Every finding on record at Reelfoot Manor Health and Rehab

Based on facility policy review, medical record review, and interview, the facility failed to provide notification of involuntary discharge to exercise appeal rights for 1 of 3 (Resident #29) residents reviewed for admission, transfer, and discharge. The findings include: 1. Review of the undated facility policy titled, Transfer and Discharge . revealed .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances .The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided .An explanation of the right to appeal the transfer or discharge to the State .The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests .Information on how to obtain an appeal form .Information on obtaining assistance in completing and submitting the appeal hearing request .For nursing facility residents with intellectual and developmental disabilities .or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations .the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is effected [affected] because .The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident .In these exceptional cases, the notice must be provided to the resident, resident's representative . 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Psychosis, Schizoaffective Disorder, Anxiety, Epilepsy, Traumatic Brain Injury, and Dementia. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #29 scored a 00 on the Brief Interview for Mental Status assessment, indicating she was unable severely cognitively impaired. Resident #29 had daily behaviors towards self, was dependent on staff for Activities of Daily Living, and received antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Review of the Physician's Orders dated 7/6/2026, revealed .Send resident to the emergency department for immediate evaluation due to increased agitation and escalating behavioral disturbances that present an immediate risk of harm to herself and others. Recommend comprehensive psychiatric evaluation to assess acute mental status and behavioral concerns . Review of the medical record revealed Resident #29 was transferred to the emergency room (ER) for a psychiatric evaluation on 7/6/2026 at approximately 1:45 PM, and the responsible party was notified of the transfer. Review of the Nursing Home Notice of Involuntary Transfer or Discharge form dated 7/6/2026, revealed .Reason for Discharge or Transfer .The nursing home says it cannot care for you. Your needs are too high .You make the nursing home unsafe for other people . The form was signed by the Administrator and the Medical Director there was no signature from the Resident and/or Responsible Party (RP). Review of the ED [Emergency Department] Provider Notes dated 7/6/2026, revealed .Chief Complaint .Psychiatric Evaluation .[Resident #29] presents for PSYCH EVALUATION. PATIENT SENT FROM [Named Long Term Care (LTC) Facility] REGARDING HER AGGRESSIVE BEHAVIOR AND MEDICINE NONCOMPLIANCE .HAS HISTORY OF NONVERBAL AUTISM, INTELLECTUAL DISABILITY, SCHIZOAFFECTIVE DISORDER AND EPILEPSY. [Named LTC Facility] REPORTS SHE NEEDS A BETTER FACILITY THAT CAN HANDLE HER BEHAVIOR .ON ARRIVAL PATIENT IS VERY AGITATED AND HAD TO BE MEDICATED. THIS IS ALL PER NURSING HOME. PATIENT AGITATED IN NEW ENVIRONMENT. AT BASELINE PER STAFF HERE WHO IS FAMILIAR WITH HER .Physical Exam was unable to be obtained on arrival due to patient's aggressive behavior. Once patient was stable after medication physical exam could be obtained. Her pull up was saturated .She is unkempt but not underweight .Jul [July] 07 [7/7/2026] .I have personally seen patient multiple times in the ER in the past .she mainly gets agitated when she stays at the ER for too long. Patient has been at the nursing home facility for quite some time and apparently, they no longer are able to keep her since she's run out of inpatient days .[DATE] [7/10/2026] .It appears that the patient going to a psychiatric facility is not an option anymore as she's completely exhausted her inpatient days. A nursing home is the only option now. Unfortunately patient has spent the last several days in our ER and it is not safe for her to be down here she keeps getting agitated by the noise. Patient will need to be admitted for psychomotor agitation and placed in a hospital bed while social work is working on long-term placement for her . During a telephone interview on 7/30/2026 at 10:43 AM, Resident #29's RP was asked about Resident #29's discharge. The RP stated, .[Named Long Term Care Facility] didn't want to take her back. The RP was asked if the facility had provided her with paperwork for the involuntary discharge that gave information about how to appeal the facility's decision not to take Resident #29 back. The RP stated, .will have to look at the paperwork I signed.I was unaware I could I appeal .I got a lot of paperwork.they told me sending her to ER for psych [psychiatric] eval [evaluation].thought they were going to do psych eval to help her.not to kick her out.wasn't till [until] people [referring to the hospital] were calling me.not taking her back.they should have had a plan.[Named Long Term Care Facility] never told me they wasn't going to take her back.it's been the hospital and Ombudsman.I've not have any conversation with anybody .left message with [Named Social Worker].hasn't called me back . During a telephone interview on 7/30/2026 at 2:26 PM, Resident #29's RP confirmed she had looked through all her paperwork from the facility, and she was not provided discharge information or how to appeal the involuntary discharge. During an interview on 7/30/2026 at 5:15 PM, the Administrator was asked about the Nursing Home Notice of Involuntary Transfer or Discharge for Resident #29. The Administrator stated, .contacted [Named Resident #29's RP].that we could not meet her needs .she needs higher care.and explained to her that it was unsafe for [Named Resident #29], other residents and staff.niece was agreeable.we went over this sheet with her and she was aware that she could appeal.I mailed it . The facility was unable to provide a signed copy of the Notice of Involuntary Transfer or Discharge for Resident #29.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 2 (Resident #14 and #29) sampled residents reviewed for behavioral health. The findings include: 1. Review of the undated facility policy titled, Behavioral Health Services, revealed .It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being.Behavioral health encompasses a resident's whole emotional and mental well-being, which includes.psychosocial adjustment difficulty.The facility will ensure that behavioral health care services are person-centered.The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside source such as physician, psychiatrists, or neurologist. 2. Review of the [Named Hospital] record review revealed Resident #14 was admitted to the hospital on [DATE] to 4/14/2026 with diagnoses including Intellectual and Developmental Disability, Bipolar Disorder, Aggression, and Agitation. Review of the (Named Hospital) History and Physical dated 3/19/2026, revealed .41 -year-old male with a history of bipolar disorder, intellectual disability untreated pituitary tumor per prior records, and prior psychiatric admission admitted to this facility for 22 days in January 2026 presents with increasing aggression & [and] agitation, reportedly striking a wall and threatening to harm others at the group home where he had been less than 24 hours . Review of the (Named Hospital) Psychiatric Evaluation dated 3/19/2026, revealed .Pt is a 41 y/o [year old] with a hx [history] of unspecified Bipolar .from [Named Group Home] due to violet outburst, made threats towards other residents and caseworker .Pt [patient] reports depression and anxiety . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Bipolar Disorder (mental health condition), Impulsiveness (reacts suddenly), and Malignant Neoplasm of the Pituitary Gland (Cancer of the Pituitary Gland.) Review of Physician's Order dated 4/14/2026, revealed .guanFACINE HCL [Hydrochloride] [a medication to treat impulsive behaviors] Oral Tablet 1 MG [Milligram] .Give 1 tablet by mouth two times a day for IMPULSIVITY . Review of Physician Order dated 4/14/2026, revealed .hydrOXYzine Pamoate [used to treat Anxiety] Oral Capsule 50 MG .Give 1 capsule by mouth every 8 hours as needed for ANXIETY for 14 Days . Review of Physician Order dated 4/14/2026, revealed .QUEtiapine Fumarate [used to treat Mood] Oral Tablet 100 MG .Give 1 tablet by mouth two times a day for MOOD . Review of Physician Order dated 4/14/2026, revealed .QUEtiapine Fumarate Oral Tablet 300 MG .Give 2 tablet by mouth at bedtime for MOOD . Review of the Progress Note dated 4/15/2026, revealed .agitation and aggressive when needs are not met. Resident with inappropriate language skills toward staff at the time. Threatens staff with bodily harm and destruction of area too. Review of the Progress Note dated 4/16/2026, revealed .Resident continues with excessive food and drink requests, agitation and aggressive when needs are not met. Resident with inappropriate language skills toward staff at times . Memory impairment appears to be an excuse for behavior by resident, memory selection is exceptional especially for medication amount and time . Review of the Progress Note dated 4/17/2026, revealed .Resident continues with excessive food and drink requests, agitation and aggressive when needs are not met. Resident with inappropriate language skills toward staff at the time. Threatens staff with bodily harm and destruction of area too. Resident's needs are met in every way possible and resident redirected to area of safety such as room and dining area. Memory impairment appears to be an excuse for behavior by resident, memory selection is exceptional especially for medication amount and time. Review of the Progress Note dated 4/19/2026 at 5:30 AM, revealed .as this nurse came up hall from passing meds resident was standing at nurses station facing away from this nurse as i [I] got close to nursing station resident turned and started screaming at this nurse stating where the [Explicit derogatory curse word] is everyone i [I] need a sandwich right now! i [I] told resident we did not have any sandwiches at nurses station that he had snacks in room he then threatened to knock this nurses head off and proceeded to come at me then grabbing my cart and pushing it as hard as he could at me slowly getting closer and closer to me at this time i [I] made clear to resident that i [I] would call the [Named Town] police dept if he proceeded to try to come into my personal space with the perceived threat of harm he then slammed the cart toward me again stating [Explicit derogatory curse word] you iwill [I will] kill you! i [I] then picked up my phone and called [Named Town] police dept as i [I] got off phone resident returned to room. Review of the Progress Note dated 4/19/2026 at 5:39 AM, revealed .[Named Town] police dept arrived, as this nurse and officer knocked and entered residents room he looked up and stated [Explicit derogatory curse word] you both officer spoke with resident in room alone when officer came out he stated resident had calmed down and was going back to bed to sleep officers stated if needed to call them back. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #14 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of the Progress Note dated 5/2/2026 at 8:00 AM, revealed .At 6:40 AM resident came to NS [nurses' station] this Nurse gave him a cup of milk per his request. then he started asking for a cigarette. This Nurse and [Named Nurse], LPN [Licensed Practical Nurse] had starting counting the Narcotics. He repeated. [Nurses name], LPN informed this resident that he had No cigarettes. He immediately started cursing, grabbed the med cart, shook it very hard. Before we could begin trying to Re-Direct him he grabbed the water pitcher on the med cart, knocked it over. Water and Ice went where [everywhere]. He went to his room. Police was called by [Nurses name], LPN., DON [Director of Nursing] was notified also. Policeman arrived talked with resident, staff and will do a report. Review of the Progress Note dated 5/17/2026 at 7:12 AM, revealed .Behaviors Note: Resident came up to nurse's station asking for tea, this nurse stated it will be a minute, the resident came over to this nurse's cart and slammed the narc box lid down and stated bitch I said now. This nurse asked resident to go to table, and we would bring him some tea to the table. Resident turned and went and sat down. Review of the Progress Note dated 5/18/2026 at 1:29 AM, revealed .when this nurse entered room to wash feet apply lotion and socks resident stated to this nurse f**k [Explicit derogatory curse word] you get out of my room before i [I] knock your head off this nurse left room to avoid agitating resident further. Review of the Progress Note dated 5/18/2026 at 1:19 PM, revealed .Residents observed with increased agitation and aggressive behaviors during shifts primarily directed towards female staff when requests were not immediately met. behaviors included raises voices, hostile tone, and refusal of care. attempts at verbal redirection and deescalation were not immediately effective. The resident required multiple approaches, calm setting and time and space before behaviors stopped. will continue to monitor for triggers for aggressive behavior. Review of the Progress Note dated 5/20/2026 at 11:22 AM, revealed .Resident observed in dinning [dining] area becoming verbally aggressive towards staff after being redirected regarding mealtimes. resident began yelling profanities and making threatening statements towards staff members, stating he would hurt someone. resident then forcefully flipped a dinning [dining] room table, creating a safety hazard for nearby residents and staff. This nurse immediately implemented deescalation techniques, maintained safe distance and removed other residents from area to prevent injury. resident continues to posture aggressively but did not make physical contact with anyone. additional assistance came from city police for support. The resident agreed to be sent to hospital to be evaluated by psych services. resident was escorted aware [away] from the dinning [dining] room on the stretcher, quiet with no injury obtained to staff nor residents. resident vitals w/n/l at time of departure. Review of the Progress Noted dated 5/20/2026 at 10:32 PM, revealed .resident returned from hospital on stretcher with 2 EMT's [Emergency Medical Technician] taken to room got off stretcher and walked to bed started asking for sandwiches [,] milk [,] and tea before getting into bed advised by this nurse i [I] would find him some snacks but there was no milk and onlyalittle [only a little] tea left resident stated i [I] dont [don't] want to be at this f*****g [explicated word] place snacks taken to room and left for resident . Review of the Progress Note dated 5/21/2026 at 6:49 AM, revealed .resident at desk asking for sugar which we do not have when told there was none resident yelled F**K! F**K [Explicit derogatory curse word] all you [Explicit derogatory curse word] and walked away from desk others stated he had already been to kitchen door banging for 5 mins which they did not open. Review of the Social Services Progress Note dated 5/21/2026 at 9:33 AM, revealed .This social worker sent multiple referrals to behavioral units following this resident's ongoing aggressive behaviors. Review of the Progress Note dated 5/21/2026 at 3:22 PM, revealed .Resident was at nursing station demanding for packs of sugar and when told we did not have any up here, he started yelling and cussing at the staff. Review of the Progress Note dated 5/31/2026 at 4:59 PM, revealed .Resident has become aggressive and combative with staff and residents at this time. Resident has thrown everything off the top of the medication cart and facility property. This nurse called the police. This nurse notified the administrator and [named Assistant Director of Nursing] LPN. Administrator advised this nurse to sent [send] patient to the ER [emergency room] for a mental evaluation. This nurse attempted to call the [Named Hospital] ER to give report and spoke with [Named Nurse], RN supervisor who refused to take the patient because he was seen yesterday for his behavior. This nurse removed his roommate due to resident stating he is going to destroy his room as well. Facility will continue to monitor his behavior at this time. Review of the Nurses Note dated 5/31/2026 at 5:45 PM, revealed .Resident has become aggressive again. Police still in facility at this time. EMS [Emergency Medical Services] says they can't take the patient to the ER due to him being alert and oriented x4 and refusing. Police also stated they can't take him due to his medical diagnosis . Review of the Nurse's Note dated 5/31/2026 at 6:36 PM, revealed .Resident continues to exhibit an explosive personality and challenging behaviors. Review of the Medical Director Progress Note dated 6/3/2026 at 5:14 PM, revealed .I spoke with staff at Reelfoot Manor today regarding the recent behavior of this resident. He has been displaying the following behaviors: - threatening staff and/or residents with violence - non-adherence with medical treatment which causes escalation of his psychiatric illness and behavior - patient is cognitively impaired and will not or cannot respond to re-direction by staff. Given his status and risk to residents and staff my medical opinion and order is that he be transferred to ER for urgentpsychiatric [urgent psychiatric] evaluation and alternative placement as Reelfoot cannot accommodate his psychiatric care. During an observation on 6/3/2026 at 8:05 AM, revealed Resident #14's door closed. During an observation on 6/3/2026 at 9:09 AM, revealed the Wound Care Nurse in Resident #14's room performing wound care, Resident #14 sitting on bed allowing wound care to be performed while watching the television. During an observation on 6/3/2026 at 9:17 AM, revealed that Resident #14 was sitting on the side of the bed eating and watching the television. Review of Physician Order dated 6/3/2026, revealed .I have discussed the status of this resident and his recent at risk behaviors and I am ordering the following 1. Transfer to ER of choice for urgent Psychiatric evaluation for placement in appropriate facility to manage his uncontrolled aggressive, threatening violence, non-adherence to medications putting himself and others (residents and staff at risk for injury and other complications . Review of the Medical Record revealed Resident #14 was in the facility from 4/14/2026 until 6/3/2026 for 50 days. Psych services were only provided on 4/14/2016 and 5/11/2026 despite the numerous outburst and behaviors. During an interview on 6/3/2026 at 9:35 AM, the Admissions Nurse was asked if the Resident had seen psych services. The Admissions Nurse stated, .Not sure, I don't see a progress note. During an interview on 6/3/2026 at 10:58 AM, the Social Services Director (SSD) was asked if the facility had psych services that came into the facility to see the residents. The SSD stated, .Yes, but please let me clarify that with the administrator because to my knowledge the lady [ Nurse Practitioner] that is here today I thought was the psych NP [Nurse Practitioner] also. During an interview on 6/4/2026 at 9:20 AM, the Interim Director of Nursing (DON) was asked if Resident #14 was receiving psych services. The Interim DON stated .Yes, to my knowledge, [Named NP] is a NP that was here providing dual services of medical and psych services. The Interim DON was asked the reason Resident #14 was discharged to the hospital on 6/3/2026. The DON stated, .Because of the other weekend [5/29/2026] he had that incident, when they notified her [DON], I told them we had to find placement for him. He has been sent to the ER and they would send him back .the police have been involved .I had to get [Named Medical Director] more involved to send him out because we are not equipped for those types of behaviors. During an interview on 6/4/2026 at 9:45 AM, the Administrator was asked if Resident #14 was receiving psych services. The Administrator stated, .To my knowledge he was, but did not know that [named Psych Service Provider] and [named medical provider] were different. I was told the NP did psych also and did not find out until yesterday [6/3/2026] that she [Nurse Practitioner] did not do psych. The Administrator was asked if she could show were Resident #14 was receiving psych services. The Administrator stated, .I'm not 100% [percent] certain if he did or not. During an interview on 6/4/2026 at 10:36 AM, the Medical Director was asked if he was aware of Resident #14's behaviors and if he knew if the resident was receiving psych services. The MD stated.I was not called about his behaviors and was only made aware when I read it in the chart and was called by [Interim DON] last night and I put in a note and orders to send him out.I cannot confirm he was seen by psych. The MD was asked if the facility was able to care for Resident #14's psych behaviors. The MD stated, .with these behaviors they are not. 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Psychosis (characterized by a loss of contact with reality), Autistic Disorder(where the brain develops and processes differently from others affecting how they communicate, socialize, and experience sensory input), Schizoaffective Disorder (a mental health condition that combines symptoms of schizophrenia with a mood disorder), Anxiety, Epilepsy, Mood Disorder (baseline mental state with extreme emotional fluctuations), Traumatic Brain Injury, and Mild Intellectual Disabilities. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #29 was rarely or never understood and her cognitive skills for daily decision making were severely impaired. Resident #29 had difficulty focusing and was easily distracted, had behaviors that significantly interfered with the resident's participation in activities or social interactions, and disrupted care or the living environment. Resident #29 required a wheelchair and was dependent on staff for all Activities of Daily Living and required moderate assistance for all transfers. Resident #29 received medications to manage Mental Disorders, Anxiety, and Depression. Review of the Care Plan dated 4/6/2026, revealed .has a communication problem r/t inability to hear and non-verbal communication.Ensure/provide a safe environment.may cry or scream to express her frustration and difficult to redirect.may make sounds or gestures to get attention, reach for a person she wants.may use gestures or sporadic verbal efforts to speak.speech is difficult to understand due to slow, slurred and pressured speech. Review of the Care Plan dated 4/7/2026, revealed . has a potential for drug related side effects from use of antipsychotic, antianxiety and antidepressant.Psych and Pharmacy to make recommendations as needed. Review of the Care Plan dated 4/9/2026, revealed .as [has] a diagnosis of Schizoaffective Disorder, Schizophrenia, Anxiety, IDD [Intellectual and Developmental Disabilities], Autistic Disorder.Psych consult as needed and periodic review of medications. Review of the Care Plan dated 4/15/2026, revealed .is at moderate risk to high risk for an elopement and currently wanders.Disoriented to place, Impaired safety awareness, intrudes upon other's spaces without knowledge of doing so, Wandering is aimless.Request Psych Services as needed. Review of the Physician's Orders dated 3/26/2026, revealed .Oxcarbazepine HCI [a medication used to treat Epilepsy and can help manage symptoms of Bipolar DisorderOral Tablet 500 MG.Give 1 tablet by mouth two times a day for MOOD. Review of the Physician's Orders dated 3/26/2026, revealed .Topiramate [a medication used for seizures which can also be used for tremors] Oral Tablet 100 MG.Give 1 tablet by mouth two times a day for SCHIZOAFFECTIVE DISORDER.May be seen by specialists as needed including.Psychologist, Psychiatrist. Review of the Physician's Orders dated 5/12/2026, revealed .fluPHENAZine [a medication used to treat Schizophrenia and manage psychotic symptoms] HCl Oral Tablet 5 MG.Give 1 tablet by mouth two times a day for delusional psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. Review of the Physician's Orders dated 5/21/2026, revealed .chlorpromazine HCI [a medication used to manage hallucinations, delusions, disorganized thinking and behavioral problems] Oral Tablet 50 MG.Give 1 tablet by mouth two times a day for PSYCHOSIS. Review of the Physician's Orders dated 5/26/2026, revealed .clonazepam [ medication that slows down the central nervous system] Oral Tablet 0.5 MG.Give 2 tablet by mouth every 8 weeks for anxiety. Observation on 6/1/2026 at 2:35 PM, revealed Resident #29 in the dining room with a staff member sitting one on one with her. The resident continuously screamed out, attempted multiple times to get out of her chair and stand up, requiring multiple attempts at redirection. Resident #29 crawled back in the wheelchair backwards and sat on her knees. Resident #29 then climbed out of the wheelchair and walked to the table next to her with a stumbling gait. The staff member had to redirect her back to her chair again. Resident was screaming loudly, opening her mouth in exaggerated movements. Resident was able to give a high five to the staff member on command but was very confused and distracted. Observation on 6/2/2026 at 8:14 AM, revealed Resident #29 in the dining room with a staff member sitting at her side. Resident was making shrieking noises and trying to get up out of the wheelchair, requiring multiple attempts at redirection. Observation at 6/2/2026 at 10:50 AM, revealed Resident #29 sitting in the hallway in her wheelchair with staff standing next to her. Resident #29 was making continuous wailing noises. Observation on 6/3/2026 at 7:19 AM, revealed Resident #29 in the dining room being wheeled around in her wheelchair. Resident #29 was making continuous, shrill, high pitched noises. Observation on 6/4/2026 at 7:25 AM, revealed Resident in the dining room with staff. Resident #29 was shrieking and hollering out. Review of the Psych admission Note dated 3/27/2026, revealed .Resident being seen for initial psychiatric evaluation . Review of the Progress Note dated 5/12/2026, revealed .This is a follow-up psychiatric and medical evaluation .history of severe intellectual disability and chronic psychiatric illness . The facility was unable to provide documentation Resident #29 received Psych services from 3/29/2026 until 5/12/2026. During an interview on 6/4/2026 at 11:18 AM, the Administrator was shown the Psych notes that were provided that were dated 3/29/2026. The Administrator was asked if there were any other psych notes that could be added. The Administrator stated .If that is all that they gave you I'm going to say that is all that they could find .

Based on policy review, Intake Status Report form review, medical record review, and interview, the facility failed to perform a complete and thorough investigation for resident-to-resident altercations for 2 of 15 (Resident #55 and #56) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled Abuse, Neglect and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Abuse means the willful infliction of injury .resulting physical harm, pain or mental anguish .which can include .resident to resident altercations .Investigation of Alleged Abuse .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect .Written procedures for investigation include .identifying staff responsible for the investigation .investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victims, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .mistreatment has occurred, the extent, and cause .providing complete and thorough documentation of the investigation . 2. Review of the medical record review revealed Resident #55 was admitted to the facility on [DATE], with diagnosis of Heart Disease, Atrial Fibrillation, Bipolar Disorder, Anxiety, and Dementia. Review of a Progress Note dated 1/1/2025, revealed .Resident was hit by another resident on the right side of his neck. Has red area to right side of neck . Review of the Intake Status Report form dated 1/2/2025, revealed on 1/1/2025, Resident #55 was allegedly hit 3 or 4 times in the head, neck and back area. Resident #55 had a red mark on the right side of his neck. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he had severe cognitive impairment. The facility was unable to provide a 5-day report or an investigation related to this reported incident dated 1/1/2025. 3. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Heart Failure, Anxiety, and Chronic Kidney Disease. Review of the Intake Status Report, form dated 10/10/2024, revealed Resident #56 was allegedly hit by another resident and then Resident #56 hit back. Review of the quarterly MDS assessment dated [DATE], revealed Resident #56 scored a 5 on the BIMS assessment, which indicated he had severe cognitive impairment. Review of the Care Plan dated 2/26/2025, revealed . has the potential to demonstrate physical behaviors.10/10/24 Resident struck another resident. The facility was unable to provide a 5-day report or an investigation related to this reported incident dated 10/10/2024. During an interview on 6/4/2026 at 10:31 AM, the Administrator confirmed she was the Abuse Coordinator. The Administrator was asked about the facility reportable dated 10/10/2024 for Resident #56, and could she provide any documentation related to the 5-day follow-up. The Administrator stated, No, I cannot. The Administrator was asked if she could provide documentation that a thorough investigation was completed. The Administrator stated, No. The Administrator was asked if she could provide a 5-day follow up for Resident #55 and the 1/1/2025 incident. The Administrator stated, No, Ma'am. The Administrator was asked if she could provide documentation that a thorough investigation was completed. The Administrator stated, No Ma'am.

Based on policy review, medical record review, observation, and interview, the facility failed to implement appropriate interventions to prevent falls, failed to assess residents at risk for falls, and failed to assess residents after each fall for 6 of 6 sampled residents (Resident #15, #7, #22, #29, #39, and #48) reviewed for falls; the facility failed to ensure a safe environment when disposable razors were found in 1 of 36 resident bathrooms (Resident #39's room); and when 3 of 3 sampled residents (Resident #7, #39, and #41) were not using smoking aprons when smoking. The facility's failure to provide and implement appropriate interventions resulted in harm when Resident #15 sustained two falls which resulted in a laceration to the middle of the forehead, multiple skin tears, and a hematoma (bleeding outside the blood vessel) on the left side of the forehead. The findings include: Review of the facility's policy titled, Falls and Fall Risk, Managing, dated 5/2021, revealed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling .The interdisciplinary team will attempt to identify appropriate interventions to reduce the risk of falls .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Review of the facility's policy titled, Assessing Falls and Their Causes Guidelines, dated 5/2021, revealed .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying cause of fall .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .Equipment and Supplies .Tools to assess resident's level of consciousness and neurological status .When a resident falls, the following information should be recorded in the resident's medical record .Completion of a falls risk assessment .Appropriate interventions taken to prevent future falls . Review of the medical record, revealed Resident #15 was admitted on [DATE] to Room #317, was transferred to Room #311 on 11/1/2021, and readmitted to the facility on [DATE] with diagnoses of Acute Kidney Failure, [CONDITION(S)], Dementia, Anxiety Disorder, Hypertension and History of Falls. Review of the Care Plan dated 12/31/2020, revealed Resident #15 had a potential for falls related to weakness and poor safety awareness. The following interventions were identified: Keep bed in lowest position, keep the call light within reach, place a concave mattress on the bed, and remind the resident to call for assistance with ambulation. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive skills, he required extensive assistance from staff for activities of daily living, and had no limitations in range of motion. Review of the quarterly MDS assessment dated [DATE], revealed Resident #15 had a BIMS score of 9, which indicated the resident had moderate cognitive deficits, he required extensive assistance from staff for activities of daily living, and had no functional limitations in range of motion. Review of the Care Plan revised 6/2/2021, revealed the following additional interventions had been added to the Care Plan, .1/9/2021 .Proper footwear of non slip soles or gripper socks .1/11/2021 .Place Dycem [non-slip mat] in wheelchair .6/2/2021 .Place fall mat on right side of bed . Review of the Fall Risk assessment dated [DATE], revealed Resident #15 was a high risk for falling. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had a BIMS score of 4, which indicated the resident had severe cognitive deficits, he required extensive assistance from staff for activities of daily living, and had no functional limitations in range of motion. Review of a Progress Note dated 2/7/2022, revealed .Resident start shouting hello repeatedly. This nurse went to check and resident was observed on floor partially sitting beside bed, no injuries noted . Review of the Incident Report dated 2/7/2022, revealed Resident #15 had an unwitnessed fall and .Resident start [started] shouting hello .nurse went to check and resident was observed on floor partially sitting beside bed . The Care Plan was not updated after the fall. Review of the Fall Risk assessment dated [DATE], revealed Resident #15 was a high risk for falling. Review of the Incident Report dated 2/11/2022, revealed Resident #15 had an unwitnessed fall and .Resident hollering out for help. Was noted to be in dining room lying on left side with laceration noted to mid [middle] forehead . Review of Resident #15's (Named) Hospital Report dated 2/11/2022, revealed .Procedure Orders .Closed with skin staples [staples which hold the edges of a wound together] .Wound [laceration to the middle forehead] dressed . There was no Fall Risk Assessment completed after the fall on 2/11/2022 and the Care Plan was not updated. Review of an Incident Report dated 3/10/2022, revealed Resident #15 had a witnessed fall .Resident slid out of bed on to floor. Brief wet . There was no Fall Risk Assessment completed after the fall on 3/10/2022. The Care Plan was updated to reflect the bed in lowest locked position and to remind Resident #15 to call for assistance. Review of an Incident Report dated 4/20/2022, revealed Resident #15 had an unwitnessed fall and .Resident noted to be on the floor lying on left side and partially on bedside table. Multiple skin tears noted to left arm, skin tear to left knee, hematoma to left side of forehead, and bruising to left shoulder .Resident was sent to the hospital and returned . Review of a Progress Note dated 4/20/2022, revealed .Called to residents [resident's] room at approximately 1545 [3:45 PM] called to residents [resident's] room due to resident being on the floor. Entered room and noted resident to be lying on the floor on left side with face down. Assessed resident and noted resident to have a hematoma 2 cm [centimeter] x 3 cm to left side of forehead with 0.25 cm abrasion [open wound caused by the skin rubbing against a rough surface] to center. Multiple skin tears noted to left .part of arm. Skin tear to left knee. [Named Doctor] and telehealth notified with new orders to send resident to hospital . Review of Resident #15's (Named Hospital) records dated 4/20/2022, revealed, .Pt [patient] hit his head .[NAME] [has] a knot on his head .Barriers to Learning .Cognitive deficits .DIAGNOSIS Abrasion of left knee .Forehead contusion .Skin tear of left upper arm . Review of a (Named Ambulance Service) Physician Certification Statement dated 4/20/2022, revealed .history of falls . The Care Plan was not updated after the fall on 4/20/2022. Observation in the resident's room on 5/16/2022 at 10:22 AM and 5/17/2022 at 2:15 PM, revealed Resident #15 in bed on his right side, lying on a regular mattress, a wheelchair at the bedside with a blue cushion in the seat of the wheelchair. There was no concave mattress on the bed and there was no Dycem mat in the wheelchair. There were signs in the room stating to call for assistance before getting up. Observation in the Dining Room on 5/16/2022 at 3:08 PM, and 5/18/2022 at 11:27 AM, revealed Resident #15 up in his wheelchair. Observation in the hallway on 5/18/2022 at 2:56 PM, revealed there was no Dycem mat in Resident #15's wheelchair and the resident had on a pair of regular white socks. During an interview on 5/18/2022 at 3:34 PM, the Assistant Director of Nursing (ADON) confirmed that a resident with a BIMS score of 5 or 7 would not be able to be reminded to use the call light. The ADON confirmed a Fall Risk Assessment should be completed on admission, quarterly, and after each fall and that the staff should have Care Plan interventions implemented for the residents. During an interview on 5/18/2022 at 3:49 PM, the MDS Coordinator confirmed the Care Plan should be updated after each fall. The MDS Coordinator confirmed Resident #15 should have a Dycem mat in his wheelchair, a concave mattress on his bed, and should be wearing non-skid socks according to the Care Plan. The MDS Coordinator confirmed Resident #15 was not capable of using his call light or calling for assistance. During a telephone interview on 5/18/2022 at 4:48 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #15 had a fall mat at the bedside and did not remember Resident #15 ever having a concave mattress on his bed. During an interview on 5/18/2022 at 5:47 PM, LPN #1 confirmed he had been employed since July of 2021. LPN #1 confirmed he had not seen a concave mattress on Resident #15's bed and that Resident #15 was not capable of using his call light or calling for assistance. During an interview on 5/18/2022 at 6:13 PM, the Clinical Reimbursement Specialist (CRC)/MDS Coordinator stated, .I have a binder that tells what interventions are in place and the staff have to read and sign a paper when reviewed . The CRC/MDS Coordinator confirmed she used to put the interventions into the task bar to alert staff, but with the new management, it's no longer done. The CRC/MDS Coordinator confirmed Resident #15 had a room change and the concave mattress was not moved to the new room. During an interview on 5/18/2022 at 6:39 PM, Certified Nursing Assistant (CNA) #2 stated she had not seen a concave mattress on Resident #15's bed or a Dycem mat in his wheelchair. CNA #2 stated when the day shift staff dressed Resident #15, they placed regular white socks on his feet instead of the non-skid socks and Resident #15 was unable to use his call light or ask for assistance. Observation at the Nurses' Station on 5/18/2022 at 6:42 PM, revealed CNA #2 accessed Resident #15's task bar on the computer for review. The task bar did not include the use of the Dycem mat, the concave mattress, or the non-skid socks. During an interview on 5/19/2022 at 9:27 AM, CNA #1 confirmed she had not seen a concave mattress or Dycem mat in use for Resident #15. CNA #1 confirmed that regular socks were used for Resident #15. CNA #1 confirmed they do not have access to the resident's Care Plan, and the nurses tell them the interventions. CNA #1 confirmed Resident #15 was not able to use his call light. During an interview on 5/19/2022 at 10:46 AM, the Director of Nursing (DON) confirmed the CRC/MDS Coordinator adds the intervention to each resident's Care Plan during the morning meeting. The DON stated she audits the room and had identified a lot of things that needed to be addressed. The DON confirmed the Fall Risk Assessments should be completed on admission, post-fall, and quarterly. The DON was asked if Resident #15 could read or understand the signs posted in his room for him to call for assistance and use the call light for assistance. The DON stated, .he could at one time .they put the signs up for visual monitoring for him .I don't think he can be educated to do so . The DON confirmed the concave mattress was not transferred with Resident #15 when he was moved to a different room, and everything should have been moved with the resident. During a telephone interview on 5/19/2022 at 6:24 PM, the Medical Director stated .I know he [Resident #15] will get up and walk .no one knows he is walking .he loses his balance .he gets confused .he is hard of hearing .it is hard to explain to him what he needs to do .he's not cognitive enough to be educated or read signs at his bedside or use a call light .call for assistance when needed .I doubt seriously he could read, he would not understand the signs in the room . The Medical Director confirmed he would expect the staff to have appropriate interventions identified for falls and that the interventions should be implemented. The facility's failure to provide appropriate interventions and have the interventions implemented resulted in harm when Resident #15 sustained a fall that resulted in a laceration to the forehead and required staples, had a fall with multiple skin tears and a hematoma to his forehead. Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes, History of Falls, [CONDITION(S)], Hypertension, and Depression. Review of the Fall Investigations dated 1/13/2022, 1/28/2022, and 3/1/2022 revealed Resident #7 had falls with no injuries. Review of the medical record, revealed there were no Fall Risk Assessments completed after the falls on 1/13/2022, 1/28/2022, and 3/1/2022. Review of the quarterly MDS dated [DATE], revealed Resident #7 had moderately impaired cognition. Review of the Care Plan dated 3/9/2022, revealed Resident #7 was assessed as being at risk for falls with an intervention to place a Dycem mat in the wheelchair. Observation in the Dining Room on 5/19/2022 at 2:46 PM, revealed CNA #1 assisted Resident #7 to a standing position from his wheelchair and there was no Dycem mat in the wheelchair. CNA #1 confirmed she had never seen a Dycem mat in Resident #7's wheelchair. Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Dementia, [CONDITION(S)], Depression, [CONDITION(S)], and Hypertension. Review of a Progress Note dated 3/14/2022, revealed .Was notified at approximately 1930 [7:30 PM] that resident had fallen at approximately 1924 [7:24 PM] . Review of an Incident Report dated 4/13/2022, revealed .Resident was found laying perpendicular to bed in floor . Review of the medical record, revealed no Fall Risk Assessments were completed for Resident #22 after the falls on 3/14/2022 and 4/13/2022. Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, [CONDITION(S)], Dementia, Anxiety, [CONDITION(S)] Disease, and [CONDITION(S)] Disorder. Review of the Fall Investigation dated 2/17/2022 revealed, .Resident called out and said he was in the floor . Review of the medical record, revealed a Fall Risk Assessment was not completed after Resident #29's fall on 2/17/2022. Review of the annual MDS dated [DATE], revealed Resident #29 had severely impaired cognition. Review of the Care Plan dated 4/22/2022, revealed Resident #29 was at risk for falls with documented interventions for the bed to be in the low position, a Dycem mat in the wheelchair, and a fall mat at the beside. Observation in the resident's room on 5/19/2022 at 8:25 AM, revealed Resident #29 lying in bed. The bed was not in the lowest position, there were no fall mats on the floor, and there was no Dycem mat in the wheelchair. During an interview on 5/19/2022 at 8:38 AM, CNA #9 confirmed the bed was not in the lowest position, there were no fall mats on the floor, and there was no Dycem mat in the wheelchair. Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)], Muscle Weakness, Reduced Mobility, and Restless Leg Syndrome. Review of the Fall Investigations dated 1/13/2022 and 1/19/2022, revealed Resident #39 had falls with no injuries. Review of the medical record revealed Fall Risk Assessments were not completed after the falls on 1/13/2022 and 1/19/2022. Review of the quarterly MDS dated [DATE], revealed Resident #39 had intact cognition. Review of the Care Plan dated 5/3/2022, revealed Resident #39 was at risk for falls with an intervention for fall mats to be placed at the bedside. Observation in Resident #39's room on 5/18/2022 at 3:00 PM, 5/19/2022 at 8:00 AM and 10:00 AM, revealed no fall mats at the resident's bedside or in the resident's room. Review of the medical record, revealed Resident #48 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], Parkinsonism, Peripheral Vascular Disease, Alzheimer's Disease, Dysphagia, [CONDITION(S)], Cerebral Infarction, Hypertension, Depression, and [CONDITION(S)]. Review of the quarterly MDS dated [DATE], revealed Resident #48 was moderately cognitively impaired. Review of the Care Plan dated 5/10/2022, revealed Resident #48 was at risk for falls with an intervention to place a Dycem mat in the wheelchair. During observation in the Common Area on 5/19/2022 at 2:54 PM, revealed CNA #7 and CNA #10 assisted Resident #48 to a standing position from the wheelchair to reveal there was a pillow on top of the cushion in the wheelchair and no Dycem mat in the wheelchair. CNA #7 and CNA #10 confirmed they had provided care for Resident #48 for a long time, and they had not seen a Dycem mat in the wheelchair. During an interview with the Director of Nursing (DON) and ADON on 5/19/2022 at 11:11 AM, the DON confirmed Fall Risk Assessments should be done quarterly and when a resident had a fall. Random observation Resident #39's room on 5/16/2022 at 10:52 AM and 5/16/2022 at 11:37 AM, revealed 3 blue disposable razors in an emesis basin and 1 blue disposable razor on the bathroom counter. During an interview on 5/16/2022 at 11:42 AM, the ADON confirmed there should not be disposable razors in the resident bathrooms. Review of a Tobacco Users list revealed Resident #7, #39, and #41 were on the list and used tobacco. Review of the Care Plan dated 3/9/2022 revealed Resident #7 was at risk for injury related to smoking, required staff supervision, and required the use of a smoking apron. Review of the Smoking Evaluation for Resident #7 dated 5/11/2022, revealed .Does the resident have cognitive loss .yes .Does the resident have dexterity problem .yes .Adaptive equipment needed .Smoking apron . Review of the Care Plan dated 9/28/2017, revealed Resident #39 wanted to smoke and was to use a smoking apron. Review of the Smoking Evaluation for Resident #39 dated 3/8/2022, revealed .Does the resident have cognitive loss .no .Does the resident have dexterity problem .no .Adaptive equipment needed .Staff supervision . Review of the Care Plan dated 6/18/2021, revealed Resident #41 wanted to smoke and there were no interventions to utilize a smoking apron. Review of the Smoking Evaluation for Resident #41 dated 5/2/2022, revealed .Does the resident have cognitive loss .no .Does the resident have dexterity problem .no .Adaptive equipment needed .Smoking apron . Observation in the Smoking Area on 5/16/2022 at 4:08 PM, revealed Resident #7, #39 and #41 were outside the facility in their wheelchairs, smoking, and the Social Worker was supervising them. The residents were not wearing smoking aprons. Observation in the Smoking Area on 5/17/2022 at 10:10 AM, revealed Resident #7 smoking and supervised by staff. Resident #7 was not wearing a smoking apron. Observation in the Smoking Area on 5/17/2022 at 4:05 PM, revealed Resident #7, #41, and #39 smoking and were supervised by staff while smoking. The residents were not wearing a smoking apron. During an interview on 5/18/2022 at 8:08 AM, the Administrator confirmed residents should have smoking aprons when smoking and the aprons were not ordered until 5/16/2022. During an interview on 5/19/2022 at 9:20 AM, the Scheduler/Restorative CNA was asked if she ordered supplies. The Restorative CNA stated .Yes, I order the smoking aprons .ordered them on Monday [5/16/2022] . The Restorative CNA confirmed she was made aware of the missing aprons on Monday when the survey team entered the facility.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unattended and unsecured in 2 of 36 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), when 1 of 5 nurses (Licensed Practical Nurse (LPN) #4) left medications unattended and unsecured on top of the medication cart, and when 2 of 3 medication carts (C Hall Medication Cart and D Hall Medication Cart) were left unlocked and unattended during medication administration. The findings include: Review of the facility's policy titled, Storage of Medications, revised 4/2007, revealed .The facility shall store all drugs and biologicals in a safe, secure .manner .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a .safe .manner .Only persons authorized to prepare and administer medications shall have access . Observation in room [ROOM NUMBER] on 5/16/2022 at 10:04 AM and 11:04 AM, revealed one container of medicated vapor ointment on an overbed table, unsecured and unattended. Observation in room [ROOM NUMBER] on 5/16/2022 at 10:54 AM and 11:15 AM, revealed 1 bottle of [MEDICATION(S)] Powder on the overbed table, unsecured and unattended. Observation at the D Hall Medication cart on 5/17/2022 at 8:26 AM, revealed LPN #4 prepared medication for Resident #22, removed the box of [MEDICATION(S)] (a pain medication) from the treatment cart and placed it on top of the medication cart. LPN #4 entered the resident's room, left the medication unattended and unsecured on top of the medication cart, exited the room, and walked to the Nurses' Station. The medication remained on top of the medication cart unattended and unsecured. Observation at the C Hall Medication Cart on 5/17/2022 at 3:29 PM, revealed LPN #1 prepared medication for Resident #4, entered Resident #4's room, and left the C Hall Medication Cart unlocked and unattended. During an interview on 5/17/2022 at 3:33 PM, LPN #1 confirmed the medication cart should be locked when not in use. During an interview on 5/18/2022 at 8:08 AM, the Director of Nursing (DON) confirmed all medications should be stored in a locked medication cart. Observation on the D Hall Medication Cart on 5/18/2022 at 9:17 AM, revealed LPN #3 prepared the medications for Resident #11, placed the cart in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER], walked to room [ROOM NUMBER] and administered Resident #11's medication, leaving the medication cart unlocked and unattended in the hallway. During an interview on 5/18/2022 at 9:25 AM, LPN #3 confirmed the medication cart should not have been left unlocked and unattended. During an interview on 5/18/2022 at 10:42 AM, the Director of Nursing (DON) confirmed the medication carts should be locked and the staff should not leave medication on top of the medication carts unattended.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when 2 of 9 staff members (Certified Nursing Assistant (CNA) #6 and #7) failed to use courtesy titles for 3 of 43 residents (Resident #1, #6, and #32) observed during dining, and when a catheter bag was not concealed in a privacy bag for 1 of 1 sampled resident (Resident #42) reviewed for an indwelling catheter. The findings include: Review of the facility's policy titled, Respect and Dignity; Right to Personal Property, dated 5/2021, revealed .Residents have the right to be treated with respect and dignity . Review of the facility's policy titled, Indwelling Urinary Catheters, dated 5/2021, revealed .Cover the urine bag to provide privacy . Dining observation on the 400 Hall on 5/16/2022 at 11:45 AM, revealed CNA #6 delivered Resident #1's meal tray. CNA #6 stated, Hey momma . Dining observation on the 400 Hall on 5/16/2022 at 11:47 AM, revealed CNA #6 delivered Resident #6's meal tray. CNA #6 stated, Hey momma, ready to eat . Dining observation on the 400 Hall on 5/17/2022 at 7:48 AM, revealed CNA #7 delivered Resident #32's meal tray. CNA #7 stated, Good Morning Sweetheart . During an interview on 5/19/2022 at 10:50 AM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed it was not appropriate to use Momma or Sweetheart when addressing a resident. Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 4/29/2022, revealed Resident #42 had an indwelling urinary catheter. Observation in the resident's room on 5/16/2022 at 10:27 AM, 5/17/2022 at 8:07 AM, 5/17/2022 at 2:17 PM, and on 5/18/2022 at 11:58 AM, revealed Resident #42's indwelling urinary catheter bag was uncovered on the left side of the bed, facing the door, with urine visible in the drainage bag. During an interview on 5/18/2022 at 10:56 AM, the ADON confirmed Resident #42's indwelling urinary catheter bag should be covered at all times, and stated, it's a dignity issue.

Based on policy review, observation, and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when wheelchairs were in disrepair and covered with dried food particles, smears, and an unknown liquid for 2 of 10 resident wheelchairs (Resident #15 and #48) observed. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment ., dated 5/2021, revealed .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected . Observation in Resident #15's room on 5/16/2022 at 10:22 AM, revealed Resident #15's wheelchair had dried brown stains covering the sides of the cushion of the wheelchair. Observation in the Dining Room on 5/16/2022 at 3:08 PM, revealed Resident #15 seated in his wheelchair that had brown stains covering the sides of the cushion of the wheelchair. Observation in the Common Area on 5/17/2022 at 9:01 AM and 3:15 PM, and on 5/17/2022 at 9:05 AM and 4:28 PM, revealed Resident #48 seated in a wheelchair that had dried food particles and smears on the chair arms, chair tray, lower bars of the wheelchair and the wheels. The chair tray appeared to be broken and was bent downward toward her lap. During an interview on 5/18/2022 at 8:44 AM, the Assistant Director of Nursing (ADON) inspected Resident #48's wheelchair. He confirmed the wheelchair was dirty, needed to be cleaned, and the arm support was not working properly. Observation in the Dining Room on 5/18/2022 at 11:27 AM, revealed Resident #15 seated in his wheelchair and the wheelchair had brown stains covering the sides of the cushion of the wheelchair. Observation in the hallway on 5/18/2022 at 3:04 PM, revealed Resident #15 seated in his wheelchair. Certified Nursing Assistant (CNA) #4 assisted the resident to a standing position. The seat cushion had large brown stains and dried particles on the top and the bottom of the cushion. There was a large amount of liquid on the seat of the wheelchair under the wheelchair cushion . During an interview on 5/18/2022 at 3:04 PM, CNA #4 confirmed the brown stains on the resident's wheel chair were dried food particles. CNA #4 confirmed the liquid in the cushion smelled like urine. CNA #4 confirmed the wheelchairs should be cleaned on the 11:00 PM to 7:00 AM shift and CNA #4 stated .the entire wheelchair is filthy . Observation in the resident's room on 5/19/2022 at 9:21 AM, revealed Resident #15's wheelchair had a large puddle of liquid under the seat cushion. During an interview on 5/19/2022 at 10:46 AM, the Director of Nursing (DON) confirmed the CNAs are responsible for cleaning the wheelchairs, wheelchairs should not be dirty or have unknown liquids in the seats of the wheelchair, and the wheelchairs should be in working order. She stated, .they need to check the wheelchair before they put the resident in it .they should check the wheelchair after meals .

Based on facility investigation, policy review, medical record review, observation, and interview, the facility failed to timely and thoroughly investigate an incident of resident-to-resident abuse for 2 of 9 sampled residents (Resident #17 and #27) reviewed. The findings include: Review of the facility's policy titled, Abuse Investigations, revised 11/2017, revealed .Reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 had severely impaired cognition, had disorganized thinking, was inattentive, and had wandering behaviors. Observation on 5/17/2022 at 4:22 PM in the Common Area and in the hall leading into the Nurses' Station, revealed Resident #17 walking aimlessly in the hall, walked into the middle of the Nurses' Station, and the nursing staff redirected him out of the Nurses' Station, back into the hall. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #27 had intact cognition and had no behaviors. Observation in the 400 Hall on 5/17/2022 at 4:22 PM, revealed Resident #27 propelling himself in his wheelchair, stopped at the Social Service office, and knocked on the door. Review of the facility's investigation of a resident to resident altercation documented the following: a. 1 handwritten statement, dated 3/7/2022 by the Director of Nursing (DON).[Resident #27] states .last night this guy [Resident #17] came into my room and started going through my stuff on my table, so I got my grabber here and stabbed at him 3 times. Then the guy picked up my water pitcher and hit me here (pointing to his left knee) . b. 1 undated handwritten statement by Licensed Practical Nurse (LPN) #2.On 3/7/22 [2022] [at] approximately [4:30 PM] spoke with resident [Resident #27] about recent report of an altercation [with] another resident [Resident #17]. Resident [Resident #27] stated that a man [Resident #17] came in his room [and] was rumaging [rummaging] through stuff on his bedside table. Resident [Resident #27] stated he then grabbed his grabber and stabbed the other resident [Resident #17] 3 times [and] other resident hit him on the left knee [with] his water pitcher [no] injuries noted to residents [Resident #27's left] knee . c. 1 handwritten statement by LPN #3. was the nurse for C/D [300/400 Halls] on 3/6/22-3/7/22 [2022] night shift. I was not aware of an altercation that happen in [Resident #27's room number] . d. 1 handwritten statement by the DON documented the DON interviewed Resident #27's roommate who confirmed Resident #17 had come in their room and picked up something from Resident #27's table, Resident #27 jabbed at him with his stick, and Resident #17 picked up the pitcher and hit Resident #27. e. 1 handwritten statement by LPN #4.[Resident #27] reported to Admin [Administrator] that resident [Resident #17] came into room at approx [approximately] 130am [1:30 AM] on 3-7-22 [2022] and hit him. Head to toe assessment performed no bruising, redness or abrasion noted . f. 1 handwritten statement by Certified Nursing Assistant (CNA) #8, a CNA on the second shift. [Resident #27] informed me that at 1:30 am [AM] a man [Resident #17] with white hair came in to his room and woke him up while touching his possessions on his tray table. He said .I stabbed him 3 times with my grabber, he hit me with my cup . The facility's investigation of the allegation of resident-to-resident abuse by Resident #27 did not include interviews/statements from other staff members working the night of the alleged abuse. During an interview on 5/19/2022 at 11:00 AM, the DON was asked if all the night shift staff should have been interviewed about the allegation of resident-to-resident abuse initiated by Resident #27. The DON stated, .I guess I should have

Based on medical record review, observation, and interview, the facility failed to ensure the Care Plan was implemented and followed for Activities of Daily Living (ADL) for 1 of 1 sampled resident (Resident #48) reviewed. The findings include: Review of the medical record, revealed Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 4/12/2022, revealed .The resident has an ADL Self Care Performance Deficit r/t [related to] [CONDITION(S)] [Cerebral Vascular Accident] with [CONDITION(S)] .Interventions .Keep nails clean and trimmed . Review of the quarterly Minimum data Set (MDS) dated [DATE], revealed Resident #48 had moderately impaired cognition and required extensive assistance from staff for personal hygiene. Observation in the Common Area on 5/16/2022 at 3:15 PM, 5/17/2022 at 9:01 AM and 4:28 PM, and on 5/18/2022 at 8:44 AM, revealed Resident #48 had long nails and a dried brown substance under the nails. During an interview on 5/18/2022 at 8:45 AM, the Assistant Director of Nursing (ADON) confirmed Resident #48's nails were dirty and had a dried brown substance under the nails and stated, .she needs nailcare bad .

Based on policy review, medical record review, and interview, the facility failed to ensure the completion of a Discharge Summary with a recapitulation of the resident's stay and a transfer form at the time of discharge for 1 of 1 sampled residents (Resident #50) reviewed. The findings include: Review of the facility's policy titled, Discharge Summary and Plan, dated 5/2021, revealed .When the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment . Review of the medical record, revealed Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note dated 2/15/2022, revealed .Resident [Resident #50] discharged to .[Named Facility] via transportation van . The facility was unable to provide a completed Discharge Summary and a transfer form for Resident #50. During an interview on 5/19/2022 at 2:48 PM, the Assistant Director of Nursing (ADON) confirmed the transfer form and the discharge form should be completed. ADON #1 confirmed the forms were not completed.

Based on medical record review and interview, the facility failed to ensure medications were administered for 1 of 5 sampled residents (Resident #8) reviewed and failed to implement treatment orders following an injury for 1 of 6 sampled residents (Resident #48) reviewed. The findings include: Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #8 was severely cognitively impaired and received antipsychotic and antidepressant medications. Review of the facility's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MARS revealed missed doses of [MEDICATION(S)] on the following dates: A. 3/7/2022 at 10:00 PM B. 3/13/2022 at 10:00 PM C. 3/17/2022 at 10:00 PM D. 3/23/2022 at 10:00 PM E. 3/24/2022 at 10:00 PM F. 3/26/2022 at 10:00 PM G. 3/27/2022 at 10:00 PM H. 4/2/2022 at 10:00 PM I. 4/3/2022 at 10:00 PM J. 4/6/2022 at 10:00 PM K. 4/21/2022 at 2:00 PM L. 5/8/2022 at 10:00 PM M. 5/15/2022 at 10:00 PM During an interview on 5/18/2022 at 4:33 PM, Registered Nurse (RN) Supervisor #1 was asked about the missing does of [MEDICATION(S)]. RN Supervisor #1 stated, No .there should be initials and a reason if the medication was held .not just blank . Review of the medical record, revealed Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note dated 1/10/2022 revealed, .resident [Resident #48] kicked left foot out hitting in on wheelchair. Resident with .laceration to left outer ankle. Laceration cleaned with wound cleaner, patted dry, TAO [Triple Antibiotic Ointment] and border gauze [a type of wound dressing] applied and area wrapped with [MEDICATION(S)] [a cloth dressing wrap] . Review of the medical record, revealed there was no order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/19/2022 at 11:14 AM, the Assistant Director of Nursing (ADON) was asked if a treatment order was obtained for the laceration sustained on 1/10/2022. The ADON stated, .I don't see a treatment order at all .there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on policy review, medical record review, observation, and interview, the facility failed to provide appropriate urinary catheter care and failed to provide a Physician's Order for an indwelling urinary catheter for 1 of 1 sampled resident (Resident #42) reviewed. The findings include: Review of the facility policy titled, Indwelling Urinary Catheters, dated 5/2021, revealed .Wash and dry your hands thoroughly .fill the wash basin .put on gloves .Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry .pour .water down the commode .place soiled linen into designated container .put on clean gloves .remove gloves and discard into the designated container. Wash and dry your hands .provide privacy .exposing the perineal area .With non-dominant hand separate the labia of the female resident .use a washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke .change the position of the washcloth and cleanse around the urethral meatus .With a clean washcloth, rinse with warm water using he above technique .Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward .Discard disposable items .Remove gloves and discard into designated container .Wash and dry your hands thoroughly .Clean the .overbed table .wash and dry your hands thoroughly . Review of the medical record, revealed Resident #42 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had an indwelling urinary catheter and required extensive staff assistance for Activities of Daily Living (ADLS). Review of the medical record, revealed there was no Physician's Order for an indwelling urinary catheter or for catheter care. Observation in the resident's room on 5/17/2022 at 2:20 PM, revealed Certified Nursing Assistant (CNA) #5 entered Resident #42's room, donned gloves, entered the bathroom, filled a basin with water, placed the basin on the overbed table, closed the privacy curtain, removed the resident's brief and top sheet, and threw the brief and top sheet on the floor. She used a washcloth to wipe down each side of the resident's legs several times and the washcloth had brownish stains on it when she finished. She turned the washcloth and wiped between the resident's legs and threw the soiled washcloth on the floor. CNA #5 positioned the resident on her left side and, used a new washcloth, wiped front to back, and threw the washcloth on the floor. CNA #5 positioned the resident on her left side, and used a washcloth to clean downward, and wiped from back to front. The washcloth had a large amount of brownish stains covering it when she finished, and she threw the washcloth on the floor. CNA #5 positioned the resident in the supine position, used a clean washcloth, holding the catheter, cleaned down the length of the catheter, and then dried the length of the catheter. CNA #5 positioned the resident on her left side and applied a new draw sheet, incontinent pad, and brief. She used a dry towel to wipe Resident #42's buttocks and a brown stain was on the towel when she finished. She threw the soiled towel on the floor and rolled the resident to her right side. She obtained the soiled linen and threw it on the floor. She then applied a brief, repositioned the resident in bed, picked the dirty linen up from the floor, exited the resident's room, and placed the dirty linen in the barrel. During an interview on 5/17/2022 at 2:28 PM, CNA #5 confirmed the brown stains on the washcloth and towel were stool. During an interview on 5/18/2022 at 10:56 AM, the Assistant Director of Nursing (ADON) confirmed Resident #42 did not have orders for an indwelling catheter or for catheter care. During an interview on 5/18/2022 at 2:36 PM, the ADON was asked what procedure staff should follow in performing indwelling catheter care. The ADON stated .should wash their hands .fill basin with warm soap water .gather washcloth .grab catheter near the meatus .do one long stroke down the catheter .discard that washcloth .get another washcloth .rinse with one long stroke .make sure the catheter tubing not kinked .secured it [catheter] should be with a leg strap .peri [perineum]care .fill basin with warm soapy water .separate meatus .clean with one part of the washcloth .wipe on one side .with a clean part of the washcloth wipe down the other side .rinse in the same manner .pat dry .turn resident to their side .with a clean washcloth and soapy water .wipe down one side .wipe down other side .rinse .pat dry .they should know how to do peri-care properly .when they turn the resident on the back side . should change water in basin .change gloves and wash their hand .if had a BM [bowel movement] they should have cleaned them first before doing peri-care .change the water get new water and new gloves . The ADON confirmed the linen should not be thrown on the floor of the resident's room during indwelling catheter care. The ADON confirmed staff members should follow the procedure for indwelling catheter care and hand washing.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for a resident with enteral feedings when staff failed to ensure there was a Physician's Order for monitoring and cleaning a Percutaneous Endoscopic Gastrostomy (PEG) (a tube inserted into the stomach for the administration of nutrition and fluids) for 1 of 1 sampled resident (Resident #37) reviewed. The findings include: Review of the facility's policy titled Gastrostomy/Jejunostomy Site Care . dated 6/2021, revealed .The purpose of this procedure is to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection .Verify that there is a physician's order for this procedure . Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed there was no Physician's Order for PEG site care and monitoring of the PEG. Observation in Resident #37's room on 5/16/2022 at 2:58 PM, revealed the resident receiving a tube feeding of [MEDICATION(S)] connected to the enteral infusion pump and infusing at 35 milliliters per hour. During an interview on 5/19/2022 at 10:53 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were asked how often a PEG tube site should be cleaned and monitored for signs and symptoms of infection. The DON stated, Once per shift. The ADON confirmed there was no Physician's Order for PEG site monitoring and cleaning and confirmed there should be a Physician's Order for monitoring and cleaning the PEG site.

Based on policy review, medical record review, observation, and interview, the facility failed to obtain Physician Orders for oxygen for 1 of 1 sampled resident (Resident #37) reviewed. The findings include: Review of the facility's policy titled, Oxygen Administration, revised 6/2021, revealed .Verify that there is a physician's order .After completing the oxygen setup .following information .recorded in .resident's medical record .date and time .name and title .who performed procedure .rate of oxygen flow, route .signature and title . Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 used oxygen. Review of the Order Summary Report dated 5/3/2022, revealed there was no Physician's Order for Resident #37's oxygen, oxygen care, and maintenance. Observation in the resident's room on 5/16/2022 at 10:39 AM and 4:15 PM, and on 5/17/2022 at 7:53 AM and 4:34 PM, revealed Resident #37 was receiving Oxygen at 3 liters per minute through a bi-nasal cannula. During an interview on 5/19/2022 at 10:43 AM, the Assistant Director of Nursing (ADON) confirmed there was not a Physician's Order for Resident #37's oxygen.

Based on policy review, medical record review, and interview, the facility failed to ensure side effects of antipsychotic medications were monitored for 1 of 5 sampled residents (Resident #39) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled, Behavior Assessment and Monitoring, revised 2/2014, revealed .The IDT [Interdisciplinary Team] will monitor for side effects and complications .lethargy, abnormal involuntary movements, anorexia, and recurrent falling . Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of Depression, Anxiety, Convulsions, and Mood Disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated ,d+[DATE] /2022, revealed Resident #39 received an antipsychotic medication 7 days of the review period and received it on a routine basis. Review of the Order Summary Report dated 5/3/2022, revealed .[MEDICATION(S)] [an antipsychotic medication] .15 MG [Milligrams] .at bedtime .Start Date 03/28/2022 . Review of the Resident #39's Medication Administration Record (MAR) dated 3/2022, 4/2022, and 5/2022, revealed Resident #39 received scheduled an antipsychotic of [MEDICATION(S)] from 3/28/2022 to 5/18/2022. Review of the facility's Behavior Monitoring Records from 3/2022-5/2022, revealed Resident #39 had not been monitored for the side-effects of the use of an antipsychotic medication. During an interview on 5/19/2022 at 10:15 AM, the Assistant Director of Nursing (ADON) confirmed that residents who are prescribed antipsychotic medications should be monitored for side-effects related to the medication.

Based on policy review, medical record review, and interview, the facility failed to ensure a Physician's Order was obtained to provide Hospice services for 1 of 1 sampled resident (Resident #42) reviewed. The findings include: Review of the facility's policy titled, Physician's Services, dated 5/2021, revealed .The medical care of each resident is under the supervision of a Licensed Physician. Orders for the resident's immediate care and needs will be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist . Review of the facility's policy titled, Hospice Program, dated 6/2021, revealed .Obtain a physician's order for Hospice services including diagnosis . Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 5/2/2022, revealed Resident #42 was receiving Hospice services. Review of the medical record, revealed there was not a Physician's Order to provide Hospice services. During an interview on 5/18/2022 at 10:56 AM, the Director of Nursing (DON) confirmed Resident #42 should have a Physician's Order for Hospice services.

Based on observation and interview, the facility failed to provide a functioning call light for 1 of 31 sampled residents (Resident #22). The findings include: Observation in the resident's room on 5/16/2022 at 7:49 AM, 9:02 AM, and 3:46 PM, and on 5/18/2022 at 11:21 AM and 12:33 PM, revealed Resident #22 did not have a call light available to call for assistance. During an interview on 5/18/2022 at 8:50 AM, the Assistant Director of Nursing (ADON) confirmed Resident #22 did not have a call light. He confirmed she should have a call light in her room.

Based on policy review, observation, and interview, the facility failed to ensure medications were securely locked and inaccessible in 1 of 5 medication storage areas (C-D Hall). The findings include: The facility policy titled, Storage of Medication, dated 4/2007 documented, .store all drugs and biologicals in a safe, secure .manner. Observation at the C-D Hall medication storage room on 1/13/2020 at 11:00 AM and 11:50 AM, showed the medication storage room was unsecure, without a door knob or a lock on the door. During an interview conducted on 1/13/2020 at 2:56 PM, the Director of Nursing (DON) was asked should the medication room be unsecure with medications inside. The DON stated, No.

Based on policy review, medical record review, observation, and interview, the facility failed ensure documentation was complete and accurate for enteral tube feeding residuals for 1 of 4 sampled residents (Resident #55) reviewed for enteral tube feedings. The findings include: The facility's policy titled, Administering Medications through an Enteral Tube, dated 2/2018, documented, .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .For .gastrostomy tubes, check placement and gastric contents .If there is more than 100 ml (milliliters) of stomach content, withhold medication and notify the physician . Review of the medical record, showed Resident #55 had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Contact RD (Registered Dietician) if residual occurs . Review of the (MONTH) 2020 Medication Administration Record [REDACTED]. Observation in the resident's room on 1/12/2020 at 10:30 AM and 2:36 PM, and on 1/13/2020 at 9:55 AM, showed [MEDICATION NAME] 1.2 was infusing at 60ml/hr per pump to Resident #55. During an interview on 1/14/2020 at 4:55 PM, the Director of Nursing (DON) was asked if the enteral tube feeding residuals were documented. The DON stated, There are none in January. The DON was asked if the residuals for enteral feedings should be documented. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect for Resident #1 and #63 when of 1 of 1 (Assistant Director of Nursing (ADON)) staff members failed to knock before entering the residents' room and 3 of 3 (ADON, Licensed Practical Nurse (LPN) #4, and Certified Nursing Assistant (CNA) #1) staff members failed to provide privacy during wound care for Resident #46. The findings include: 1. The facility's Exercise of Rights / Resident Rights policy revised (MONTH) (YEAR) documented, .8. Residents' private space and property shall be respected at all times .Staff will knock and request permission before entering residents' rooms .12. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during .treatment procedures . 2. Observation in Resident #1's room on 3/5/19 at 2:09 PM, the ADON entered Resident #1's room without knocking, and failed to respect the resident's private space. Observation in Resident #63's room on 3/6/19 at 1:00 PM, the ADON entered the room [ROOM NUMBER] times without knocking, and failed to respect Resident #63's private space while staff were providing wound care. 3. Interview with the ADON on 3/6/19 at 1:35 PM, in the 100 hall, the ADON was asked what should be done prior to entering a resident's room. The ADON shook her head and stated, Knock. Interview with the Director Of Nursing (DON) on 3/6/19 at 2:21 PM, in the 100 hallway, the DON was asked if staff should enter a resident's room without knocking. The DON stated, No. 4. Observations in Resident #46's room on 3/6/19 at 11:04 AM, the window curtain in Resident #46's room was left open during wound care. CNA #1 assisted Resident #46 to a standing position, CNA #1 lowered Resident #46's pants and brief exposing her abdomen and buttocks. Resident #46 was potentially visible to anyone in the facility yard or occupying the rooms on the 400 hall. The facility staff did not provide privacy, promote dignity, and respect for Resident #46 by failing to close the curtains to the outside window. Interview with the DON on 3/6/19 at 11:30 AM, in the Conference Room, the DON was asked if a resident should receive wound care with the blinds and curtains open to hallway and the outside. The DON stated, No .