN DD emphasized that the expectation is for all staff to check the tray ticket for the correct name, food, and allergy information to prevent potential harm such as an anaphylactic reaction. An interview was conducted on 05/14/2025 at 1:05 pm, Certified Nursing Assistant (CNA) EE stated she has been employed at the facility for about five months and regularly passes meal trays on the hall where R56 is located. She confirmed she checked the resident's name, informed them of the items on the tray, and assisted with setup. She stated she verifies that residents are not receiving incorrect food and confirmed that R56 is allergic to chocolate. She recognized the cake on the tray as chocolate but admitted she was unsure what Black Forest Cake meant and did not realize it contained chocolate. An interview was conducted on 5/14/2025 at 1:28 pm, Dietary Aide (DA) FF stated she has worked in the facility for six years. She was on the tray line and said she follows the tray ticket instructions for portions and items to be included. DA FF acknowledged the possibility that she may have unintentionally placed an incorrect item on a tray. An interview was conducted on 5/14/2025 at 1:31 PM, Dietary Aide (DA) GG stated she has been working in the facility for nearly three years. Her role involves checking tray tickets and verifying that the correct meal components are included. She confirmed she added the chocolate cake to tray's and stated that if a resident has a chocolate allergy, they are typically given fruit instead. An interview was conducted on 5/14/2025 at 1:35 pm, Dietary Aide (DA) HH confirmed her responsibility was to add drinks, desserts, condiments, and silverware on the day in question. She stated she ensures the tray slip matches the items included but emphasized that DA GG was the last person verifying the trays before they were placed on the cart. An interview was conducted on 5/14/2025 at 1:39 pm, Dietary Aide (DA) II stated she had been employed at the facility for about a week. On the day in question, she stated she was stationed in the middle of the tray line serving beverages and desserts, including the cake. She confirmed that DA GG was responsible for final verification. DA II stated she checks the tray tickets but did not notice any residents listed with a chocolate allergy. An interview was conducted on 5/14/2025 at 1:43 pm, Dietary Kitchen Manager (DKM), who has served in her role for two years, explained the process: cooks plate the food per the tray ticket, and dietary aides add beverages, condiments, and desserts. She stated that dietary staff are trained to review tray slips, which include residents' allergies at the top and bottom. DKM confirmed that if a resident is allergic to chocolate, it should be visibly indicated, and substitutions such as fruit are expected. Observations and interviews were conducted on 5/14/2025 at 1:52 pm, in R56's room, DKM, DA FF, DA GG, DA HH observed and confirmed R56's tray to contain a piece of chocolate cake. DA GG stated she was sure she had removed the chocolate cake, but she could not confirm if another staff member placed it back. She mentioned she was aware that R56 is allergic to chocolate. The DKM further confirmed that R56 is also not supposed to have rice, and this preference was not followed. Staff present collectively acknowledged that R56 does not like rice and is allergic to chocolate and should not have been served. The DKM stated her expectation is for all dietary staff to follow tray tickets carefully and the failure to adhere to these protocols has the potential to result in an allergic reaction and resident dissatisfaction. An interview was conducted on 5/15/2025 at 3:47 pm, the Administrator stated that the expectation is for dietary staff to follow tray slips carefully, especially regarding resident allergies and food preferences. Additionally, CNAs are expected to verify the tray slip before serving the tray to the resident, ensuring that the correct meal is provided. Failure to do so may result in a resident receiving a food item they are allergic to, which could lead to serious medical complications.

Based on staff interviews, record review, and review of the facility's policy and procedures titled Required Training - Partner Education and Tracking and the Alliant Health Solutions Staff development, the facility failed to ensure seven out of 37 Certified Nursing Assistants (CNA) completed the required 12 hours of annual in-service training. Findings include: Review of the facility's policy titled Required Training - Partner Education and Tracking dated 7/15/2016 under section titled, Curriculum(s) and sub-section title Annual revealed, based on job roles, all partners are assigned an annual training curriculum designed to meet federal standards and company expectations. Review of the Alliant CNA Annual Report dated 12/18/2023 for review period 8/1/2022 - 7/31/2023 revealed a staff development review was conducted on 12/18/2023 and problems identified were seven full time Certified Nursing Assistants (CNA) without the required 12 in-service hours per the code of Federal Regulations (42CFR483.35/483.95). Recommendations included, please submit a plan of correction on how the facility will monitor CNA staff for required in-service hours in the future. Comments included the facility may want to include more in-service on Alzheimer's, dementia, and cognitively impaired. The letter listed each CNA who did not meet the Federal in-service requirements with their certification date, certification number, certification expiration date, and total of in-service hours completed during the review period. During the review period CNA KK completed seven and sixty-five hundredths 7.65 hours, CNA LL completed four and one quarter (4.25) hours, CNA MM completed nine and four tenths (9.40) hours, CNA JJ completed two and seven tenths (2.70) hours, CNA NN completed zero (0) hours, CNA OO completed two and eight tenths (2.80) hours, and CNA PP completed one and fifteen hundredths (1.15) hours. Review of the course completion history dated 8/1/2023 - 1/18/2024 for the CNA's who were deficient during the review period revealed that they had completed computer modules during the current review period. The document revealed CNA JJ had completed 25.48 hours, CNA KK had completed one and seventy-five hundredths (1.75) hours, CNA LL had completed 12.95 hours, CNA II had completed three and five tenths (3.5) hours, CNA MM had completed seven and five tenths (7.50) hours, CNA NN had completed 11.88 hours, and CNA OO had completed one and seventy-two hundredths (1.72) hours during this period. Interview with the Clinical Competency Coordinator on 1/18/2024 at 2:04 pm revealed that she had been in this position since February of 2023 and she was not able to locate documentation of the previous Clinical Competency Coordinators in-person in-services conducted, therefore she could only confirm in-services she had conducted since February 2023 through the end of the audit period of staff who had completed computer modules which was submitted to Alliant. She stated she spoke with a representative from Alliant who instructed her there was no way to correct the compliance from the last review period but suggested for her to develop a plan of correction to prevent this from happening during the current review period and in the future. She revealed as the clinical competency coordinator her expectation of staff was to complete their computerized modules each month as they are assigned. She stated there was no excuse for staff not to complete them and if they had completed the monthly assigned modules, they would have easily met the 12-hour educational requirement for CNA's. Interview with the Director of Health Services (DHS) on 1/18/2024 at 2:25 pm revealed she expected the entire clinical staff including the CNAs to complete their monthly assigned computer modules. She stated if this was done, they would have easily met the 12-hour requirement. She stated that she expects this to be followed to keep the staff on track with their education requirements. Interview with CNA II on 1/18/2024 at 2:35 pm, confirmed she did not meet the 12-hour education requirement during the facilities audit period and planned to make education a priority going forward. She stated that she did not think her work duties prevented her from completing the modules in a timely manner. Interview with the Administrator on 1/18/2024 at 4:22 pm revealed that her expectation that all CNA's complete their education hours and they have 12 months to complete them as they are assigned new modules monthly. She stated the Clinical Competency Coordinator was speaking with staff individually to determine barriers for completing the education modules in a timely manner.

Based on staff interviews and record reviews, the facility failed to refer a Level II PASRR (Preadmission Screening and Resident Review) to the appropriate state-designated authority for evaluation and determination of specialized services for one of 43 sampled Residents (R) (R47) reviewed with serious mental illness. This deficient practice has the potential to delay specialized care and treatment for the resident. Findings include: Review of R47's Georgia Department of Medical Assistance PASRR Level 1 Application (DMA-613) Resident Identification Screening Instrument dated 6/3/2022 revealed, the resident did not have a primary diagnosis of Dementia, Serious Mental Illness, or Mental Disorder. Review of R47's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, for Section A: Identification Information, indicated the resident admitted on [DATE], Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment, Section N: Medications, indicated use of antipsychotics. Review of R47's medical records revealed diagnoses that included cerebral infarction and alcohol dependence with other alcohol-induced disorder, psychotic disorder with delusions due to known physiological condition (added 9/8/2022), anxiety disorder due to known physiological condition (added 12/18/2022), Major Depressive Disorder MDD (added 8/10/2022). Review of R47's Physician Orders included buspirone tablet 7.5 milligrams (mg) dated 12/18/2022, Depakote (divalproex) tablet, delayed release 250 mg; amount three tabs oral at bedtime dated 6/3/2022, risperidone tablet three mg one tablet oral once a day and behavior monitoring every shift dated 6/6/2022. Review of R47's care plan indicated he received psychotropic medications including antipsychotic and antianxiety related to Traumatic Brain Injury (TBI), Major Depressive Disorder, Bipolar, paranoia, and anxiety; the resident had impaired cognition related to short term memory loss and was at risk for further decline related to the history of Subarachnoid Hemorrhage (SAH)/TBI, CVA (Cerebral Vascular Accident). During an interview with Social Worker AA on 1/19/2024 at 11:30 am revealed a Level II had not been submitted for R47. She revealed the criteria for mental health diagnosis that could trigger a Level II include, schizophrenia, major depressive disorder, and mood disorder. She revealed if a resident had one of these diagnoses she would submit a PASRR Level I application to see if that would trigger a Level II. During an interview with the Admissions Director (AD) on 1/19/2024 at 11:45 am revealed the hospital completed the PASRR Level I application before the resident was admitted . The AD revealed if the primary diagnosis required a Level II the facility would submit the information to the authorized state agency. During an interview with the Administrator on 1/19/2024 at 11:45 am revealed the resident came to the facility with a Level I and if a Level II was needed the Social Worker would complete the form and send it to authorized state agency. She revealed if a resident during their stay was diagnosed with a qualifying diagnosis, a Level I should have been submitted that would trigger a Level II. During an interview with the Administrator on 1/19/2024 at 2:30 pm, she reported that [NAME] Health did not have a policy for PASRRs.

Based on observations, staff and resident interviews, record review, and review of the facility's policy and procedures titled Specialty [NAME]: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, the facility failed to assist one of 43 sampled Residents (R) (R101) in gaining access to vision services by making an appointment and arranging transportation. Findings include: Review of the facility's policy titled Specialty [NAME]: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health dated 12/6/2022, Policy Statement revealed, It shall be the responsibility of this healthcare center to obtain regular and emergency specialty services for each patient/resident to ensure the highest well-being of the residents. The healthcare center has specialty service providers who provides consultation, participates in in-service education, and is available in case of emergency. Interview on 1/16/2024 at 3:54 pm with R101 revealed that he had reported to staff in the facility that his vision had declined in his right eye on multiple occasions. He stated he had told a nurse and the physician about this. He reported the last time he spoke to anyone about his vision was about two weeks ago but was unable to identify who he had spoken with. Interview on 1/17/2024 at 1:40 pm with R101 revealed that he had experienced vision problems in the past. He revealed he had surgery on both eyes in 2021 and had to have a second surgery on his right eye in 2021. R101 could not articulate the type of surgery he had, nor could he remember what the physician told him about his vision at that time. Review of the Electronic Medical Record (EMR) revealed R101 was admitted to the facility with diagnoses listed but not limited to low vision, one eye, unspecified eye and transient visual loss, left eye. Review of R101's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section B - Hearing, Speech, and Vision, R101 vision was assessed as adequate - sees fine detail, including regular print in newspaper/books and corrective lenses (contacts, glasses, or magnifying glass) were used. Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) of 13, which indicated R101 was cognitively intact. Review of R101's care plan dated 12/29/2023 revealed there were no interventions noted for visual needs. Review of nursing admission observation dated 8/18/2023 under section titled Eyes, Ears Nose, and Throat indicated R101 had no decrease in peripheral vision, no visual disturbances, both left and right eyes were clear, the sclera white, and conjunctiva was normal. Review of the EMR revealed physician's orders for R101 dated 8/18/2023 documented may have podiatry/dental/ophthalmic care as needed and on 11/26/2023 Ophthalmology consult special instructions included - second request, patient needs to see ophthalmology for decreased vision. Review of the EMR revealed progress note entered by the physician on 10/2/2023 and documented in his note that the patient informs of decreased vision to left eye, informs it comes and goes for some time and is chronic in nature. New orders for ophthalmology, consult earliest available. Review of the EMR revealed on 11/21/203 the physician documented in his progress note the patient informs he would like to see ophthalmology for decreased visual acuity. New orders written for ophthalmology consult and social worker notified. Review of EMR revealed an office note from a retina medical practice dated 8/26/2021 documented a post-operative visit check of repaired cataract (lens) fragments in eye following cataract surgery right eye. The history of present illness indicated blurred vision in right eye of moderate severity located in central vision with a hazy quality. Other diagnoses listed were mile non-proliferative diabetic retinopathy both eyes and diabetes type two with ocular complications. Interview with Social Worker AA on 1/17/2024 at 1:40 pm she verified and confirmed that the physician documented on a progress note on 10/2/2023 and 11/21/2023 the resident requested to see an ophthalmology and documented he ordered ophthalmology consult on both notes and noted on 11/21/2023 he spoke with the social worker. She verified and confirmed that the physician entered an order in the EMR on 11/26/2023 for an ophthalmology appointment with second request documented as part of the order. She stated she would have to look at her emails from the time these orders were documented to verify R101 was placed on the schedule for the contracted physician specialty group to see an ophthalmologist, she stated she would update the surveyor of her findings. She revealed the ophthalmologist only comes to the facility about once every six months and she was unsure of when their last visit was. (Social Work AA did not update the surveyor on her findings). Interview with the Assistant Director of Health Services (ADHS) on 1/17/2024 at 3:25 pm revealed she was familiar with R101. She verified and confirmed the physician documented on a progress note on 10/2/2023 and 11/21/2023 the resident requested to see an ophthalmology and documented he ordered ophthalmology consult on both notes and noted on 11/21/2023 he spoke with the social worker. She verified and confirmed that the physician entered an order in the EMR on 11/26/2023 for an ophthalmology appointment with second request documented as part of the order. She stated if R101 had an appointment it would be in the appointment schedule book. She reviewed the schedule books for January 2024 and December 2023, but the resident did not have an appointment in the books. Interview with the Administrator on 1/17/2024 at 3:55 pm revealed that since she had been in the facility, they have made a lot of changes. She stated they had identified getting referrals scheduled as a problem. She stated she was rebuilding the entire team in this facility. She stated they were working to get R101 an appointment to have his eyes checked tomorrow. Interview with the Director of Health Services (DHS) on 1/17/2024 at 4:07 pm revealed she was familiar with R101 and was not aware that he had requested a referral to see an ophthalmologist. She stated she knew he had a history of diabetes mellites type two and with that could mean he may have a history of diabetic retinopathy. She stated that since working in this facility they had noticed there was a problem with the process of scheduling referral appointments, and they had been working to improve this process starting with the initial appointment referral through scheduling follow up appointments.

Based on observations, staff interviews, record review, and review of the facility's procedure titled Small Volume Nebulizer, the facility failed to follow infection control measures during the storage of nebulizer equipment for one of two Residents (R) (R9) who receive nebulized medications. Findings include: Review of the facility's procedure titled Small Volume Nebulizer dated 2019 revealed under the section titled, Supplies listed a plastic bag for storing the mouthpiece and tubing when not in use. Under the section titled, Procedure revealed, .17. Dissemble and rinse the SVN (small volume nebulizer) and mouthpiece, shaking out excess moisture. Store the setup in the bag at the bedside. Change the nebulizer cup and tubing according to the facility policy. Observation on 1/16/2024 at 11:40 am of nebulizer set up/mask not in use on R9's nightstand uncovered and unbagged. Observation on 1/16/2024 at 2:08 pm of nebulizer set up/mask not in use on R9's nightstand uncovered and unbagged. Observation on 11/17/2024 at 11:08 am of nebulizer set up/mask not in use on R9's nightstand uncovered and unbagged. Review of the Electronic Medical Record (EMR) revealed R9 was admitted to the facility with diagnoses listed but not limited to unspecified asthma, history of acute respiratory failure with hypoxia, and history of viral pneumonia. Review of R9's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of R9's care plan dated 11/21/2022 indicated she required oxygen use related to asthma, shortness of breath, hypoxia. Goals included but not limited to will maintain optimal breathing and oxygen level within constraints of diagnoses. Intervention included but not limited to nebulizer treatment as per orders. Review of R9's EMR revealed physician orders dated 3/17/2023 included but was not limited to albuterol sulfate solution for nebulization; 2.5 milligrams (mg)/ 3 (three) milliliters (ml) (0.083%), amount 3 ml; inhalation twice a day at 9:00 am and 9:00 pm; and on 4/27/2023 Oxygen: Change respiratory circuit/supplies weekly. Once a day on Sunday's. Interview with Certified Nursing Assistant (CNA) EE on 1/17/2024 at 1:27 pm revealed when oxygen tubing / nebulizer set ups should be stored inside a clear plastic bag when not in use. Interview with Registered Nurse (RN) DD on 1/17/2024 at 1:55 pm revealed nebulizer tubing and mask should be stored in a clear plastic bag when not in use. Interview with Licensed Practical Nurse (LPN) FF on 1/17/2024 at 2:26 pm, she verified and confirmed the nebulizer mask was sitting on R9's nightstand and was not covered or inside a clear plastic bag. She stated the mask should be stored inside a clear plastic bag when not in use and the tubing and mask are changed weekly on Sunday by nursing. She stated she would obtain new tubing/mask for R9 and a bag to store them in for R9. Interview with the Director of Health Services on 1/17/2024 at 4:07 pm revealed the process of caring for nebulizer tubing/mask was the nurse should administer the medication via nebulizer as ordered by the physician, then after the nebulizer was complete the nurse should clean the mask with soap and water and allow to air dry, then once the mask was dry it should be stored in a clear plastic bag. She stated she expected nursing to follow this process on every occasion when the nebulizer was used.

Based on interviews, record review, and review of the facility policy, the facility failed to ensure residents were free from abuse. Specifically, the facility failed to ensure four residents (R) (residents (R9, R14, R25, and one unknown resident) were free from sexual abuse by R10; and eight residents (R15, R11, R19, R20, R16, R17, and R18) were free from physical abuse in a sample of 35 residents. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/27/2020 revealed: It is the policy of PruittHealth and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. Sexual abuse incidents: 1. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R10 with a Brief Interview of Mental (BIMS) score of seven, indicating severely impaired cognition. Resident was documented as having no behaviors. He required one person supervision with walking in room and corridor, and independent with no setup help needed for locomotion on and off the unit. He had diagnoses including but not limited to Dementia and Psychotic Disorder. a. Review of the Quarterly MDS dated [DATE] revealed R9 with a BIMS score of four, indicating severe cognitive impairment. R9 requires one-person limited assistance with walking in room and locomotion on the unit. Resident required one-person extensive assistance with walking in the corridor and locomotion off the unit. Resident had diagnoses including but not limited to Cerebral Vascular Accident (CVA) and Dementia. No behaviors were documented. Review of Facility Reported Incident (FRI) dated 5/29/2023 revealed R10 walked up to R9 with his penis out and touched R9's head/neck area and pulled her head downwards towards him. Family of R9 called the police and R10 was arrested for this incident. R10 did not return to the facility. Review of the police report dated 5/29/2023 revealed R10 was arrested for an offense of sodomy, aggravated sodomy and charged with criminal intent and public indecency During an interview on 9/18/2023 at 10:24 a.m., Licensed Practical Nurse (LPN) AA stated she was charting at the nurses' station and two certified nursing assistants (CNAs) brought the incident between R9 and R10 to her attention. LPN AA stated she observed R9 seated in a chair and R10 standing to the left of R9 with his penis protruding from his pants. LPN AA stated she removed both residents from the area and reported the incident. During an interview on 9/18/2023 at 11:01 a.m., LPN EE stated she was charting at the nurses' station and CNAs brought the incident between R9 and R10 to her attention. LPN EE stated she saw R10's penis in his hand and was standing near R9, who was seated in a Geri chair. LPN EE stated they reported the incident and called the family. b. Review of the Annual MDS assessment dated [DATE] revealed R14 with a BIMS score of three, indicating severe cognitive impairment. No behaviors were documented. The resident required one-person extensive assistance with walking in the room, and no setup/ independent locomotion on and off the unit. R14 had a diagnosis including but not limited to Alzheimer's Disease. Review of FRI dated 9/12/2022 revealed R14 informed staff she had consensual sex with R10. There was no documented evidence the facility put interventions in place related to the incident. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she viewed this incident with R14 and R10 as consensual sex. Due to the Administrator's view, no interventions were implemented related to the incident. During an interview on 9/18/2023 at 10:24 a.m., LPN AA further revealed R14 stated she had sex with another resident and was able to identify R10. LPN AA stated she also reported this incident. 2. Review of R10's Progress Note dated 7/29/2022, revealed, Resident asked another female resident for sexual favor. Facility staff was unable to identify the female resident in this incident. Review of R10's Progress Note dated 4/23/2022, revealed, Resident observed going in and out of female resident's room. One female resident reported that Resident asked her to perform a sex act. That female resident was visibly shaken when reporting the problem. Facility staff were able to identify this resident as R25 (BIMS of 11, indicating moderate cognitive impairment and no behaviors documented). During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she was unaware of these incidents occurring on 7/29/2022 and 4/23/2022, therefore no interventions were implemented. During an interview on 9/18/2023 at 11:15 a.m., the Social Services Director (SSD) stated she was aware of the 4/23/2022 incident where R10 asked R25 for a sexual favor. The SSD stated she did not do anything about this incident. The SSD stated that she should have put R10 on a behavioral management program immediately but did not do so until 5/26/2022. Physical Abuse incidents: 3. Review of the Quarterly MDS assessment dated [DATE] revealed R19 with a BIMS of 15, indicating cognitively intact. Resident required one-person supervision with locomotion on and off the unit. The resident uses a wheelchair. No behaviors documented. Review of the Quarterly MDS Assessment also dated 8/10/2023 revealed R20 with a BIMS of 10, indicating moderate cognitive impairment. Resident required one person supervision with locomotion on and off the unit. The resident uses a wheelchair. R20 had a diagnosis of Alzheimer's Disease. Review of FRI dated 8/29/2023, R19 alleged R20 hit her and pulled her hair and R19 threw water in R20's face. R19 stated R20 and Family of R20 dragged R19 to the ground. Staff heard the incident and observed R19 on the floor. There was no documented evidence the facility put interventions in place related to the incident. 4. Review of the Quarterly MDS assessment dated [DATE] revealed R16 with a BIMS score of 12, indicating moderate cognitive impairment. No behaviors documented and resident required one person supervision with locomotion on and off the unit. The resident used a wheelchair. R16 had diagnoses including but not limited to CVA with hemiplegia or hemiparesis and Depression. Review of the Admission MDS assessment dated [DATE] revealed R17 with a BIMS of three, indicating severe cognitive impairment, wandering behavior one to three days, used a wheelchair and required one-person limited assistance with locomotion on the unit. Review of FRI dated 8/24/2023 revealed R16 and R17 got into a physical altercation and R17 scratched R16 in his face. Review of R16's Progress Note dated 8/24/2023 revealed, [R17] hit [R16] and he was bleeding from the nose. The writer cleaned resident nose with normal saline and also take care of the nose from bleeding upon assessment. 5. Review of the Admission MDS dated [DATE] revealed R15 with a BIMS of 15, no behaviors documented, and required one-person extensive assistance with walking in room and locomotion on and off the unit. The resident used a wheelchair. The resident was discharged on [DATE]. Review of the Quarterly MDS assessment dated [DATE] revealed R11 with a BIMS of 15, no behaviors documented and required no setup/ independent with all Activities of Daily Living (ADLs). Review of FRI dated 4/23/2023 revealed R15 and R11 got into a physical altercation. R11 sustained scratches and bruises. 6. Review of the Annual MDs assessment dated [DATE] revealed R18 with a BIMS score of 8, indicating moderate cognitive impairment. No behaviors were documented. The resident required one person supervision with walking and locomotion, used a wheelchair and walker. The resident had diagnoses including but not limited to CVA with hemiparesis or hemiplegia, Dementia, and Depression. Review of FRI dated 12/16/2022 revealed R18 received a scratch on right arm from [R10] after words exchanged. During an interview on 9/12/2023 at 4:00 PM, the Administrator confirmed she was the Abuse Coordinator for the facility. The Administrator stated although she reported the physical altercations above, she did not put interventions in place to prevent the incidents from recurring.

Based on interviews, record reviews, and review of the facility policy, the facility failed to thoroughly report and investigate incidents of abuse. Specifically, the facility failed to report and/or thoroughly investigate incidents of sexual abuse for four residents (R) (residents (R9, R14, R25, and one unknown resident); and of physical abuse for eight residents (R15, R11, R19, R20, R16, R17, R10, R18) in a sample of 35 residents. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/9/2020 revealed It is the policy of PruittHealth and its affiliated provider entities (collectively, the Organization) to investigate allegations and occurrences of patient abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. Documentation of the investigation should include, but not be limited to, the following: * Date and time of alleged occurrence. * Patient's full name and room number (or address, if at home). * Names of accused and any witnesses. * Names of PruittHealth partners staff who investigated the allegation. * Any physical evidence and description of emotional state of patient(s). * Details of the alleged incident and injury. * Signed statements from pertinent parties; * Cognitive status of victim(s) and patient(s) who are witnesses (e.g., whether they are alert, oriented, and able to answer questions appropriately, which could help in determining whether the witness is credible and able to testify); * Information gathered from the investigation. * Action taken by provider (e.g., safeguarding the patient and preventing a reoccurrence); * The conclusions reached by the investigator; * Name, address, and phone number of the responsible party and relatives of the Victim(s); and * Any other police or ombudsman reports or other documentation related to the investigation. Sexual abuse incidents: 1. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R10 with a Brief Interview of Mental (BIMS) score of seven, indicating severely impaired cognition. a. Review of the Quarterly MDS dated [DATE] revealed R9 with a BIMS score of four, indicating severe cognitive impairment. Review of Facility Reported Incident (FRI) dated 5/29/2023 revealed R10 walked up to R9 with his penis out and touched R9's head/neck area and pulled her head downwards towards him. Review of the facilities records revealed no evidence that the facility thoroughly investigated the incident and did not report the incident to the police. Family of R9 called the police and R10 was arrested for this incident. During an interview on 9/18/2023 at 10:24 a.m., Licensed Practical Nurse (LPN) AA stated she observed R9 seated in a chair and R10 standing to the left of R9 with his penis protruding from his pants. LPN AA stated she removed both residents from the area and reported the incident. During an interview on 9/18/2023 at 11:01 a.m., LPN EE stated she saw R10's penis in his hand and was standing near R9, who was seated in a Geri chair. LPN EE stated they reported the incident and called the family. b. Review of the Annual MDS dated [DATE] revealed R14 with a BIMS score of 3, indicating severe cognitive impairment. Review of FRI dated 9/12/2022 revealed R14 informed staff she had consensual sex with R10. There is no documented evidence that this incident was thoroughly investigated. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she viewed this incident with R14 and R10 as consensual sex. Due to the Administrator's view, this incident was not thoroughly investigated. During an interview on 9/18/2023 at 10:24 a.m., LPN AA further stated R14 stated she had sex with another resident and was able to identify R10. LPN AA stated she also reported this incident. 2. Review of R10's Progress Note dated 7/29/2022, revealed, Resident asked another female resident for sexual favor. Facility staff was unable to identify the female resident in this incident. Review of R10's Progress Note dated 4/23/2022, revealed, Resident observed going in and out of female resident's room. One female resident reported that Resident asked her to perform a sex act. That female resident was visibly shaken when reporting the problem. Facility staff was able to identify this resident as R25. (BIMS of 11, indicating moderate cognitive impairment). There is no documented evidence that the incidents were thoroughly investigated. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated she was unaware of these incidents, and they were never reported or investigated. During an interview on 9/18/2023 at 11:15 a.m., the Social Services Director (SSD) stated she was aware of the 4/23/2022 incident where R10 asked R25 for a sexual favor. The SSD stated she did not do anything about this incident. Physical Abuse incidents: 3. Review of the Quarterly MDS assessment dated [DATE] revealed R19 with a BIMS of 15, indicating cognitively intact. Review of the Quarterly MDS Assessment also dated 8/10/2023 revealed R20 with a BIMS of 10, indicating moderate cognitive impairment. Review of FRI dated 8/29/2023, R19 alleged R20 hit her and pulled her hair and R19 threw water in R20's face. R19 stated R20 and Family of R20 dragged R19 to the ground. Staff heard the incident and observed R19 on the floor. 4. Review of the Quarterly MDS assessment dated [DATE] revealed R16 with a BIMS score of 12, indicating moderate cognitive impairment. Review of the Admission MDS assessment dated [DATE] revealed R17 with a BIMS of three, indicating severe cognitive impairment. Review of FRI dated 8/24/2023 revealed R16 and R17 got into a physical altercation and R17 scratched R1 in his face. Review of R16's Progress Note dated 8/24/2023 revealed, [R17] hit [R16] and he was bleeding from the nose. The writer cleaned resident nose with normal saline and also take care of the nose from bleeding upon assessment. 5. Review of the Admission MDS dated [DATE] revealed R15 with a BIMS of 15. Review of the Quarterly MDS assessment dated [DATE] revealed R11 with a BIMS of 15. Review of FRI dated 4/23/2023 revealed R15 and R11 got into a physical altercation. R11 sustained scratches and bruises. 6. Review of the Annual MDs assessment dated [DATE] revealed R18 with a BIMS score of 8, indicating moderate cognitive impairment. Review of FRI dated 12/16/2022 revealed R18 received a scratch on right arm from [R10] after words exchanged. There is no documented evidence that the incidents of physical abuse were thoroughly investigated. During an interview on 9/12/2023 at 4:00 PM, the Administrator confirmed she was the Abuse Coordinator for the facility. The Administrator stated although she reported the physical altercations above, she did not thoroughly investigate the incidents. The Administrator stated she did not substantiate the incidents as abuse.

Based on interviews, record review, and review of the Administrator position description, facility Administration failed to effectively oversee an abuse prevention program to promote, foster and maintain an abuse free environment. The facility census was 113. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the Administrator's position description signed by the Administrator on 2/6/2022 revealed the job purpose is to direct the day-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers . Key responsibilities include current knowledge of state and federal laws governing the operation of nursing facilities .Demonstrates knowledge of and respect for the rights, dignity and individuality of each patient/resident in all interactions. Demonstrates competency in the protection and promotion of resident rights. The Administration failed to demonstrate competency consistently and effectively in the protection and promotion of residents' rights to be free from abuse that were included in the Administrator's job description. 1. Administration failed to maintain an environment free from sexual abuse for four residents (R9, R14, R25, and one unknown resident) all perpetuated by R10; and failed to maintain an environment free from physical abuse for eight residents (R#15, R#11, R#19, R#20, R#16, R#17, R#10, R#18) Cross refer to F600. 2. Administration failed to ensure that incidents of sexual abuse of four residents (R#9, R#14, R#25, and one unknown resident) and of physical abuse of eight residents (R#15, R#11, R#19, R#20, R#16, R#17, R#10, R#18) were thoroughly investigated, and corrective actions implemented, including protection of the residents, in a timely manner. Cross refer to F610. During an interview on 9/12/2023 at 4:00 PM, the Administrator stated that she was the Abuse Coordinator. She stated that she did not substantiate the above incidents as abuse. The Administrator stated and she considered an incident to be abuse only if the resident states he/she feels abused. During an interview on 9/13/2023 at 11:45 a.m., Regional Nurse Consultant (RNC) NN, stated she was unaware of many of the incidents of physical and sexual abuse that had occurred at the facility. RNC NN stated she had told the Administrator over and over to reach out to me when these types of things happen.

Based on record review, family interview, and staff interview, the facility failed to notify the resident's representative timely of a fall with injury and hospitalization for one resident (R) (9) of three residents reviewed for change in condition. Findings include: R9 was admitted to the facility on [DATE] with the following diagnoses: vascular dementia, dysphagia, aphasia, and adult failure to thrive. Review of the 4/28/2023 Admission Minimum Data Set (MDS) Assessment revealed a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. Review of the 4/29/2023 Progress Note revealed, Resident was found on the floor away from her room and was observed with swelling and blood on her mouth. Prior to the fall, resident was observed wandering on the hall. NP (Nurse Practitioner) .was called and ordered for resident to be sent to the hospital. Resident was transferred to the hospital. No contact listed on the face sheet to be notified. During an interview on 9/12/2023 at 4:19 p.m., Family of R9 stated he came to visit R9 and her lip was swollen, and she had stitches in her lip. I was shocked because I wasn't called and didn't know anything had happened to her. Review of R9's electronic medical record (EMR) revealed R9's Admission Packet and hospital referral forms, which contained Family of R9's contact information, was uploaded into the EMR on 4/27/2023. During an interview on 9/18/2023 at 1:11 p.m., the Admissions Coordinator (AC) stated, If the resident representative's number is not listed on the face sheet, the staff can look on the hospital face sheet or elsewhere in the medical record. During an interview on 9/18/2023 at 6:47 p.m., Licensed Practical Nurse (LPN) FF stated she wrote the 4/29/2023 progress note. LPN FF stated she did not contact the (Family of R9) because there was no number on the face sheet. LPN FF additionally stated that she did not check other locations in R9's medical record. LPN FF stated that Family of R9 was upset the next day when he came to the facility, and no one had contacted him. During an interview on 9/18/2023 at 3:28 p.m., the Administrator stated family should be notified regarding any change in condition. The Administrator stated staff should have checked the entire medical record for contact information and had not done so for R9 fall and hospitalization .

Based on record review, interview, and facility policy review, the facility failed to develop a care plan for two residents (R) (R9 and R10) from a total sample of 35 residents. Specifically, the facility failed to develop a care plan that addressed R9 and R10's wandering behavior that led to elopements from the facility. Findings include: Review of facility policy titled, Elopement Prevention, revised 6/2/2017, revealed, Prior to or at the admission each resident shall be assessed for risk factors for unsafe wandering. An appropriate care plan shall be implemented to address each resident's needs. 1. R9 was admitted to the facility on [DATE] with the following diagnoses: vascular dementia, dysphagia, aphasia, and adult failure to thrive. Review of Progress Notes dated 5/29/2023 and 6/22/2023 revealed R9 had eloped from the facility on these dates. Review of R9's Elopement Risk Observation dated 5/12/2023 revealed an elopement score of 15, indicating high risk for elopement. Review of R9's clinical record revealed a plan of care for wandering was not developed until 7/10/2023. An interview on 9/18/2023 at 12:19 p.m., the Director of Nursing (DON) stated that the unit manager is responsible for developing and updating care plans related to nursing. The DON stated since R9 had a risk for elopement, a care plan should have been developed prior to her eloping but was not developed. The DON stated MDSC (Minimum Data Set Coordinator) and the unit managers should have worked together to develop a plan of care. The DON confirmed the wandering care plan was not developed until 7/10/2023 after R9 had eloped twice. 2. R10 resided at the facility from 4/4/2022 through 6/1/2023 with the following diagnoses: cerebral infarction and dementia. Review of a Progress Note dated 6/25/2022 revealed R10 had eloped from the facility and was located in a nearby neighborhood. Review of a Progress Note dated 7/27/2022 revealed, Resident was observed outside building on sidewalk. Staff redirected resident back inside building. There was no care plan in the clinical record related to R10's wandering and elopement behavior. An interview on 9/18/2023 at 12:19 p.m., the DON confirmed R10 did not have a care plan for wandering or elopement. During an interview on 9/18/2023 at 1:28 p.m., MDSC LL and MDSC MM confirmed there was no wandering care plan for R10 and a wandering care plan had not been developed for R9 until after two elopements. MDSC LL and MDSC MM stated the unit managers were responsible for developing the wandering care plans. MDSC LL and MDSC MM both stated when a resident elopes or wanders, it should be captured on admission or immediately after it happens. Cross refer to F689.

Based on record review and interview, the facility failed to ensure that audiology orders were implemented, as ordered by the physician, for one resident (R7) from a total sample of 35 residents. Findings include: R7 was admitted to the facility on [DATE] with the following diagnoses: Parkinson's disease and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating R7 was cognitively intact. During an interview on 9/11/2023 at 12:31 p.m., R7 stated, I can't hear because of all the wax in my ear. They got it out one ear but not the other. R7 indicated the facility was supposed to follow up with a different physician but had not. Review of audiology report dated 5/31/2023 revealed, Cerumen was successfully removed from the right ear canal, however, cerumen in the left ear canal could not be removed completely. Recommend Debrox drops and follow up with ENT (ear, nose, throat) physician to remove cerumen in left ear canal. Review of R7's electronic medical record (EMR) revealed the last order for Debrox drops was 3/24/2023 - 3/28/2023. There were no additional orders following the 5/31/2023 audiology appointment. The EMR also revealed no documented follow up with an ENT physician. During an interview on 9/18/2023 at 12:19 p.m., the Director of Nursing (DON) stated the charge nurse should update orders in the system upon the resident's return from an appointment. The DON stated, These orders should have been followed up on but were not. During an interview on 9/18/2023 at 6:58 p.m., the Nurse Practitioner (NP) stated, I have told the staff that if residents go to any outside appointments, they should notify me of the orders and to make a copy and put them in my folder so that I can know what is going on.

Based on observation, record review and interview the facility failed to ensure that after verbal abuse was reported and the resident was protected for one (1) resident (R#1) of the nine (9) sampled residents. Resident #1 suffered actual verbal abuse and alleged physical abuse. Based on the corrective actions that the facility implemented immediately upon discovery, it was determined that a past noncomplaince beginning on 12/25/2015 and corrected on 12/29/2015. On 12/25/2016, R#1 was verbally abused and allegedly physically abused by a Certified Nursing Assistant. Upon discovery of the allegation on 12/27/2015, the facility took immediate actions including: 1. All staff was re-educated on the Abuse Policy including reporting and recognition of Abuse by the Administrator, Director of Nursing and/or Social Services, completed on 12/29/15. 2. All new staff will be educated during the orientation program by the Administrator and the Social Service Director with post testing. All 129 staff have been educated. 3. A Resident Rights inservice was conducted including the Hand in Hand module. 4. The staff identified to witness the verbal abuse was re-educated and had received training in September and December 2015. Direct one-to one (1:1) education was also provided. In addition a verbal reprimand was completed on timely reporting. 5. Residents were interviewed by social services to ensure they felt safe and had no reports of abuse. 6. Weekly meetings will continue to be held with residents to address concerns of issues that affect them. 7. The Family Council has been reinstated and the first meeting was conducted on 1/10/2016. 8. Mandatory manger rounds to communicate with staff, residents and family members occur daily. 9. All identified problems will be forward to the QAPI for investigation and resolution. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. Review of the record revealed the primary language is Spanish. The resident has [DIAGNOSES REDACTED]., [MEDICAL CONDITION] below Knee-Secondary to Diabetes, Diabetes, Muscle Weakness-general, Lack of Coordination, Cognitive communicate deficit, [MEDICAL CONDITION], and Chronic Ischemic [MEDICAL CONDITION]. Review of the Minimum Data Set (MDS) 3.0 Assessment Summary Report dated 12/1/15 indicated a Brief Interview for Mental Status (BIMS) score of 4.0, indicating severe cognitive impairment. Observation on 1/6/16 at 9:30 a.m. revealed resident #1 lying in bed, eyes closed with bruising under left eye. The head of bed elevated with padded grab bars (2) up. Fall mats on the left and right side of bed. Interview on 1/6/15 at 11:30 a.m. with R#1 revealed that she did not remember what happened to her eye. Review of the Police Department Incident Report indicated that on 12/27/15 around 11:46 a.m. the police indicated that they made contact with R#1 family. The police officer revealed that the family was in the room with the resident to help her explain the incident. The police officer revealed that the family explained they had come to visit R#1 daughter for Christmas. When they arrived on 12/27/15 around 11:00 a.m. they observed R#1 had a swollen black eye. They stated they asked R#1 what happened. Then R#1 stated to the family that on 12/25/15 early in the morning a Certified Nursing Assistant (CNA) entered the room to change her. During the changing process the CNA punched, R#1 in the left eye. R#1 described the CNA was a black female around 5' 8 with short black hair, slimmer body build and appeared to be young. R#1 revealed that the CNA had taken care of her before on different days; but, did not know her name. The police asked the resident if she would be able to recognize the CNA again; she revealed that she would. The resident was asked if the CNA was at work that day, she revealed that the CNA was not at work. Review of Situation Behavior Assessment Report (SBAR) Communication Form dated 12/27/15 indicated situation- drainage in left eye. Request: family at bedside of R#1. Family called 911, and wants R#1 to be transferred to emergency room (ER) for drainage of left eye. R#1 transferred to ER per family request via stretcher. Review of the Physician's Interim Orders indicated an order dated 12/27/15 for X-Ray of left orbit. Review of the physician's orders [REDACTED]. Review of the Discharge Instructions for R#1 dated 12/27/15 from the hospital indicated discharge instructions-Nasal Fracture and Subconjunctival Hemorrhage-Brief (which may be due to injury or to straining ( lifting,sneezing, or coughing). Review of the Ear Throat NoseMedical Doctor (MD) indicated R#1 was seen on 12/31/15 and [MEDICATION NAME] Propionate 50 MCG/ACT Suspension 2 spray each nostril QD (every day) was ordered. Review of the Radiology Report dated 1/4/16 indicated exam: X-Rays of the Nasal Bones, findings: No gross nasal bone fracture. Bone mineral density is preserved. The maxillary spine is grossly intact bilaterally. Review of Eye MD assessment of R#1, dated 1/5/16 indicated a [DIAGNOSES REDACTED]. 1. Interview on 1/6/16 at 2:29 p.m. with Housekeeping staff NN revealed attending classes on abuse. Housekeeping staff NN revealed that he had not seen any physical abuse towards the residents. Continued interview on 1/6/16 at 2:29 p.m. with Housekeeping staff NN revealed that on 12/25/15 at about 9:45 a.m., he was asked to get some pillowcases. Housekeeping staff NN revealed that he and Housekeeping staff OO were outside of R#1 room. Housekeeping staff NN revealed that CNA JJ was inside of the doorway of R#1 by herself. Housekeeping staff NN revealed that he heard CNA JJ say to the R#1 , don't give me a f-cki-n- hard time about putting on your clothes!. Housekeeping staff NN revealed that when CNA JJ saw him, JJ closed the door. Housekeeping staff NN revealed that JJ later came out and asked another CNA (KK) to help her. Housekeeping staff NN revealed that he left the area. Housekeeping staff NN further revealed seeing R#1 on 12/25/15 in the morning and, that R#1 did not have any problems with her eye. Housekeeping staff NN revealed seeing R#1 on 12/26/15 around 7:00 a.m. to 7:15 a.m. when he arrived for dusting and mopping of the floor. Housekeeping staff NN stated that R#'1's eye were puffy, messed up, black and bruised. Housekeeping staff NN revealed that one of the nurses that speak Spanish, the Supervisor on the weekend spoke Spanish asked R#1 what happened and no one knows. Review of a written signed statement by Housekeeping NN confirmed the above interview, including hearing the verbal abuse from CNA JJ to R#1, and leaving the area without intervention. In review of the written statement, he described the door to be slammed. 2. Interview on 1/6/15 at 1:19 p.m. with CNA KKrevealed that she has had inservice on abuse. She revealed on 12/25/15 CNA JJ asked if she could come over to help with R#1. She revealed that after she finished with her resident, she went to assist CNA JJ with R#1. She revealed that while helping with R#1, she noticed one of resident's eye was closed. She revealed that she asked, CNA JJ why was the resident's eye closed and CNA JJ stated that she did not know, but that she noticed that the R#1 eye was grayish. Continued interview on with CNA KK revealed that License Practical Nurse (LPN) LL completed an assessment on R#1, and notified the Supervisor Registered Nurse (RN) MM. CNA KK revealed that she did not hear any noise coming from R#1 room, and normally R#1 would fight when care was given but, R#1 was at ease. CNA KK continued to reveal that LPN LL had given R#1 medication to keep R#1 calm. Then, CNA KK asked R#1, what happened to her eye, she revealed that the resident revealed that a lady hit her; but, she could not remember who. CNA KK revealed that the eye looked grayish. She revealed that this occurred right before 11:30 am - lunch time (on 12/25/15). She revealed that R#1 did not seem to be frighten of CNA JJ. CNA KK revealed that R#1 did not make any type of move as if afraid of the CNA JJ. CNA KK revealed that the door was open across the hall from R#1 room; and, that she did not hear any screaming from R#1, whose her door was cracked open. Review of the Medication Record for R#1 dated 12/1/15 through 12/31/15 indicated [MEDICATION NAME] (a medication used for anxiety) tablet 0.5 mg one (1 )tablet was administered given 12/25/15 at 8:00 a.m. and 1:00 p.m. Second interview on 1/8/16 at 2:00 p.m. with CNA KK revealed that they (CNA JJ) were transferring R#1 with the Hoyer lift from the bed to the chair, when she noticed R#1 eye, it was grayish, the eye was not able to be opened, and it was red. CNA KK revealed that the R#1 was not combative because the nurse had given her medication and the nurse said that it was a reaction to medication. 3. Interview on 1/8/16 at 1:34 p.m. with LPN LL confirmed that she was the nurse on duty 12/25/15 of the 7-3 shift. LPN LL revealed she saw R#1 on 12/25/15 as follows: at 7:00 a.m. to 7:30 a.m., rounds were made and R#1, had no problems; at 9:00 a.m. R#1 received medications and had no problems, and; at 11:00 a.m. to 12:00 p.m. Supervisor RN MM, CNA JJ and CNA KK were in R#1 room, when R#1 left eye was discolored and was a little swollen. LPN LL revealed that she asked what happened to the the eye, and no one knew what had happened. LPN LL stated that all the staff noticed the resident's eye at the same time. She revealed that she asked the resident what happened to the eye, and R#1 did not say any thing. LPN LL revealed documenting and completing the Situation Behavior Assessment Report (SBAR) communication form. LPN LL revealed that she notified the MD and Family. LPN LL revealed that she talked to the MD, they were not sure of what had happened to the resident's eye, an eye ointment was ordered. LPN LL stated the family said, okay about the eye. LPN LL revealed that the CNAs have had abuse inservices. She revealed that the CNA's were using the Hoyer Lift. Review of the SBAR Communication Form dated 12/25/15 indicated situation-increase swelling, increase redness, increase discoloration to left eye. Request: On call Nurse Practitioner (NP) notified-new order received to start [MEDICATION NAME] 0.5% oint every six (6) hours for seven (7) days. Responsible Party J notified. 4. Interview on 1/6/16 at 1:35 p.m. with Supervisor Registered Nurse (RN) MM revealed that she had inservice on abuse and that there had been no complaints about resident abuse to her. Supervisor RN MM confirmed being the supervision on 12/25/15. RN MM stated that the staff called her to say that the family of R#1, called to say that they were taking R#1 out for the day. Supervisor RN MM revealed that R#1 had to be taken out in a reclining chair, because the resident could not sit in a wheelchair. Supervisor RN MM stated that she went to do the assessment on R#1, and noted the resident's left eye was red and swollen. Supervisor RN MM revealed that she instructed the LPN LL to notify the Medical Doctor (MD) and the family. Supervisor RN MM revealed that LPN LL notified the MD and the family about the eye and the need of a recliner. The family decided not to take R#1 out at that time. Supervisor RN MM revealed assessing the eye to have an infection due to the redness and the swelling. The MD was notified and antibiotics were ordered. Supervisor RN MM that all of this took place around the time that the residents were dining on 12/25/2015. Supervisor RN MM revealed that she requested all the staff write a statement, since they did not know what happen to R#1 revealed that she notified the Administrator and the Director of Nursing of what had happened. Supervisor RN MM revealed that she did not talk to the family, or R#1, however she stated that R#1 did not appear to be afraid of anyone of make any type of motions indicating fear while they were in the room. Supervisor RN MM revealed that LPN LL talked to the family on 12/25/2015, about the eye, and again on that the resident's eye was red; and, on Sunday 12/27/15 when the family came to visit R#1. 5. Interview on 1/6/16 at 3:54 p.m. with LPN PP of the 3-11 shift revealed that she has had inservices on abuse. She revealed that she had not seen any abuse towards the residents. LPN PP revealed that R#1 was sometime combative; and, that usually more that one person takes care of the resident. LPN PP revealed that she came in on the evening of the allegation (12/25/15) and saw the left eye of R#1 red with pockets under it. LPN PP revealed that she asked the R#1 what happened to her eye, and R#1 would not answer. LPN PP revealed that she went and got a nurse that speaks Spanish to ask her what happen to her eye. She revealed that the resident would not explain any thing to the nurse LPN QQ . She revealed that the R#1 was started on antibiotics for her eye and it started clearing up. She revealed that the next day the swelling started going down, and the left eye sclera was clearing. She revealed that she did not see any problems with the R#1 nose. She revealed that she sent in the evening CNA to R#1; but, she would not talk to her about her eye. 6. Interview on 1/6/16 at 4:09 p.m with CNA RRof the 3-11 shift revealed that she has had inservices on abuse. She revealed that she has not seen any abuse; and, there had been no report from any family members about abuse. She revealed that she took care of R#1, that she asked R#1 what happened to her eye, R#1 revealed that she did not remember what happened to her eye. She revealed that she has a good relationship with R#1. 7. Interview on 1/6/16 at 4:21 p.m. with LPN QQ of the 3-11 shift revealed that he has had inservice on abuse. He revealed that he has not seen any abuse towards the residents. LPN QQ revealed that nurse PP asked him to go and talk to R#1, to see if she would tell him what happened to her eye. He revealed that he and the resident spoke the same language (Spanish). LPN QQ revealed that R#1 revealed that she did not know what happened. 8. Interview on 1/6/15 at 1:03 pm with the Social Worker II revealed that she interviewed R#1 and other staff members about the abuse allegation to R#1. She revealed that she turned her investigation over to the Administrator. She revealed that R#1 revealed that a thin white lady hit her in the eye with her fist. She revealed that R#1 further revealed that she was not afraid of the staff members. She revealed that the allegation supposedly occurred on the 7-3 shift on 12/25/15. She revealed that she talked to CNA JJ who revealed that CNA KK assisted her with R#1. 9. Interview on 1/6/16 at 3:43 pm with the Administrator revealed that she had training with all the staff since the allegations; and, that there was abuse training before the allegations. She revealed that she was unable to substantiate the cause of the eye injury and that she turned in her investigation to the state regulatory agency. She revealed that she went to the hospital to interview the resident; but, was not allowed to do so. She revealed that she was told by the nursing staff that they felt that it was an eye infection; because, the R#1 constantly played in feces and rubbed her eyes. She revealed that a Psych consult was completed on the resident. She revealed that the CNA JJ was inconsistent about what happened to R#1. The CNA JJ was terminated. She revealed that there had been no problems with the CNA prior to this allegation. Interview on 1/8/16 at 2:02 pm with the Administrator revealed that the MD saw the resident on 1/5/16. She revealed that the R#1 had been seen by the ENT and the EYE doctors before the MD visit. She revealed that the MD did not believe that R#1 had a nasal fracture; but, he did believe that there was trauma to her eye. She revealed that the nurses are doing two (2) hour checks on the resident,monitoring her constantly and reporting to the family. She revealed that no facility has accepted the R#1; so the family plan to take R#1 home by the end of the month.

Based on review of the Policy entitled, Prevention of Abuse, Neglect and Exploitation, record review and interview the facility failed to effectively implement their own policy to assure that resident abuse did not occur, and when it occurred the facility failed to ensure that employees followed the policy. This failure resulted in actual harm to one (1) resident (R#1) of the sampled (9) residents. On 12/25/2016, R#1 was verbally abused and allegedly physically abused by a Certified Nursing Assistant. Upon discovery of the allegation on 12/27/2015, the facility took immediate actions including: 1. All staff was re-educated on the Abuse Policy including reporting and recognition of Abuse by the Administrator, Director of Nursing and/or Social Services, completed on 12/29/15. 2. All new staff will be educated during the orientation program by the Administrator and the Social Service Director with post testing. All 129 staff have been educated. 3. A Resident Rights inservice was conducted including the Hand in Hand module. 4. The staff idenitified to witness the verbal abuse was re-educated and had received training in September and December 2015. Direct one-to one (1:1) education was also provided. In addition a verbal reprimand was completed on timely reporting. 5. Residents were interviewed by social services to ensure they felt safe and had no reports of abuse. 6. Weekly meetings will continue to be held with residents to address concerns of issues that affect them. 7. The Family Council has been reinstated and the first meeting was conducted on 1/10/2016. 8. Mandatory manger rounds to communicate with staff, residents and family members occur daily. 9. All identified problems will be forward to the QAPI for investigation and resolution. Cross reference to F223 Findings include: Review of the policy entitled, Prevention of Abuse, Neglect and Exploitation, revision date of 9/21/2015, revealed the following: Procedures: 1. Providers are to identify, correct and intervene in situation in which abuse, neglect, or exploitation may occur. This should include an analysis of: The supervision of staff to identify in appropriate behaviors, such as using derogatory language; Interview on 1/6/16 at 2:29 pm with Housekeeping staff NN revealed that on 12/25/2015 at 9:45 a.m. that he was outside of R#1 room, and that CNA JJ was inside of the room with R#1, and CNA JJ said to R#1, don't give me a f-cki-n- hard time about putting on your clothes!!. He revealed that when she saw him, JJ closed the door. He revealed that he left. Interview on 1/6/16 at 1:35 p.m. with Supervisor Registered Nurse (RN) MM revealed that there had been no complaints about resident abuse to her. Supervisor RN MM revealed that she was the supervisor on duty 12/25/15.

Based on observation, record review and interview the facility failed to ensure that the plan of care was implemented to include assistance of two (2) when giving care to one (1) resident (R#1) of the nine (9) sampled residents. On 12/25/2016, R#1 was verbally abused and allegedly physically abused by a Certified Nursing Assistant. Upon discovery of the allegation on 12/27/2015, the facility took immediate actions including: 1. All staff was re-educated on the Abuse Policy including reporting and recognition of Abuse by the Administrator, Director of Nursing and/or Social Services, completed on 12/29/15 . 2. All new staff will be educated during the orientation program by the Administrator and the Social Service Director with post testing. All 129 staff have been educated. 3. A Resident Rights inservice was conducted including the Hand in Hand module. 4. The staff identified to witness the verbal abuse was re-educated and had received training in September and December 2015. Direct one-to one (1:1) education was also provided. In addition a verbal reprimand was completed on timely reporting. 5. Residents were interviewed by social services to ensure they felt safe and had no reports of abuse. 6. Weekly meetings will continue to be held with residents to address concerns of issues that affect them. 7. The Family Council has been reinstated and the first meeting was conducted on 1/10/2016. 8. Mandatory manger rounds to communicate with staff, residents and family members occur daily. 9. All identified problems will be forward to the QAPI for investigation and resolution. Cross reference to F 223 Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. Review of the record revealed the primary language is Spanish. The resident has [DIAGNOSES REDACTED]., [MEDICAL CONDITION] Below Knee-Secondary to Diabetes, Diabetes, Muscle Weakness-general, Lack of Coordination, Cognitive communicate deficit, [MEDICAL CONDITION], and Chronic Ischemic [MEDICAL CONDITION]. Review of the Minimum Data Set (MDS) 3.0 Assessment Summary Report dated 12/1/15 indicated a Brief Interview for Mental Status (BIMS) score of 4.0, indicating severe cognitive impairment. Review of R#1 Care Plan dated 7/4/2012 revealed a problem statement, Socially inappropriate/disruptive behavior, yells out at staff and other residents and refuses to participate in therapy. Interventions include, two (2) staff to provide care, if resident is upset, do not provide care. Review of R#1 Care Plan dated 8/18/15 indicated residents makes false statements about staff, approach included to respond immediately to any criticism or complaints. Refer concerns to appropriate persons to discuss solutions. Respond calmly without defense to negative type statements. Review of R#1 Care Plan dated on 3/20/15, indicated socially inappropriate/disruptive behavior R#1 yells out at staff and other residents, plays with feces, and refuses to participate in therapy. Interview on 1/6/16 at 2:29 p.m. with Housekeeping (HSK) NN revealed that on 12/25/2015 at about 9:45 a.m., he was asked to get some pillowcases. HSK NN revealed that he and HSK OO were outside of the room of resident #1. HSK NN revealed that CNA JJ was inside of the room with resident #1 by herself. HSK NN revealed that he heard CNA JJ say to resident #1 , don't give me a f-cki-n- hard time about putting on your clothes!. Per the interview with Housekeeping employee NN, CNA JJ entered R#1 room alone, after verbally abusing R#1.