Every finding on record at Resthave Home-Whiteside County

Based on interview and record review the facility failed to ensure abuse allegations were investigated for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 repeatedly yelling at, cursing at, and calling R1 names. The findings include:On 6/9/26 at 9:30 AM, V1 (Administrator) said, The last abuse investigation was done in August 2025 and was not related to [R1] or [R2].R1's face sheet showed he was admitted to the facility 9/15/23 with diagnoses to include Parkinson's Disease without dyskinesia, hypertensive heart disease with failure, chronic congestive heart failure, peripheral vascular disease, and symptoms and signs involving cognitive functions and awareness. R1's 6/2/26 facility assessment showed he has moderate cognitive impairment and requires moderate assistance from staff for most of his cares.R1's care plan initiated 9/18/23 showed, [R1] has a diagnosis of Parkinson's Disease affecting his cognition. R1's care plan initiated 9/16/23 showed, [R1] has impaired cognitive function. 3/11/26 - Code Alert added to wheelchair (device to set off an alarm at the doors to alert staff if resident is trying to exit the facility). R1's care plan initiated 6/3/25 showed, . He has Parkinson's Disease, causing impaired cognition. [R1] has a female friend that he spends time with at the facility. [R1] has a special friend that he spends most of his time with. Both families are good with this arrangement.R2's face sheet showed she was admitted to the facility 3/3/23 with diagnoses to include polyarthritis, hypertension, dementia without behavior disturbance, muscle weakness, pain in right hip, pain in left knee, and depression. R2's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires substantial to maximum assistance from staff for most cares. R2's care plan initiated 6/17/25 showed, . [R2] has a special male friend at [the facility] that she spends most of her time with. R2's care plan initiated 1/28/26 showed, [R2] at times will raise her voice at her male friend/peer. Diagnosis of Dementia. [R2] will decrease frequency of raising her voice at peer through the review date. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. [NAME] B/T (Behavior Tracking) if this resident is witnessed raising her voice/yelling at peer(s)/her male peer/friend. There have been no changes to the interventions on this care plan since it was initiated 1/18/26. R2's 9/21/25 Behavior Note entered at 7:30 PM showed, Resident resting in bed, her s.o. (significant other) [R1] is also a resident present in the room visiting. [R2] ordering hm to perform small tasks in room, very demanding and talking down to significant other. CNA (Certified Nursing Assistant) heard from hallway [R2] tell him [R1] that he was F*cking stupid. R1's 11/7/25 Behavior Note entered at 9:27 AM showed, Resident and other resident [R2] have been found multiple times in each other's rooms, screaming profanities and yelling at one another using abusive language. Even after redirection, the two continue to argue and cause a scene. Other residents and visitors near can hear this language and behavior and have shown concern. This nurse will speak with the social worker to discuss a plan of action regarding behaviors.R2's 5/14/26 Behavior Note entered at 2:48 PM showed, While this nurse was receiving AM (morning) report at approximately 6:10 AM, this nurse and other staff could hear resident yelling at another resident, that she is in a relationship with. Resident was verbally yelling insults at the other resident. This nurse went into resident's room and separated the two. Later in the morning, resident was being pushed down the hallway by the resident she is in a relationship with. This nurse could hear resident cussing at him about her feet not being on her foot pedals the right way. As the other resident was trying to assist resident with her foot placement, resident yelled at him, 'You shit for brains! Not like that!'. This nurse explained to resident that this nurse would be letting social services know about this behavior, as it had been on going on at this point for nearly half the shift, and is not fair to the other resident. Resident looked at this nurse and yelled, 'The shit you are!' This nurse did report verbal abuse issues to. [V3 Social Services Director]. Later in the shift, this nurse again had to intervene and separate these residents, as resident again began to verbally assault her boyfriend with cuss words and derogatory statements.R2's 6/7/26 Behavior Note entered at 3:03 PM, Resident was in her room with another male, resident, and was overheard by staff, yelling at him. This nurse approached resident's room and inquired of the happenings. Resident states, 'Oh go away, he's just too dumb to understand what I am asking him to do.' . Before this nurse could intervene, resident yelled, 'I asked you for a rag! What are you blind?!' . Resident became upset and started to cuss at this nurse and the male resident. Later in the afternoon, this nurse was walking by resident's room and overheard her yelling, 'You're too stupid to understand!' . This nurse explained to the resident that what she was doing is verbal abuse, and it is not acceptable to treat another person this way, especially when they are trying to help. Resident states, 'The shit it is!' . On 6/9/26 at 10:32 AM, V7 CNA (Certified Nursing Assistant) said, [R1] and [R2] have been in a relationship for a couple years. They do not get along; they argue quite a bit. She gets frustrated because she wants him to do everything for her. This happens every day. I think it is abusive. I think they should probably be moved so they aren't so close to each other. We report it but administration knows, they have seen it.On 6/9/26 at 10:38 AM, V5 LPN (Licensed Practical Nurse) said, [R2] yells at [R1], she calls him an idiot and cusses at him. He puts up with a lot and he still does a lot for her. Both are confused, him more than her. Sometimes we go in and suggest that they separate for a while. Sometimes he returns yelling back if it's been a lot and that is when we go in and suggest they take some time apart. I feel that the things she says are abusive to him.On 6/9/26 at 11:13 AM, V4 LPN said, It is known throughout the facility that they are companions. On and off, she is very verbally aggressive and abusive to him. I have separated them multiple times, in fact this weekend I had to separate them again . I know they both have failing cognitive faculties. For instance, the last two times I witnessed verbal abuse from [R2], [R1] was trying to help her, and he was doing word for word what she was asking him to do. She was just insulting his intelligence. She was asking him a couple weeks ago to do something, and she called him 'shit for brains'. so I went and separated them. Then this weekend, the same scenario happened but they were in her room. she was yelling at him. I said, '[R2] apparently you are having a bad day, but I'm not letting [R1] sit here and take this. He doesn't deserve this.' Then later in the day, right before church, I heard a commotion, and she was yelling at him again. V4 said they are reporting a lot of verbal aggression from R2 towards R1 to Social Services. V4 said she requested to have R1's room moved to provide some separation between R1 and R2. and that way R1 and R2 wouldn't be right next to each other. V4 said she has gone to V3 (Social Services Director) at least 3 times suggesting room changes. V4 said V3 told her when they do R1 and R2's care plan meeting they talk about things and that some of these things were being addressed but V4 said it continues to happen. V4 said she has not reported anything to V1 (Administrator) because V3 (Social Services Director) is on the Abuse Committee. V4 said she feels Administration is 100% aware of this situation between R1 and R2. V4 said this has been an ongoing issue for months and months and that every episode has not been documented as often it happening, because it happens so frequently that most of their days would be spent documenting R2's behavior. V4 said R2's behavior is abusive, and she is constantly taking shots at R1's intelligence and cussing at him. When I report it, I'm told to keep documenting it because they go over these things in their care plans. [V3] told me that all I can do is document it. On 6/9/26 at 11:31 AM, V6 LPN said, [R2] usually has [R1] attempting to do things for her like turn her call light on, pull her back in the chair, fix her clothes, things like that and physically he can't do it. A lot of times he doesn't understand what she is trying to say and gets confused when she yells at him. She yells a lot of different things at him, calls him names, tells him he is stupid because he isn't understanding. She has sworn at him. I would consider what she says and when she yells at him as abusive at times. Administration is aware, I have said something to the [V2] DON in the past and from what I understand another nurse has reported it to [V3 Social Services Director] . Pretty much [V2] said to separate them until they stop. I will separate them and take [R1] to his room but [R2] will immediately start yelling out for him, and because their rooms are across the hall from each other he hears her and goes right back.On 6/9/26 at 12:50 PM, V3 Social Services Director said, [V1 Administrator] and myself are the abuse coordinators. [R1] and [R2] both came in at separate times, but they made a connection a couple years ago. I don't know how they define the relationship, but we would see them as a couple or two very, very close friends. They are together throughout the day at meals, activities, events, that sort of thing. How they get along fluctuates. There are some tensions like any relationship. There are arguments between the two of them, but generally speaking, they have a very respectful relationship. I would say they both have low cognition. Behaviors have been reported to me, from time to time there is tension or stress, and they tend to separate, or staff separate them as well. I saw the behavior notes today. I never heard or witnessed that verbal aspect as far as firsthand or being there in the moment. She does get frustrated, just in general and gets frustrated with him as well. Staff report general stress in the moment. If she is trying to say something and he isn't quite getting it, they intervene and try to help and fix what he needs and that fixes it in the moment. If she is cursing at him or saying derogatory things, that wouldn't be a good thing. (Reviewed Behavior Notes with V3) These particular details were not shared with me. These would require a 1:1 conversation.I would say they should separate the individuals and reduce or alleviate the stress in that particular moment. When things have been shared with me about [R1] and [R2], staff have already intervened. That is something we do on going, intervene. To prevent this from happening, we are trying to meet the needs of the individuals of course, being aware of where individuals are at, and if they are in a certain situation that is stressful maybe we are stopping and keeping an eye on things, it depends on the moment and the situation. We do behavior tracking.On 6/9/26 at 3:15 PM, V1 Administrator said, The abuse coordinator role is shared by myself and [V3]. We usually go by an on-call calendar. One of us is designated every day to be on call. Staff can come to any of us. It should be immediate reporting if something happens. There has been some aggravation between the two of them (R1 and R2) and as both of their dementia and cognitive deficits have gotten worse, the behaviors are getting worse. Nothing has been brought to my attention as far as a level of abuse. It would be something down the line we could do is to move one of them if the behaviors have continued. The aggravation seems to be getting worse, and we may have to consider moving them to different sides of the building. Right now, they are right across the hall from each other. For the most part, their relationship has been very positive. It has been just recently that the aggravation has gotten worse. Verbal behaviors are considered abusive if they are using profanity, yelling, name calling, or derogatory statements. If staff were to witness any of those, I would expect a phone call to be made so an abuse investigation could be started immediately. (V1 reviewed 5/14/26 Behavior Note showing V3 was notified.) [V3] should have reported that there was an abuse allegation. (V1 reviewed the Behavior Tracking documentation.) It is concerning for him to be getting yelled at like this. I would expect these behaviors to be identified, investigated, and the resident should be protected.The facility's policy and procedure reviewed 9/3/25 showed, Preventing and Reporting Abuse/Neglect; Purpose: To provide a safe environment and protect residents and the facility. Policy: [The facility] does not tolerate abuse or neglect of its residents. Each resident will be free from abuse, neglect. in any manner that would demean or humiliate them. Resident will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents. Definitions and criteria used to determine abuse or neglect: . 3. Verbal or psychological abuse, which may include but is not limited to the use of words, signs, or gestures to intimidate, demean, curse, harass, punish, humiliate, cause emotional anguish or distress, ridicule, or threaten harm to the resident, or words, signs or gestures or actions that the person knows for regressive behavior by that resident. Procedure: . The interdisciplinary team will formulate care plans to address needs and interventions of those residents with a history of or potential for aggressive behavior as well as those at a higher risk due to total dependence for cares and significant cognitive/communication deficits. Any staff member who witnesses or suspects abuse or neglects must contact the facility's abuse coordinator. Should the Administrator not be named abuse coordinator on the date of witnessed or suspected abuse or neglect, then the contacted abuse coordinator, who would include either Director of Nursing or Social Services Director must contact Administrator immediately. In the absence of the ADM (administrator), DON, or SSD (Social Services Director), the incident shall be reported to a charge nurse, who will notify one of these abuse coordinators immediately. The Administrator, Director of Nursing and/or Social Services Director will interview and/or examine the resident involved and initiate an investigation. When the alleged perpetrator is another resident of the facility, that resident shall be evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility. Referral to the Social Work Consultant, Ombudsman or other appropriate personnel to assist in the evaluation or referral will be considered.

Based on observation, interview, and record review the facility failed to provide behavioral health services for 1 of 3 residents (R2) reviewed for behavior services in the sample of 6. This failure resulted in R1 being repeatedly yelled at, cursed at, and called names by R2.The findings include:The facility's policy and procedure revised 5/11/2019 showed, . Behavior Tracking/Management Program. Purpose: To provide a means to collect data regarding individual resident behaviors. This data will be used for the following reason: To collect a baseline to determine the extent of the problem(s); To Monitor the effectiveness of the plan of care developed; To monitor for behavior (including problems individuals have been placed on psychotropic medications for); To monitor for changes in behavior. FORMAT: Behavior monitoring will be individualized to the resident. At a minimum, the monitoring charting includes frequency of the behavior, interventions used, and effectiveness of interventions. METHOD: Behavior tracking will be evaluated, along with observation of the resident, and interviews with staff/family/ or other involved individuals This data will be incorporated into the comprehensive assessment. MONITORING: The Social Service Director and DON will monitor Behavior tracking for completion and accuracy. Periodic monitoring will also be done by the Social Service Consultant, and this will consist of review of the tracking and interviews of direct staff. PROCEDURE: 1) Behavior Management Team will meet on a regular basis to review residents' behaviors, diagnosis related to these behaviors, and interventions, both pharmaceutical and non-pharmaceutical. Each resident will be re-evaluated routinely and upon significant change in behavior. 2) Behavior Tracking will be kept for each resident in the residents' chart. SSD (Social Services Director compiles data and tracks for any pattern or change in behaviors. 3) Interdisciplinary Team will monitor for contributing factors with changes in behaviors such as but not limited to medical reasons. change in family situation, and environmental issues. The interdisciplinary team will also review if the approaches used are successful for resident or if other approaches may need to be discussed/attempted. 4) The Care Plan Team will review each resident every 90 days or upon significant change in condition. The Care Plan team will develop and revise as needed a plan of care for resident with behaviors with individualized interventions. R1's face sheet showed he was admitted to the facility 9/15/23 with diagnoses to include Parkinson's Disease without dyskinesia, hypertensive heart disease with failure, chronic congestive heart failure, peripheral vascular disease, and symptoms and signs involving cognitive functions and awareness. R1's 6/2/26 facility assessment showed he has moderate cognitive impairment and requires moderate assistance from staff for most of his cares.R1's care plan initiated 9/18/23 showed, [R1] has a diagnosis of Parkinson's Disease affecting his cognition. R1's care plan initiated 9/16/23 showed, [R1] has impaired cognitive function. 3/11/26 - Code Alert added to wheelchair (device to set off an alarm at the doors to alert staff if resident is trying to exit the facility). R1's care plan initiated 6/3/25 showed, . He has Parkinson's Disease, causing impaired cognition. [R1] has a female friend that he spends time with at the facility. [R1] has a special friend that he spends most of his time with. Both families are good with this arrangement.R2's face sheet showed she was admitted to the facility 3/3/23 with diagnoses to include polyarthritis, hypertension, dementia without behavior disturbance, muscle weakness, pain in right hip, pain in left knee, and depression. R2's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires substantial to maximum assistance from staff for most cares. This same assessment showed R2 had no verbal behaviors directed toward others (e.g. threatening others, screaming at others, cursing at others). R2's care plan initiated 6/17/25 showed, . [R2] has a special male friend at [the facility] that she spends most of her time with. R2's care plan initiated 1/28/26 showed, [R2] at times will raise her voice at her male friend/peer. Diagnosis of Dementia. [R2] will decrease frequency of raising her voice at peer through the review date. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. [NAME] B/T (Behavior Tracking) if this resident is witnessed raising her voice/yelling at peer(s)/her male peer/friend. There have been no changes to the interventions on this care plan since it was initiated 1/18/26. R2's 9/21/25 Behavior Note entered at 7:30 PM showed, Resident resting in bed, her s.o. (significant other) [R1] is also a resident present in the room visiting. [R2] ordering hm to perform small tasks in room, very demanding and talking down to significant other. CNA (Certified Nursing Assistant) heard from hallway [R2] tell him [R1] that he was F*cking stupid and attempted to de-escalate situation and separate couple. [R2] then started yelling at CNA telling her that [R1] was not ready to leave. CNA politely informed resident that she was talking to significant other [R1] and asked him again if he wanted to get ready for bed. [R1] declined, CNA reported situation to this nurse. 7:45 PM This nurse then entered room, [R1] still doing small tasks. [R2] had decreased negative verbalizations in the presence of nurse. This nurse asked [R1] if he was doing O.K. or if he would like to get ready for bed. He stated he would but just wanted to finish last shore and would only be 5-10 more minutes. [R2] agreed to him leaving then. R1's 11/7/25 Behavior Note entered at 9:27 AM showed, Resident and other resident [R2] have been found multiple times in each other's rooms, screaming profanities and yelling at one another using abusive language. Even after redirection, the two continue to argue and cause a scene. Other residents and visitors near can hear this language and behavior and have shown concern. This nurse will speak with the social worker to discuss a plan of action regarding behaviors.R2's 1/8/26 Behavior Note entered by DON (Director of Nursing) at 12:57 PM showed, This nurse was at the nurse's station when she heard loud shouting. I got up to check on resident and find the source of yelling. As I got closer to her room, I could hear this resident yelling 'Behind you! By your elbow! Don't you know where your elbow is?', this nurse entered room of resident and noticed her male companion was also in the room, sitting in her recliner. This nurse asked, '[R2], is there something you need help with? I can hear you yelling at [R1] from the desk.R2's 1/24/26 Behavior Note entered at 4:48 PM showed, Resident in room and staff at nurse's desk, was able to hear resident yelling and crying. Peer resident in room at the time. Staff heard peer resident tell [R2], 'I can't help you with that.' Resident then cried out loudly 'Just do it.'. Staff entered room and separated the 2 residents. Resident wanted to be boosted back in wheelchair. R1's 1/24/26 Behavior Note entered at 4:54 PM showed, Resident was in a peer resident room. Yelling was heard coming out of the room. Peer resident was yelling at this resident to perform a task that he is unable to do. Resident was heard telling peer resident 'I can't help you with that. This resident was assisted out of peer resident room to his own room. Resident told CNA (Certified Nursing Assistant) He can't drive that thing. He was able to drive it yesterday and today he can't.' CNA told resident that peer resident was a woman and resident agreed and then continued to refer to peer resident as a 'he'.R2's 5/13/26 Behavior Note entered at 3:20 PM by V2 DON showed, Resident noted yelling several times at male friend throughout shift. This nurse intervened and assisted resident with her requests when possible, however, sometimes her requests were unclear. Both this resident and male friend encouraged to use call light to ask staff for assistance with tasks. R2's 5/14/26 Behavior Note entered at 2:48 PM showed, While this nurse was receiving AM (morning) report at approximately 6:10 AM, this nurse and other staff could hear resident yelling at another resident, that she is in a relationship with. Resident was verbally yelling insults at the other resident, as he did not understand what she was asking of him. This nurse went into resident's room and separated the two. Later in the morning, resident was being pushed down the hallway by the resident she is in a relationship with. This nurse could hear resident cussing at him about her feet not being on her foot pedals the right way. As the other resident was trying to assist resident with her foot placement, resident yelled at him, 'You shit for brains! Not like that!' This nurse immediately intervened and separated the two for a second time, asking the male resident to go ahead to his room and this nurse would assist resident in what she needed. This nurse explained to resident that this nurse would be letting social services know about this behavior, as it had been on going on at this point for nearly half the shift, and is not fair to the other resident. Resident looked at this nurse and yelled, 'The shit you are!' This nurse did report verbal abuse issues to. [V3 Social Services Director]. Later in the shift, this nurse again had to intervene and separate these residents, as resident again began to verbally assault her boyfriend with cuss words and derogatory statements.R2's 6/7/26 Behavior Note entered at 3:03 PM, Resident was in her room with another male, resident, and was overheard by staff, yelling at him. This nurse approached resident's room and inquired of the happenings. Resident states, 'Oh go away, he's just too dumb to understand what I am asking him to do.' This nurse observed male resident holding out a rag to resident, and he states, 'Here, this is what you asked for.' Before this nurse could intervene, resident yelled, 'I asked you for a rag! What are you blind?!' This nurse informed resident that the male resident, indeed had and was holding out to her, the rag that she had asked him to get for her. Resident became upset and started to cuss at this nurse and the male resident. This nurse promptly removed the male resident from resident's room and placed him into his own room. Later in the afternoon, this nurse was walking by resident's room and overheard her yelling, 'You're too stupid to understand!' This nurse entered resident's room and observed the male resident holding out a book to resident. This nurse inquired of the issue. Resident states, I asked him for that book, and he can't understand anything!' The male resident states, 'You told me a book, this is the one I found.' This nurse explained to the resident that what she was doing is verbal abuse, and it is not acceptable to treat another person this way, especially when they are trying to help. Resident states, 'The shit it is!' This nurse informed the male resident that it was time to leave the situation. The male resident agreed to allow this nurse to push him in his wheelchair back to his own room. When this nurse attempted to assist the male resident, resident put her feet straight out in front of the male resident's wheelchair and began to kick her feet up and down, in an attempt to keep the male resident from leaving. This nurse asked resident to please not put herself or the male resident at risk for injury, and resident stopped this behavior.R2's Behavior Tracking completed by the CNAs for March 2026 showed, [NAME] B/T (Behavior Tracking) if this resident is witnessed raising her voice/yelling at peer(s)/her male peer/friend. This behavior was documented as R2 having 85 documented instances of yelling at R1 in the month of March 2026. R2's April 2026 behavior tracking showed this behavior was documented as occurring 92 times. R2's May 2026 behavior tracking showed this behavior was documented as occurring 28 times. R2's June 2026 behavior tracking showed as of June 8th, this behavior was documented as occurring 12 times. All documented behaviors showed the intervention, sit and talk with him/her was completed. All except one documented behavior on June 7, 2026, showed this intervention was not effective. R1 and R2's rooms were located directly across the hall from each other. On 6/9/26 at 10:32 AM, V7 CNA (Certified Nursing Assistant) said, [R1] and [R2] have been in a relationship for a couple years. They do not get along, they argue quite a bit. She gets frustrated because she wants him to do everything for her. This happens every day. I think it is abusive. I think they should probably be moved so they aren't so close to each other. We report it but administration knows, they have seen it.On 6/9/26 at 11:13 AM, V4 LPN said, It is known throughout the facility that they are companions. On and off, she is very verbally aggressive and abusive to him. I have separated them multiple times, in fact this weekend I had to separate them again . I know they both have failing cognitive faculties. For instance, the last two times I witnessed verbal abuse from [R2], [R1] was trying to help her, and he was doing word for word what she was asking him to do. She was just insulting his intelligence. She was asking him a couple weeks ago to do something, and she called him 'shit for brains'. so I went and separated them. Then this weekend, the same scenario happened but they were in her room. She was asking him for a rag and when I was in there, he was handing her the rag, and she was yelling at him. I told her that he was handing her the rag. I said, '[R2] apparently you are having a bad day, but I'm not letting [R1] sit here and take this. He doesn't deserve this.' Then later in the day, right before church, I heard a commotion, and she was yelling at him again. He was holding a book out to her, and she was just verbally insulting him all over again. I said, '[R1], I'm so sorry, you are very tolerant, but I'm separating you again and I want you to stay apart until at least church.' V4 said when she went to remove R1 from R2's room, R2 put her feet up straight out and started kicking her feet to try and keep her from removing R1. V4 said she told R2 that it was dangerous to keep kicking her feet like that and could hurt R1 or herself doing this. V4 said they are reporting a lot of verbal aggression from R2 towards R1 to Social Services. V4 said she requested to have R1's room moved to provide some separation between R1 and R2. V4 said there was a room open not too long ago in the same hall, but further down. V4 said that way R1 and R3 wouldn't be right next to each other. V4 said she has gone to V3 (Social Services Director) at least 3 times suggesting room changes. V4 said V3 told her when they do R1 and R2's care plan meeting they talk about things and that some of these things were being addressed but V4 said it continues to happen. V4 said she has not reported anything to V1 (Administrator) because V3 (Social Services Director) is on the Abuse Committee. V4 said she feels Administration is 100% aware of this situation between R1 and R2. V4 said, This has been going on for months and months. every episode is not documented as often has happened, because it happens so frequently that most of our days would be spent documenting [R2's] behavior. God bless that man (R1), he is the most tolerant man and there was one day last week I think it was that he finally bit back and told her to stop yelling at him and use her damn eyes. I separated him from [R2] at that point, even though it is usually me separating [R2] from him. Her behavior is abusive. She is constantly taking shots at his intelligence. She cusses at him. When he is raising his voice back at her, that is when I can tell that it's affecting him, otherwise, he just has a flat affect and sits there. This can be heard through the halls. It is very loud. It goes on during mealtimes too now. When I report it, I'm told to keep documenting it because they go over these things in their care plans. [V3] told me that all I can do is document it. On 6/9/26 at 12:50 PM, V3 Social Services Director said, [V1 Administrator] and myself are the abuse coordinators. [R1] and [R2] both came in at separate times, but they made a connection a couple years ago. I don't know how they define the relationship, but we would see them as a couple or two very, very close friends. They are together throughout the day at meals, activities, events, that sort of thing. How they get along fluctuates. There are some tensions like any relationship. There are arguments between the two of them, but generally speaking, they have a very respectful relationship. I would say they both have low cognition. Behaviors have been reported to me, from time to time there is tension or stress, and they tend to separate or staff separate them as well. I saw the behavior notes today. I never heard or witnessed that verbal aspect as far as firsthand or being there in the moment. She does get frustrated, just in general and gets frustrated with him as well. Staff report general stress in the moment. If she is trying to say something and he isn't quite getting it, they intervene and try to help and fix what he needs and that fixes it in the moment. If she is cursing at him or saying derogatory things, that wouldn't be a good thing. (Reviewed Behavior Notes with V3) These particular details were not shared with me. These would require a 1:1 conversation.I would say they should separate the individuals and reduce or alleviate the stress in that particular moment. When things have been shared with me about [R1] and [R2], staff have already intervened. That is something we do on going, intervene. To prevent this from happening, we are trying to meet the needs of the individuals of course, being aware of where individuals are at, and if they are in a certain situation that is stressful maybe we are stopping and keeping an eye on things, it depends on the moment and the situation. We do behavior tracking. Social Services generally are putting the behavior tracking into the computer. we have our monthly psychotropic medication meeting and we review behavior tracking, medication dosages, and changes. During the meeting if we see behaviors documented, we discuss it from a medication standpoint and review to see if there are any interventions from a behavior standpoint. We discuss environmental changes, such as rearranging the room, changing get up times, or room changes. We don't document those meetings, we have them once a week, so we review everyone on a monthly basis and as needed of course. I don't recall any environmental changes being discussed for [R1] and [R2]. I don't know how often these behaviors are occurring, I would have to go back and look at the tracking. During the meeting we don't look at the nursing notes, we look at the medications. There are 3 core people in that meeting, [V1], [V21], and myself.On 6/9/26 at 2:35 PM, V2 DON (Director of Nursing) said, I'm part of the behavior committee. We break it into three parts, so everyone is done quarterly. We go through their medications and behaviors together. We talk about gradual dose reductions during that time and discuss any sort of behaviors that people are having. Even if they aren't in the group that we are discussing, that doesn't mean we can't bring it up with something that is happening that is disruptive. At times we talk about interventions, what is the cause of the behavior, what is the root cause, and what can we do to make sure that whatever the behavior is, isn't a safety risk. We are also talking about what we tried, what could we do additionally, how severe is the behavior, and if it warrants intervention. Any new interventions would be added by the Care Plan nurse. [R1] doesn't really have any behaviors, he is pleasantly confused. [R1] and [R2] bicker, she yells and wants things done for her. He wants to just serve her. I have gone in to find out what she needs, and I'll help her. It is always such piddly tasks, like picking something up off the floor. I don't think [R1] understands what she is asking him to do, sometimes I don't understand what she is asking for either. So, I think a little of her confusion comes in there too. It happens in the room most of the time. So far what we have talked about for them is that if we hear the arguments going on, go in and do whatever it is she needs, and check to see if [R1] is okay. I have taken him out of the room, but he will go right back in. If it is name calling or cursing at him, that would be abusive. (V2 reviewed R2's 6/7/26 Behavior Note) This nurse should have reported this, I read it the other day during morning meeting, and I wanted to talk to this nurse. She should have contacted the abuse coordinator. (V2 reviewed R2's 5/14/26 Behavior Note) There should have been an abuse investigation started on 5/14/26 from this note. I don't remember if I saw the 5/14/26 note. (V2 reviewed the 5/13/26 Behavior note that she entered in R2's chart) I don't consider her yelling at him to be verbal abuse, I took it as 'frustrated'. That day, she did not call him any names. It was on 5/13/26 that I first told [V3] about their bickering. I told [V3] I was down there and that we should probably move [R1]. I think it has been an issue for awhile but when I entered my last note 5/13/26, I told [V3] the poor man (R1) doesn't understand what she is asking. [V3] asked me if I had any ideas and I told him 'out of sight, out of mind'. [R2] calls for him so I think if we move him and leave her there and start having them eat in separate dining rooms, I think they would fine. At that time, he said okay and that we can talk to the family about it. They haven't been moved. Reviewing the behavior tracking, it appears concerning. Room changes were never discussed in our meeting.On 6/9/26 at 3:15 PM, V1 Administrator said, . There has been some aggravation between the two of them (R1 and R2) and as both of their dementia and cognitive deficits have gotten worse, the behaviors are getting worse. It would be something down the line we could do, is to move one of them if the behaviors have continued. The aggravation seems to be getting worse, and we may have to consider moving them to different sides of the building. Right now, they are right across the hall from each other. For the most part, their relationship has been very positive. It has been just recently that the aggravation has gotten worse. (V1 reviewed R2's Behavior Tracking documentation and Behavior Notes.) It is concerning for him (R1) to be yelled at like this. The Behavior Meetings do not include enough detail. The Social Workers run these meetings. They should be reviewing behaviors and reporting them. I would expect these behaviors to be identified, investigated, and the resident should be protected.

Based on observation, interview, and record review the facility failed to ensure a resident was free from resident-to-resident abuse for 1 of 3 residents (R1) reviewed in the sample of 6. This failure resulted in R1 repeatedly being yelled at, cursed at, and called names by R2.The findings include:R1's face sheet showed he was admitted to the facility [DATE] with diagnoses to include Parkinson's Disease without dyskinesia, hypertensive heart disease with failure, chronic congestive heart failure, peripheral vascular disease, and symptoms and signs involving cognitive functions and awareness. R1's [DATE] facility assessment showed he has moderate cognitive impairment and requires moderate assistance from staff for most of his cares.R1's care plan initiated [DATE] showed, [R1] has a diagnosis of Parkinson's Disease affecting his cognition. R1's care plan initiated [DATE] showed, [R1] has impaired cognitive function. [DATE] - Code Alert added to wheelchair (device to set off an alarm at the doors to alert staff if resident is trying to exit the facility). R1's care plan initiated [DATE] showed, . He has Parkinson's Disease, causing impaired cognition. [R1] has a female friend that he spends time with at the facility. [R1] has a special friend that he spends most of his time with. Both families are good with this arrangement.R2's face sheet showed she was admitted to the facility [DATE] with diagnoses to include polyarthritis, hypertension, dementia without behavior disturbance, muscle weakness, pain in right hip, pain in left knee, and depression. R2's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires substantial to maximum assistance from staff for most cares. R2's care plan initiated [DATE] showed, . [R2] has a special male friend at [the facility] that she spends most of her time with. R2's care plan initiated [DATE] showed, [R2] at times will raise her voice at her male friend/peer. Diagnosis of Dementia. [R2] will decrease frequency of raising her voice at peer through the review date. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. [NAME] B/T (Behavior Tracking) if this resident is witnessed raising her voice/yelling at peer(s)/her male peer/friend. There have been no changes to the interventions on this care plan since it was initiated [DATE]. R2's [DATE] Behavior Note entered at 7:30 PM showed, Resident resting in bed, her s.o. (significant other) [R1] is also a resident present in the room visiting. [R2] ordering him to perform small tasks in room, very demanding and talking down to significant other. CNA (Certified Nursing Assistant) heard from hallway [R2] tell him [R1] that he was F*cking stupid and attempted to de-escalate situation and separate couple. [R2] then started yelling at CNA telling her that [R1] was not ready to leave. CNA politely informed resident that she was talking to significant other [R1] and asked him again if he wanted to get ready for bed. [R1] declined, CNA reported situation to this nurse. 7:45 PM This nurse then entered room, [R1] still doing small tasks. [R2] had decreased negative verbalizations in the presence of nurse. This nurse asked [R1] if he was doing O.K. or if he would like to get ready for bed. He stated he would but just wanted to finish last chore and it would only be 5-10 more minutes. [R2] agreed to him leaving then. R1's [DATE] Behavior Note entered at 9:27 AM showed, Resident and other resident [R2] have been found multiple times in each other's rooms, screaming profanities and yelling at one another using abusive language. Even after redirection, the two continue to argue and cause a scene. Other residents and visitors near can hear this language and behavior and have shown concern. This nurse will speak with the social worker to discuss a plan of action regarding behaviors.R2's [DATE] Behavior Note entered by DON (Director of Nursing) at 12:57 PM showed, This nurse was at the nurse's station when she heard loud shouting. I got up to check on resident and find the source of yelling. As I got closer to her room, I could hear this resident yelling 'Behind you! By your elbow! Don't you know where your elbow is?', this nurse entered room of resident and noticed her male companion was also in the room, sitting in her recliner. This nurse asked, '[R2], is there something you need help with? I can hear you yelling at [R1] from the desk.R2's [DATE] Behavior Note entered at 4:48 PM showed, Resident in room and staff at nurse's desk, was able to hear resident yelling and crying. Peer resident in room at the time. Staff heard peer resident tell [R2], 'I can't help you with that.' Resident then cried out loudly 'Just do it.' Staff entered room and separated the 2 residents. Resident wanted to be boosted back in wheelchair. R1's [DATE] Behavior Note entered at 4:54 PM showed, Resident was in a peer resident room. Yelling was heard coming out of the room. Peer resident was yelling at this resident to perform a task that he is unable to do. Resident was heard telling peer resident 'I can't help you with that.' This resident was assisted out of peer resident room to his own room. Resident told CNA (Certified Nursing Assistant) 'He can't drive that thing. He was able to drive it yesterday and today he can't.' CNA told resident that peer resident was a woman and resident agreed and then continued to refer to peer resident as a 'he'.R2's [DATE] Behavior Note entered at 3:20 PM by V2 DON showed, Resident noted yelling several times at male friend throughout shift. This nurse intervened and assisted resident with her requests when possible, however, sometimes her requests were unclear. Both this resident and male friend encouraged to use call light to ask staff for assistance with tasks. R2's [DATE] Behavior Note entered at 2:48 PM showed, While this nurse was receiving AM (morning) report at approximately 6:10 AM, this nurse and other staff could hear resident yelling at another resident, that she is in a relationship with. Resident was verbally yelling insults at the other resident, as he did not understand what she was asking of him. This nurse went into resident's room and separated the two. Later in the morning, resident was being pushed down the hallway by the resident she is in a relationship with. This nurse could hear resident cussing at him about her feet not being on her foot pedals the right way. As the other resident was trying to assist resident with her foot placement, resident yelled at him, 'You shit for brains! Not like that!' This nurse immediately intervened and separated the two for a second time, asking the male resident to go ahead to his room and this nurse would assist resident in what she needed. This nurse explained to resident that this nurse would be letting social services know about this behavior, as it had been on going on at this point for nearly half the shift, and is not fair to the other resident. Resident looked at this nurse and yelled, 'The shit you are!' This nurse did report verbal abuse issues to. [V3 Social Services Director]. Later in the shift, this nurse again had to intervene and separate these residents, as resident again began to verbally assault her boyfriend with cuss words and derogatory statements.R2's [DATE] Behavior Note entered at 3:03 PM, Resident was in her room with another male, resident, and was overheard by staff, yelling at him. This nurse approached resident's room and inquired of the happenings. Resident states, 'Oh go away, he's just too dumb to understand what I am asking him to do.' This nurse observed male resident holding out a rag to resident, and he states, 'Here, this is what you asked for.' Before this nurse could intervene, resident yelled, 'I asked you for a rag! What are you blind?!' This nurse informed resident that the male resident, indeed had and was holding out to her, the rag that she had asked him to get for her. Resident became upset and started to cuss at this nurse and the male resident. This nurse promptly removed the male resident from resident's room and placed him into his own room. Later in the afternoon, this nurse was walking by resident's room and overheard her yelling, 'You're too stupid to understand!' This nurse entered resident's room and observed the male resident holding out a book to resident. This nurse inquired of the issue. Resident states, I asked him for that book, and he can't understand anything!' The male resident states, 'You told me a book, this is the one I found.' This nurse explained to the resident that what she was doing is verbal abuse, and it is not acceptable to treat another person this way, especially when they are trying to help. Resident states, 'The shit it is!' This nurse informed the male resident that it was time to leave the situation. The male resident agreed to allow this nurse to push him in his wheelchair back to his own room. When this nurse attempted to assist the male resident, resident put her feet straight out in front of the male resident's wheelchair and began to kick her feet up and down, in an attempt to keep the male resident from leaving. This nurse asked resident to please not put herself or the male resident at risk for injury, and resident stopped this behavior.On [DATE] at 10:32 AM, V7 CNA (Certified Nursing Assistant) said, [R1] and [R2] have been in a relationship for a couple years. They do not get along; they argue quite a bit. She gets frustrated because she wants him to do everything for her. This happens every day. I think it is abusive. I think they should probably be moved so they aren't so close to each other. We report it but administration knows, they have seen it.On [DATE] at 10:38 AM, V5 LPN (Licensed Practical Nurse) said, [R2] yells at [R1], she calls him an idiot and cusses at him. He puts up with a lot and he still does a lot for her. Both are confused, him more than her. Sometimes we go in and suggest that they separate for a while. Sometimes he returns yelling back if it's been a lot and that is when we go in and suggest they take some time apart. I feel that the things she says are abusive to him.On [DATE] at 11:13 AM, V4 LPN said, It is known throughout the facility that they are companions. On and off, she is very verbally aggressive and abusive to him. I myself, have separated them multiple times, in fact this weekend I had to separate them again . I know they both have failing cognitive faculties. For instance, the last two times I witnessed verbal abuse from [R2], [R1] was trying to help her, and he was doing word for word what she was asking him to do. She was just insulting his intelligence. She was asking him a couple weeks ago to do something, and she called him 'shit for brains'. so I went and separated them. Then this weekend, the same scenario happened but they were in her room. She was asking him for a rag and when I was in there, he was handing her the rag, and she was yelling at him. I told her that he was handing her the rag. I said, '[R2] apparently you are having a bad day, but I'm not letting [R1] sit here and take this. He doesn't deserve this.' Then later in the day, right before church, I heard a commotion, and she was yelling at him again. He was holding a book out to her, and she was just verbally insulting him all over again. I said, '[R1], I'm so sorry, you are very tolerant, but I'm separating you again and I want you to stay apart until at least church.' V4 said when she went to remove R1 from R2's room, R2 put her feet up straight out and started kicking her feet to try and keep her from removing R1. V4 said she told R2 that it was dangerous to keep kicking her feet like that and could hurt R1 or herself doing this. V4 said they are reporting a lot of verbal aggression from R2 towards R1 to Social Services. V4 said she requested to have R1's room moved to provide some separation between R1 and R2. V4 said there was a room open not too long ago in the same hall, but further down. V4 said that way R1 and R3 wouldn't be right next to each other. V4 said she has gone to V3 (Social Services Director) at least 3 times suggesting room changes. V4 said V3 told her when they do R1 and R2's care plan meeting they talk about things and that some of these things were being addressed but V4 said it continues to happen. V4 said she has not reported anything to V1 (Administrator) because V3 (Social Services Director) is on the Abuse Committee. V4 said she feels Administration is 100% aware of this situation between R1 and R2. V4 said, This has been going on for months and months. every episode is not documented as often it is happening, because it happens so frequently that most of our days would be spent documenting [R2's] behavior. God bless that man (R1), he is the most tolerant man and there was one day last week I think it was that he finally bit back and told her to stop yelling at him and use her damn eyes. I separated him from [R2] at that point, even though it is usually me separating [R2] from him. Her behavior is absolutely abusive. She is constantly taking shots at his intelligence. She cusses at him. When he is raising his voice back at her, that is when I can tell that it's affecting him, otherwise, he just has a flat affect and sits there. This can definitely be heard through the halls. It is very loud. It goes on during mealtimes too now. When I report it, I'm told to keep documenting it because they go over these things in their care plans. [V3] told me that all I can do is document it. On [DATE] at 11:31 AM, V6 LPN said, [R2] usually has [R1] attempting to do things for her like turn her call light on, pull her back in the chair, fix her clothes, things like that and physically he can't do it. A lot of times he doesn't understand what she is trying to say and gets confused when she yells at him. She yells a lot of different things at him, calls him names, tells him he is stupid because he isn't understanding. She has sworn at him. I would consider what she says and when she yells at him as abusive at times. Administration is aware, I have said something to the [V2] DON in the past and from what I understand another nurse has reported it to [V3 Social Services Director]. I think [V1 Administrator] and [V3 Social Services Director] share the abuse coordinator title. Pretty much [V2] said to separate them until they stop. I will separate them and take [R1] to his room but [R2] will immediately start yelling out for him, and because their rooms are across the hall from each other he hears her and goes right back. It wasn't a specific situation I reported to [V2], just that it was escalating. I feel like it has escalated because he is declining mentally, so he is not comprehending what she is asking. It's getting worse because it is harder for him to understand. A lot of times he doesn't even understand where he is at or what he is doing. I think he sun downs; I work second shift. He talks about being on his way to New York because his grandmother died and he has to settle their estate, he wants to rent his room for another night, things like that. I can tell when it is affecting him because sometimes you can hear the tone in his voice change when she is yelling at him, he won't yell but he will get a little gruffer in his response.On [DATE] at 12:50 PM, V3 Social Services Director said, [V1 Administrator] and myself are the abuse coordinators. [R1] and [R2] both came in at separate times, but they made a connection a couple years ago. I don't know how they define the relationship, but we would see them as a couple or two very, very close friends. They are together throughout the day at meals, activities, events, that sort of thing. How they get along fluctuates. There are some tensions like any relationship. There are arguments between the two of them, but generally speaking, they have a very respectful relationship. [R1] and [R2]'s cognition is low as far as retention and memory. I would have they have low cognition. Behaviors have been reported to me, from time to time there is tension or stress, and they tend to separate or staff separate them as well. I saw those notes today. I never heard or witnessed that verbal aspect as far as firsthand or being there in the moment. She does get frustrated, just in general and gets frustrated with him as well. Staff report general stress in the moment. If she is trying to say something and he isn't quite getting it, they intervene and try to help and fix what he needs and that fixes it in the moment. I don't think he is understanding what she is trying to say, or she isn't expressing it as well as she thinks she is. If she is cursing at him or saying derogatory things, that wouldn't be a good thing. I don't have recollection of those details being shared with me. That would require a 1:1 conversation. If it was reported that she was cursing and yelling at him, we would start an abuse investigation. I don't have recollection of any one particular incident. I would say they should separate the individuals, reduce or alleviate the stress in that particular moment. When things have been shared with me about [R1] and [R2], staff have already intervened. That is something that we do ongoing. To prevent this from happening, we are trying to meet the needs of the individuals of course, being aware of where individuals are at and if they are in a certain situation that is stressful maybe we are stopping and keeping an eye on things, it depends on the moment and the situation. We do behavior tracking. Social Services generally are putting the behavior tracking into the computer. we have our monthly psychotropic medication meeting, and we review behavior tracking, medication dosages and changes. During the meeting if we see behaviors documented, we discuss it from a medication standpoint and review to see if there are any interventions from a behavior standpoint. We discuss environmental changes, such as rearranging the room, changing get up times, or room changes. We don't document those meetings, we have them once a week, so we review everyone on a monthly basis and as needed of course. I don't recall discussing any environmental changes being discussed for [R1] or [R2]. I don't know how often these behaviors are occurring, I would have to go back and look at the tracking. During the meeting we don't look at the nursing notes, we look at the medications. There are 3 core people in that meeting, [V1], [V2], and myself.On [DATE] at 2:35 PM, V2 DON (Director of Nursing) said, I'm part of the behavior committee. We break it into three parts, so everyone is done quarterly. We go through their medications and behaviors together. We talk about gradual dose reductions during that time and discuss any sort of behaviors that people are having. Even if they aren't in the group we are discussing that doesn't mean we can't bring it up with something that is happening that is disruptive. At times we talk about interventions, what is the cause of the behavior, what is the root cause, and what we can do to make sure that whatever the behavior isn't a safety risk. We are also talking about what we tried, what could we do additionally, how severe the behavior is, and if it warrants intervention. Any new interventions would be added by the Care Plan nurse. [R1] doesn't really have any behaviors, he is pleasantly confused. [R1] and [R2] bicker, she yells and wants things done for her. He wants to just serve her. I have gone in to find out what she needs, and I'll help her. It is always such piddly tasks, like picking something up off the floor. I don't think [R1] understands what she is asking him to do, sometimes I don't understand what she is asking for either. So, I think a little of her confusion comes in there too. It happens in the room most of the time. So far what we have talked about for them is that if we hear it going on, go in and do whatever it is she needs, and check to see if [R1] is okay. I have taken him out of the room, but he will go right back in. If it is name calling or cursing at him, that would be abusive. (V2 reviewed R2's [DATE] Behavior Note) This nurse should have reported this, I read it the other day during morning meeting, and I wanted to talk to this nurse. She should have contacted the abuse coordinator. (V2 reviewed R2's [DATE] Behavior Note) There should have been an abuse investigation started on [DATE] from this note. I don't remember if I saw the [DATE] note. (V2 reviewed the [DATE] Behavior note that she entered in R2's chart) I don't consider her yelling at him to be verbal abuse, I took it as 'frustrated'. That day, she did not call him any names. It was on [DATE] that I first told [V3] about their bickering. I told [V3] I was down there and that we should probably move [R1]. I think it has been an issue for a while but when I entered my last note [DATE], I told [V3] the poor man (R1) doesn't understand what she is asking. [V3] asked me if I had any ideas and I told him 'Out of sight, out of mind'. [R2] calls for him so I think if we move him and leave her there and start having them eat in separate dining rooms, I think they would be fine. At that time, he said okay and that we could talk to the family about it. They haven't been moved. Reviewing the behavior tracking, it appears concerning. Room changes were never discussed in our meeting.On [DATE] at 3:15 PM, V1 Administrator said, The abuse coordinator role is shared by me and [V3]. We usually go by an on-call calendar. One of us is designated every day to be on call. Staff can come to any of us. It should be immediate reporting if something happens. There has been some aggravation between the two of them (R1 and R2) and as both of their dementia and cognitive deficits have gotten worse, the behaviors are getting worse. Nothing has been brought to my attention as far as a level of abuse. It would be something down the line we could do, is to move one of them if the behaviors have continued. The aggravation seems to be getting worse, and we may have to consider moving them to different sides of the building. Right now, they are right across the hall from each other. For the most part, their relationship has been very positive. It has been just recently that the aggravation has gotten worse. Verbal behaviors are considered abusive if they are using profanity, yelling, name calling, or derogatory statements. If staff were to witness any of those, I would expect a phone call to be made so an abuse investigation could be started immediately. (V1 reviewed [DATE] Behavior Note showing V3 was notified.) [V3] should have reported that there was an abuse allegation. (V1 reviewed the Behavior Tracking documentation.) It is concerning for him to be getting yelled at like this. The Behavior Meetings do not include enough detail. The Social Workers run these meetings. They should be reviewing behaviors and reporting them. I would expect these behaviors to be identified, investigated, and the resident should be protected.The facility's policy and procedure reviewed [DATE] showed, Preventing and Reporting Abuse/Neglect; Purpose: To provide a safe environment and protect residents and the facility. Policy: [The facility] does not tolerate abuse or neglect of its residents. Each resident will be free from abuse, neglect. in any manner that would demean or humiliate them. Resident will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents. Definitions and criteria used to determine abuse or neglect: . 3. Verbal or psychological abuse, which may include but is not limited to the use of words, signs, or gestures to intimidate, demean, curse, harass, punish, humiliate, cause emotional anguish or distress, ridicule, or threaten harm to the resident, or words, signs or gestures or actions that the person knows for regressive behavior by that resident. Procedure: . The interdisciplinary team will formulate care plans to address needs and interventions of those residents with a history of or potential for aggressive behavior as well as those at a higher risk due to total dependence for cares and significant cognitive/communication deficits. Any staff member who witnesses or suspects abuse or neglects must contact the facility's abuse coordinator. Should the Administrator not be named abuse coordinator on the date of witnessed or suspected abuse or neglect, then the contacted abuse coordinator, who would include either Director of Nursing or Social Services Director must contact Administrator immediately. In the absence of the ADM (Administrator), DON, or SSD (Social Services Director), the incident shall be reported to a charge nurse, who will notify one of these abuse coordinators immediately. The Administrator, Director of Nursing and/or Social Services Director will interview and/or examine the resident involved and initiate an investigation. When the alleged perpetrator is another resident of the facility, that resident shall be evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility. Referral to the Social Work Consultant, Ombudsman or other appropriate personnel to assist in the evaluation or referral will be considered.

Based on observation, interview and record review the facility failed to safely transfer a resident out of the facility van for 1 of 3 residents (R1) reviewed for safety and supervision during transfers. This failure resulted in R1 sustaining a fractured metatarsal (toe).The findings include:R1s admission record showed he was admitted to the facility on [DATE] with multiple diagnoses including cerebral palsy. The 3/31/26 quarterly resident assessment and care screening documents R1 to be cognitive intact. The same assessment showed him to have impairment on both sides of his upper and lower body. He is dependent upon staff for all of his daily activities. He uses a wheelchair and motorized scooter for mobility.The 4/3/26 facility incident report documents the nurse was called to assess R1 after he was observed by his wife falling out of the transport van onto the ground. R1 was alert and oriented to person, place and time, denied pain. He had a small laceration on his left forearm which was bleeding. The report notes he was exiting the transfer van in the entrance driveway.The 4/3/26 X-ray report of R1s left ankle shows the impression of an acute pseudo-[NAME] fracture of the fifth metatarsal with adjacent soft tissue swelling.On 4/21/26 at 8:45 AM, R1 was sitting up in a recliner, dressed and both calves on pillows. He was wearing tennis shoes, and his left ankle was visibly swollen. He had a bandage on his left arm. He said he had not been able to walk with his walker since falling. The day of the fall, he said the driver was watching all of the people around and what was happening and not paying attention. R1 said his wife was following the van in her car and watched the whole thing. She was yelling loudly for help when he fell. He denied pain but was more upset about not being able to walk. On 4/21/26 at 9:20 AM, V7 (R1s wife) said when the van returned to the facility, the driver did not have the lift up, it was still on the ground when the driver pushed (R1) out of the van. He just fell backwards out of the van. She said the handles of the wheelchair hit the ground first. Luckily, he was in a high back wheelchair that protected his neck and back. The fall looked like it was about 3 feet from the van to the ground. V7 said when she asked the driver what happened, he said he was not paying attention. She said there was an easter egg hunt going on in the yard of the facility, and he was watching that instead of her husband. V7 said now her husband has a fractured foot and is in therapy to get back to walking with his walker. He has spinal cord damage, so he does not have pain as a normal person would, the pain sensation is minimal. His foot was jerking which is different and it has settled down now. V7 said the whole thing was just frightening watching the whole thing. On 4/21/26 at 9:30 AM, V4 (transportation driver) said he had been driving the facility van for about a year. He said on 4/3/26 he was returning to the facility with R1, and when he returned there was an easter egg hunt in the yard, and he was busy talking to someone and distracted. He said the wheelchair lift was all the way down on the ground, and pushed R1 backwards out of the van, and fell about 3 feet down to the ground. V4 said he was not paying attention to what he was doing. On 4/21/26 at 10:35 am, V5 (transportation driver) arrives with a van. The resident is sitting in a wheelchair facing the front of the van. The wheelchair was secured to the floor of the van at each of the 4 wheels. V5 opens the back doors of the van, and has the lift raised and at the back of the van door. V5 unsecured the wheelchair and unlocked the wheels. While standing in front of the resident in the chair, he then pushes the resident backwards in their chair onto the lift. Once on the lift, the wheels are locked, and a security strap goes around the back of the wheelchair to ensure it does not go any further. The lift was lowered to the ground. V5 said the lift is always up before removing the safety straps of the wheelchair and unlocking the wheels. He said (R1) fell out of the new van. That van has an alarm that sounds when there is weight at the door of the van, and the lift is not in place. On 4/21/26 at 10:40 AM, V6 (transportation driver) arrives to load up a resident into new van, the one R1 fell out. V6 lowered the lift to the ground, and V5 stands on the plate at the back door for the lift. An alarm goes off and a red light by the door lights up to signal the lift is not in place. V6 said the alarm would sound when R1 was being pushed out of the door. He said the fall would have been about 3 feet to the ground.The facility policy for transportation states it is to ensure safe, efficient, and resident-centered transportation for appointments and outings. 5. Loading and Securement: Use the mechanical lift while loading resident off and on the van. While unloading the resident from the van, open the back doors and unfold the lift. Leave the lift in raised position. Wheel the resident from inside the van onto the lift and lock their wheelchair brakes. Exit the side door of the van and lower the lift to the ground. Unlock the wheelchair brakes and wheel the resident off the lift.4/22/26 at 11:15 AM, V3 Nurse Practitioner said she did go to the facility to assess R1 the day of the fall. When she arrived he was not showing any signs of pain such as grimacing and the only physical finding she made was some bruising. The staff called later that day and said he was complaining of pain. She ordered the Xray which showed a mild fracture. Could not say the fracture was from the fall, she has nothing to compare. V3 said she also made a referral to ortho, which his family refused. She ordered him to have therapy and supportive shoes. She said a fall of 3 feet there may be risk of spinal injury or concussion.

Based on interview and record review the facility failed to provide ordered laboratory services. This applies to 1 of 3 residents (R1) reviewed for laboratory services in the sample of 3. The findings include:R1's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with one of her diagnosis being myeloblastic leukemia (cancer affecting bone [NAME] leading to low hemoglobin and red blood cell counts). R1's 1/12/26 Minimum Data Set showed she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. R1's 2/3/26 Health Status Note from 12:34 PM, showed V6 R1's Daughter/Power of Attorney notified the facility R1 should be having weekly Complete Blood Count (CBC laboratory test that measures several blood values to include red blood cell counts and hemoglobin). The note showed R1's provider then ordered this lab to be done weekly. R1's 3/2/26 Health Status Note from 1:49 PM, showed R1 will be going to the local area hospital for her weekly CBC lab draws. The note showed, This change is related to past issues with current lab services. On 3/4/26 at 9:22 AM, R1 stated her daughter managed her labs; however, she believed some labs had been missed. On 3/4/26 at 11:53 AM, V6 R1's Power of Attorney/Daughter stated, They (lab technician) were either not showing up or they were missing her. The labs are for her leukemia. The facility was saying it's not a big deal [that R1's labs were not drawn], there were other ways to tell if her hemoglobin was low, but when she was first diagnosed her hemoglobin was 4 (typical female range is 11.5 to 15) and she was just a little shorter of breath, which we thought was just due to her other health problems.prior to this, at home, she was having treatments and having them [labs] drawn twice a week. On 3/4/26 all of R1's lab results were requested and on 3/4/26 at 2:40 PM the lab results provided showed R1's labs were drawn on 1/20/26 then 2/10/26 and then on 3/2/26. (No labs drawn on or shortly after 2/3/26 then following the lab draw on 2/10/26, R1's labs were not drawn for nearly 3 weeks.) On 3/4/26 at 12:14 PM, V2 Director of Nursing stated the initial issue with the labs not being completed weekly after 2/10/26 lab draw was due to an error when the nurse entered the order; however, following this error correction the lab technician failed to draw R1's labs on several occasions. V2 stated she has contacted her laboratory representative with little to no response. V2 stated R1 missed her lab draws on 2/17/26 and 2/24/26. V2 stated R1's labs were for the purpose of monitoring her leukemia diagnosis. On 3/4/26 at 2:45 PM, V1 Administrator stated the facility does not have a laboratory policy.

Based on observation, interview and record review the facility failed to ensure residents were treated with dignity for 2 of 3 residents (R1, R2) reviewed for dignity in the sample of 13.The findings include:1. R1s admission record shows he was admitted to the facility on [DATE]. His 12/2/25 resident assessment and care screening shows he is cognitively intact. The census report shows he was moved on 11/22/25 from room in (zone 2) to room in (zone 1).On 2/14/26 at 9:12 AM, R1 said he was in another room in the facility and did not like to say anything, but he did complain about the staff. There are 2 members of the staff that other residents complain about too but did not know their names. He reported these staff were mean to him. Their attitudes were not good. They were physically rough with him when he was not doing what they wanted. He said the mistreatment escalated to the point of needing to change rooms. R1 said they do not take care of him anymore, since changing rooms. R1 said he would like them to not take care of him at all. On 2/14/26 at 2:10 PM, V12, R1s daughter, said R1 had reported a complaint of the evil twins to her, and requested they not provide care for him. V12 said she requested specifically they do not have any contact with him. She said they were unkind, and to the point he was refusing care, even with family in the room. V12 said anyone choosing to work as an aide is to deal with grumpy people and they need to know how to manage them and monitor their reactions to the situations. She said she reported the twins to V11 social service, and he knew exactly who we were talking about. She said it bothered us they were aware of situations, and they are known in that way, and wondered why they are still working there. V12 said R1 did not like how he was treated, not with dignity or respect to the point of affecting his care. He would rather sit soiled than to have them in his room.On 2/14/26 at 11:18 AM, V11 said R1s family approached him and requested a room change to a different hallway. V11 said he did not know the reason. He said it was the daughter who spoke with him, and he believes it was due to a personality incompatibility with his current aides. V11 said he could not recall the names of the caregivers in question.On 2/14/26 at 11:39 AM, V9 Certified Nursing Assistant (CNA) said the twins were V3 and V4. They are also referred to as the sisters. There have been residents requesting they not provide care for them. One resident would rather sit in urine than have them assist with care. He would seek out help from staff on other hallways. V9 said she did report the situation, and he was moved to another hallway. The facility daily assignment sheets for February 1-12, 2026, show V3 and V4 were scheduled to work on zone 2 during their days to work.2. R2s admission record shows he was admitted on [DATE] and discharged on 12/29/25 after 6 days. His census report showed he resided in room on zone 2. His admitting diagnosis included sepsis following a hip replacement.R2 progress notes show on 12/29/25, V10, R2s wife, approached V11 and said she wanted to take him home. On 2/14/26 at 12:25 PM, V11 said R2s family did have some concerns regarding his stay, and he guided them through the grievance process. Their concerns were related to laundry not returning to his room, not enough fluids on his meal trays, and there were concerns with some of the caregivers. Her concern was the staff were not going at R2s pace, they were moving too fast for his needs. V11 said he did not recall the staff names. The 12/29/25 grievance form completed by V10 documents she witnessed staff not taking their time or listening to R2 when the speed at which the staff was moving him and causing him some discomfort and causing him to sit down at a speed that needed to be slower. She reported them as The Twins and were the most frequent staff members giving cares.On 2/14/26 at 1:30 PM, V10 said there were several issues with R2s stay in the facility. She said R2 had a hip replacement on 12/9/25 and had sepsis days after the surgery. He was admitted to the facility for antibiotics and therapy. She voiced complaints with dietary and laundry and said then there were the Twins, they were the worst. She had to remind them of the recent hip replacement; they would jerk him out of bed without letting him get his bearings, and plop him into a wheelchair and let him fall hard onto the toilet. She said they just did not seem to care. She said R2 was scared to speak up, he just wanted to go home. The twins just had an attitude. V10 said the mistreatment was over time, they did not treat him with dignity, they were rough and rude. She said that was pretty much the reason R2 went home early. He was afraid of retaliation if he were to speak up. She reported the situation to V11 because nobody should feel that way.On 2/14/26 at 12:26 PM, V2 Director of Nursing said she was aware of R2s concerns with V3 and V4. We told them to take the time to meet the residents' needs, and make sure to give them time. She did some sensitivity training. She said V3 and V4 are very good, they follow the rules, and they love the residents. She said R1 was not a fan of them either, and his family asked for V3 and V4 to not be his care givers, so he was moved to zone one. She said V3 and V4 are very task oriented. V2 said she spoke with R1 and R2 and all we were hearing for their complaint was they were short, not lovey dovey, and do not come across as warm and fuzzy. On 2/14/26 at 1:50 PM, V3 said she works in zone 2 every day. She was not aware of any residents she was not to provide care for and never had any issues with R1 or R2. On 2/14/26 at 1:30 PM, V4 was unable to be reached, and her voicemail was full, and unable to leave a message.On 2/14/26 at 2:30 PM, V1 Administrator said she knew there had been a couple of residents with personality complaints and had to move R1 to zone 1. She was also aware R2 had voiced concerns and filed grievance.The facility's 10/1/15 policy for Dignity documents each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on interview and record review the facility failed to implement and follow their Antibiotic Stewardship Program by not monitoring residents for inappropriate and unnecessary antibiotic use for 4 of 5 residents (R6, R13-R15) reviewed for antibiotic usage in the sample of 17. The findings include:The facility's Policy and Procedure for Antibiotic Stewardship policy dated December 2022 showed, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics to our residents. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics effects individual residents and the overall community. The policy showed all antibiotic orders will include the drug name, dose, frequency of administration, start date, stop date, route of administration, and indications for use.On 1/28/26 at 2:35 PM, V2 Director of Nursing/Infection Preventionist (DON/IP) stated she shared the IP role with V1 Administrator, however V1 was not a nurse. V2 stated, Antibiotic stewardship is something I am learning. I wasn't aware I was going to be the IP when I was hired as DON. Our ADON (Assistant Director of Nursing) was originally the IP, but she recently left abruptly. V2 stated she was responsible for monitoring antibiotic surveillance in the facility and reviewing residents' antibiotic orders once a month. V2 stated all antibiotic medication orders should have an associated diagnosis for the medication, and a medication stop date. V2 stated the facility had some residents on antibiotics prophylactically for infections because they were admitted with the order or the resident or family just wants them to stay on the antibiotic. V2 stated she reviews all residents' prophylactic antibiotic orders once a month, with the facility's nurse practitioner (V18 NP), to ensure there is a need for and an associated diagnosis for the prescribed antibiotic. 1.R6's physician order dated 1/2/26 showed R6 was prescribed Macrobid (antibiotic) 100 mg (milligram), take one capsule once a day for treatment of a UTI (urinary tract infection). The order showed no stop date for the administration of the medication. On 1/28/26 at 2:35 PM, V2 DON/IP stated R6 was started on Macrobid on 1/2/26 despite not having an acute UTI at the time, but because R6 has a history of having so many UTIs. V2 stated no repeat urinalysis was completed on R6 prior to her starting Macrobid on 1/2/26. V2 stated she had not reassessed R6 for the continued need for the medication since R6 started the medication on 1/2/26. 2.R13's physician order dated 12/30/25 showed R13 was prescribed Cephalexin (antibiotic) 250 mg, give one capsule in the morning for prophylaxis. The order showed no associated diagnosis for the order. The order showed no stop date. On 1/28/26 at 2:35 PM, V2 stated R13 was prescribed Cephalexin on 12/30/25 by his hospice service because of R13's history of UTI's, not because R13 had an acute UTI at the time. V2 stated the facility had never collected a urinalysis from R13 to assess and culture R13's urine prior to starting the Cephalexin. V2 stated she had never spoken with R13's hospice service about R13 being on the Cephalexin or his continued need for the medication. 3.R14's physician order dated 11/11/25 showed R14 was prescribed Bactrim (antibiotic) 400-80 mg, give half of a tablet once a day on Tuesday and Saturday for prophylaxis related to personal history of urinary tract infections. The order showed no stop date.On 1/28/26 at 2:35 PM, V2 stated R14 takes Bactrim because R14 apparently has had bad UTIs in the past and she wants to be on it. V2 stated R14 had never been diagnosed with an acute UTI while residing in the facility. The facility had never collected a urinalysis from R14 while she was in the facility. V2 stated she had never discussed R14's continued usage of Bactrim with V18 NP. 4.R15's admission record showed R15 was admitted to the facility on [DATE] and discharged on 1/9/26. R15's physician order dated 12/20/25 showed R15 was prescribed and received Nitrofurantoin (antibiotic) 50 mg, one capsule once a day for UTI prevention, from 12/21/25-1/9/26. On 1/28/26 at 2:35 PM, V2 stated R15 was admitted to the facility, from a local hospital, with a physician order for Nitrofurantoin. V2 stated, We just carried the order over from the hospital for his Nitrofurantoin because he had a history of UTI's. We never checked a urinalysis on (R15) prior to continuing the medication. I never spoke with (V18 NP) about the need to continue this medication.

Based on interview and record review the facility failed to ensure residents were free from the use of unnecessary antibiotics for 4 of 5 residents (R6, R13-R15) reviewed for unnecessary medications in the sample of 17.The findings include: 1.R6's physician order dated 1/2/26 showed R6 was prescribed Macrobid (antibiotic) 100 mg (milligram), take one capsule once a day for treatment of a UTI (urinary tract infection). The order showed no stop date for the administration of the medication. On 1/28/26 at 2:35 PM, V2 Director of Nursing/Infection Preventionist (DON/IP) stated she shared the IP role with V1 Administrator, however V1 was not a nurse. V2 stated she was responsible for monitoring antibiotic surveillance in the facility and reviewing residents' antibiotic orders once a month. V2 stated all antibiotic medication orders should have an associated diagnosis for the medication, and a medication stop date. V2 stated the facility had some residents on antibiotics prophylactically for infections because they were admitted with the order or the resident or family just wants them to stay on the antibiotic. V2 stated she reviews all residents' prophylactic antibiotic orders once a month, with the facility's nurse practitioner (V18 NP), to ensure there is a need for and an associated diagnosis for the prescribed antibiotic. V2 stated R6 was started on Macrobid on 1/2/26 despite not having an acute UTI at the time, but because R6 has a history of having so many UTIs. V2 stated no repeat urinalysis was completed on R6 prior to her starting Macrobid on 1/2/26. V2 stated she had not reassessed R6 for the continued need for the medication since R6 started the medication on 1/2/26. 2.R13's physician order dated 12/30/25 showed R13 was prescribed Cephalexin (antibiotic) 250 mg, give one capsule in the morning for prophylaxis. The order showed no associated diagnosis for the order. The order showed no stop date. On 1/28/26 at 2:35 PM, V2 stated R13 was prescribed Cephalexin on 12/30/25 by his hospice service because of R13's history of UTI's, not because R13 had an acute UTI at the time. V2 stated the facility had never collected a urinalysis from R13 to assess and culture R13's urine prior to starting the Cephalexin. V2 stated she had never spoken with R13's hospice service about R13 being on the Cephalexin or his continued need for the medication. 3.R14's physician order dated 11/11/25 showed R14 was prescribed Bactrim (antibiotic) 400-80 mg, give half of a tablet once a day on Tuesday and Saturday for prophylaxis related to personal history of urinary tract infections. The order showed no stop date.On 1/28/26 at 2:35 PM, V2 stated R14 takes Bactrim because R14 apparently has had bad UTIs in the past and she wants to be on it. V2 stated R14 had never been diagnosed with an acute UTI while residing in the facility. The facility had never collected a urinalysis from R14 while she was in the facility. V2 stated she had never discussed R14's continued usage of Bactrim with V18 NP. 4.R15's admission record showed R15 was admitted to the facility on [DATE] and discharged on 1/9/26. R15's physician order dated 12/20/25 showed R15 was prescribed and received Nitrofurantoin (antibiotic) 50 mg, one capsule once a day for UTI prevention, from 12/21/25-1/9/26. On 1/28/26 at 2:35 PM, V2 stated R15 was admitted to the facility, from a local hospital, with a physician order for Nitrofurantoin. V2 stated, We just carried the order over from the hospital for his Nitrofurantoin because he had a history of UTI's. We never checked a urinalysis on (R15) prior to continuing the medication. I never spoke with (V18 NP) about the need to continue this medication. The facility's Policy and Procedure for Antibiotic Stewardship policy dated December 2022 showed, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy showed all antibiotic orders will include the drug name, dose, frequency of administration, start date, stop date, route of administration, and indications for use.

Based on observation, interview and record review the facility failed to ensure tube feeding ordered by the physician was accurately measured. This applies to 1 of 2 residents (R4) reviewed for tube feeding in the sample of 17. The findings include:R4's current order summary shows, Resident has feeding tube and is NPO (nothing by mouth). The same report also shows, Jevity 1.5 cal (calorie)/fiber oral liquid (nutritional supplements), give 240 ml via [feeding tube] five times a day for nutrition support. On 1/28/26 at 11:21 AM, V4 Registered Nurse (RN) was giving R4 his scheduled tube feeding. She had an opened bottle of Jevity 1.5 calorie tube feeding formula dated 1/27/26 opened at 4:30 PM. She poured the tube feeding formula into a 30 ml (milliliter) medicine cup. A 30 ml medicine cup is marked at the top of the cup. She filled it up without making sure it was 30 mls. She continued to do that 4 times and poured each one into a 120 ml drinking cup. She stated, she does this 2 times because each time is a total of 120 mls equaling 240 mls total. The drinking cup was not full measuring 120 mls. She poured the first cup full of tube feeding formula into R4's feeding tube. Once that was complete, she used the 30 ml medicine cup to measure the tube feeding formula again. She did not make sure the amount was 30 mls and just poured the tube feeding formula into the medicine cup and then immediately into the other drinking cup. She was able to do that 2 times when the bottle of tube feeding formula was empty. She had to open another bottle of tube feeding formula to finish the tube feeding. She stated, that is how she always does his tube feedings. The 120 ml drinking cup was not full of tube feeding formula. On 1/28/26 at 4:37 PM, V2 Director of Nursing (DON) showed this surveyor a bottle of R4's tube feeding formula. Each bottle contains 1000 mls of formula. R4 is ordered to have 1,200 mls of tube feeding formula per day (240 mls X 5 = 1,200 mls). The formula bottle V4 RN used at 11:21 AM was opened and labeled that it was opened the day before prior to R4's 5:00 PM feeding. The 11:21 AM feeding, V4 RN did was R4's 5th feeding for that bottle. If R4 was given the correct amount of tube feeding formula V4 RN would have had to use 200 mls of the new bottle of formula instead she only used approximately 60 mls. The tube feeding was short 140 mls. V2 DON, confirmed this information and agreed that R4 was not given the correct amount of tube feeding formula that is ordered by the physician. She also stated, the nurses should be using the syringe that is provided to accurately measure the tube feeding formula ensuring R4 is receiving the correct amount ordered. R4's current care plan shows, R4 requires tube feeding (bolus feeds via [feeding tube] r/t esophageal dysphagia which as led to malnutrition. The facility's Enteral Nutritional Therapy, (tube feeding) policy dated 10/15/15 shows, Purpose: To provide liquid nourishment through a tube, inserted into the stomach. To provide hydration through a tube inserted into the stomach. Procedure: .5. Administer the amount of feeding to be given.

Based on interview and record review the facility failed to safely transfer a resident with the mechanical stand lift who has a history of falls. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet shows she has diagnosis including hypertensive heart disease and chronic kidney disease stage 4, atrial fibrillation, type 2 diabetes, repeated falls, reduced mobility, depression, generalized osteoarthritis, and anxiety. On 01/5/26 at 11:42 AM, V8 (Agency Certified Nursing Aide/CNA) said on 12/25/25, she received report R1 had a fall the day before and was a two person assist or mechanical stand lift. She went to find another staff member to assist her with the transfer. The other aide was busy, and she could not find staff to help her. She said she used the stand lift to transfer R1 by herself. V8 said she placed the sling under R1's armpits and secured the belt around her chest. During the transfer, R1's legs gave out, and she started to slip from the sling strap. She fell and hit her lower back on the floor. V8 said this was her first time working at the facility and she did not know when using the mechanical stand lift two staff should be assisting. She called for help, and another CNA came in, and they lifted her off the floor and placed her in the wheelchair. I should have asked the staff to assist me even though she was a stand lift and should have not lifted her off the floor until the nurse came. On 01/5/26 at 10:45 AM, V5 (Restorative CNA) said on 12/25/25, V8 was asking for the nurse and reported R1 was having pain. She did not know R1 fell from the stand lift. V8 mentioned R1 fell the day prior. R1 was a two person assist, she was alert to self and could not communicate all of her needs. Stand lifts are always two people assist. Staff should place the sling and secure the strap. If you don't have the strap in the right position, it could be a safety issue. The sling should be placed around the waist and not under the arm pits. Our lift policy is two staff are required with transfers, and all staff should know that. On 01/5/26 at 12:45 PM, V2 (Director of Nursing) said R1 had a fall from the stand lift. V8 (Agency CNA) did not follow our policy on mechanical transfers using two staff for transfers. When a resident falls staff should not move the resident until the nurse does her assessment and a resident should not be lifted off the floor. Staff should use the mechanical lift to transfer the resident off the floor for safety measures. When staff entered the room the mechanical stand lift arms were in an upright position and that will cause the sling to ride up the back. The sling should be placed around the back, and the buckle needs to be secured. That's what is going to catch them. We have an agency binder at the nurse's desk. It's ideal they look at it and its basic CNA knowledge when using the mechanical lift. R1's Incident Report dated 12/25/25 shows (V8) stated (R1) had slipped out of sit to stand machine and the sit to stand arms were in the upright position in R1's room. V8 reported moving R1 off the floor after the fall. R1's current care plan shows; is at high risk for fall due to history of falls and impaired mobility with interventions to use stand lift for transfers. R1's care plan shows she had a fall on 12/24/25 due to weakness. The facility's Transfer Policy/Use of Mechanical Lifts and Pivot Transfers revised 2019 states, two staff are required for all mechanical lift transfers.

Based on interview and record review the facility failed to protect a resident from abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of six. The findings include:The facility face sheet for R1 shows diagnoses to include Alzheimer's Disease and Down Syndrome. The facility assessment dated [DATE] shows R1 to have moderate cognitive impairment and requires moderate assistance with her activities of daily living. The facility abuse investigation dated 8/14/2025 shows a staff Nurse (V3 Registered Nurse) was observed by staff yelling at R1 and then pulling her backwards down the hall as R1 was crying and yelling. An investigation was completed, and abuse was substantiated by the facility. On 8/26/2025 at 9:37 AM, V3 RN said she was completing the monthly medications change over to the medication cart at the nursing station on 8/14/2025. V3 said R1 was sitting at the nursing station as she often does, but R1 was trying to talk to V3 and this was very distracting to V3. V3 said she asked two other staff if they would move R1 to another area so she could complete her task safely, but R1 refused each time to leave the station and continued to disrupt her. V3 said she messed up and yelled at R1 and then tried to push her away from the nursing station, but R1 put her feet down and was refusing to leave the area. V3 said she turned R1 around in her wheelchair and pulled her backwards to another area of the facility. V3 said R1 didn't want this to happen, but V3 said she did it anyway. On 8/26/2025 at 11:20 AM, V4 Certified Nursing Assistant (CNA) said she was waiting at another nursing station to get report on 8/14/2025, when she heard R1 yelling and screaming. V4 said she ran over to the other station and saw V3 dragging R1 backwards in her wheelchair. V4 said R1 was yelling and crying. V4 said she ran to get R1 away from V3 and V3 just walked away from the situation. On 8/26/2025 at 12:42 PM, V5 CNA said she was at the nurses' station after the incident with V3 on 8/14/2025. V5 said V3 told her she was overwhelmed with the medication switchover and listening to R1 talk and ask so many questions. V3 told V5 she had asked other staff to get R1 away from her but R1 refused to go so she [took matters into her own hands] and drug her backwards down the hall [kicking and screaming].On 8/26/2025 at 2:43 PM, V6 CNA said on 8/14/2025 at shift change, she was with V3 at the nursing station and was asked by V3 to try and move R1 away from the nursing station. V6 said she tried several times, but R1 did not want to move. V6 said V3 told her to get R1 moved because she was not dealing with her tonight. V6 said she told V3 she couldn't get R1 to move, and she would ask another CNA to come try, but V3 went over to R1 and tried pushing her away from the desk, but R1 put her feet down. On 8/26/2025 at 3:37 PM, V8 CNA said she had just come into work at around 10:50 PM and was looking at the assignment sheet when V3 asked her to please remove R1 away from the nursing station. V8 said she tried but R1 did not want to leave the area. V8 said after trying a few times, V3 came over to the edge of the nursing station and yelled at R1 saying [I don't want to get mean, but I've asked you nicely], then V3 counted [1,2,3] very loud and then came over to R1 and tried to push her down the hall. V8 said R1 was yelling and crying and putting her feet down and grabbing at the wheels of the wheelchair trying to stop V3 from moving her. V8 said she went over to R1 and tried to keep her from falling or getting her fingers pinched and V3 turned the wheelchair around and was pulling R1 down the hall. Just then another staff came and took R1 away from V3. On 8/26/2025 at 12:12 PM, V2 Director of Nursing said she got a call that night from one of the nurses and CNA's telling me about what V3 had done to R1. V2 said she came to the facility right away and walked V3 from the facility and suspended her until an investigation could be completed. V2 said V3 was terminated from the facility after the investigation was completed. The facility abuse policy with a review date of 12/20/2024 shows the facility does not tolerate abuse or neglect of its residents. Residents will not be subjected to abuse from anyone including staff.

Based on interview and record review the facility failed to ensure monthly medication reviews were acted on by the physician and failed to ensure the facility had a process in place to ensure the montly medications reviews were addressed in timely manner. This applies to 4 of 5 residents (R40, R28, R48 and R5) reviewed for medication review in the sample of 32. The findings include: 1. R40's Note to Attending Physician/Prescriber document from the monthly medication review dated 10/15/24 showed R40 has a current order for Zoloft 25 mg (milligrams) daily (dx: depression) and has not had a gradual dose reduction (GDR). If a gradual dose reduction attempt is not clinically contraindicated, clinical rationale MUST be documented as to why a GDR is likley to: with options for the provider to check below. This section is left blank and not signed by the provider. R40's Pharmacist's Medication Review Regime (MRR) Recommendations dated 11/19/24 showed 2nd request, MRR dated 12/17/24 3rd request, MRR dated 1/13/25 4th request, with same recommendations that Zoloft 25 mg daily has not had a GDR .a clinical rational MUST be documented as to why the GDR is likley to: with options for the provider to check below .this section is left blank. 2. R28's Note to Attending Physician/Prescriber document from the monthly medication review dated 10/15/24 showed R28 has a current order or Lexapro 10 mg daily (dx: generalized anxiety), and has not had a GDR . If a gradual dose reduction attempt is not clinically contraindicated, clinical rationale MUST be documented as to why a GDR is likley to: with options for the provider to check below. This section is left blank and not signed by the provider. R28's Consultant Pharmacist's Medication Regime Review Recommendations dated 11/19/24 2nd request, MRR dated 12/17/24 3rd request, MRR dated 1/14/25 4th request with same recommendations that Lexapro 10 mg daily has not had a GDR .a clinical rational MUST be documented as to why the GDR is likley to: with options for the provider to check below .this section is left blank. On 4/9/25 at 11:42 AM, V2 (Director of Nursing) said the previous DON left abruptly and when she took over as the DON she did not know what the MMR forms were or what to do with them. V10 (Pharmacist) reached out to her and asked if she needed help with the forms. There were times when the forms piled up and sat on the back burner for a bit. Now she knows they need to be addressed timely. 37232 3. R48's Consultant Pharmacist's Medication Regiment Review document dated 10/15/24 showed hydroxyzine (medication that can treat anxiety, nausea, vomiting, and itching) was to be discontinued based on a response to a previous pharmacy recommendation. However, the order appeared to still be active and to discontinue the order. The form had Recommendations to NURSING stamped on it. R48's Consultant Pharmacist's Medication Regimen Review document dated 11/19/24 showed the same recommendation was made as the 10/15/24 Consultant Pharmacist's Medication Regiment Review. R48's Pharmacy Consultant Medication Regimen Review document dated 12/17/24 showed a third request was sent to stop the hydroxyzine and the recommendation was sent to nursing. R48's Pharmacy Consultant Medication Regimen Review document dated 1/14/25 showed a fourth request was sent to stop the hydroxyzine and the recommendation was sent to nursing and the doctor. 4. R5's Note to Attending Physician/Prescriber document from the monthly pharmacy review dated 11/19/24 showed R5 had an as needed lorazepam order that did not have a criteria in place for use beyond 14 days. The section for Physician/Prescriber Response was blank. R5's Note to Attending Physician/Prescriber document from the monthly pharmacy review dated 12/17/24 showed, 2nd request that R5 had an as needed lorazepam order that did not have a criteria in place for use beyond 14 days. On 04/08/25 at 12:05 PM, V2 (Director of Nursing) said she receives the monthly pharmacy recommendations. V2 said she distributes the recommendations to the providers and once the providers respond, she enters the orders. 04/08/25 at 12:54 PM, V10 (Pharmacist) said if there is a recommendation made from the monthly pharmacy reviews, the recommendations should be addressed before the next monthly pharmacy review. If the recommendations are not acted on he will repeat the recommendations the following month. V10 said for R5 and R48 the recommendations were not acted on so he repeated the recommendations. The facility's Pharmacist Consultant Policy and Procedure with a revised date of 1/17 showed it is the facility's responsibility to assure that the identified party (i.e. - physician or nurse) responds to every pharmacist recommendation report. The identified party is not required to agree with the pharmacist's recommendation, but must respond to it.

Based on interview and record review the facility failed to ensure gradual dose reductions requests were implemented for residents on psychotropic medications and failed to ensure there was a stop date on an as needed psychotropic medication. This applies to 5 of 5 residents (R40, R28, R48, R5, R18) reviewed for unnecessary medications in the sample of 32. The findings include: 1. R40's Note to Attending Physician/Prescriber document from the monthly medication review dated 10/15/24 showed R40 has a current order for Zoloft 25 mg (milligrams) daily (dx: depression) and has not had a gradual dose reduction (GDR). If a gradual dose reduction attempt is not clinically contraindicated, clinical rationale MUST be documented as to why a GDR is likely to: with options for the provider to check below. This section is left blank and not signed by the provider. R40's Pharmacist's Medication Review Regime (MRR) Recommendations dated 11/19/24 showed 2nd request, MRR dated 12/17/24 3rd request, MRR dated 1/13/25 4th request with same recommendations that Zoloft 25 mg daily has not had a GDR .a clinical rational MUST be documented as to why the GDR is likely to: with options for the provider to check below .this section is left blank. R40's MRR form dated 2/11/25 shows Zoloft dose decreased to 12.5 mg per GDR recommendations. R40's Physician Order Sheets shows orders for Zoloft 25 mg daily. On 4/9/25 at 11:42 AM, V2 (DON) said she addresses the GDR's with the physician. When she receives the forms she gives them to the provider and they are supposed to give them back to her and not to the nurse on the floor. V2 confirmed R40's zoloft did not get decreased. 2. R28's Note to Attending Physician/Prescriber document from the monthly medication review dated 10/15/24 showed R28 has a current order or Lexapro 10 mg daily (dx: generalized anxiety), and has not had a GDR . If a gradual dose reduction attempt is not clinically contraindicated, clinical rationale MUST be documented as to why a GDR is likely to: with options for the provider to check below. This section is left blank and not signed by the provider. R28's Consultant Pharmacist's Medication Regime Review Recommendations dated 11/19/24 2nd request,, MRR dated 12/17/24 3rd request, MRR dated 1/14/25 4th request with same recommendations that Lexapro 10 mg daily has not had a GDR .a clinical rational MUST be documented as to why the GDR is likely to: with options for the provider to check below .this section is left blank. On 4/9/25 at 11:42 AM, V2 (DON) said the previous DON left abruptly and when she took over as the DON she did not know what the MRR forms were or what to do with them. V10 (Pharmacist) reached out to her and asked if she needed help with the forms. There were times when the forms piled up and sat on the back burner for a bit. Now she knows they are not recommendations and need to be addressed timely V2 said she addresses the GDR's with the physician. When she receives the forms she gives them to the provider and they are supposed to give them back to her and not to the nurse on the floor. 5. R18's admission Record dated April 8, 2025 shows she was admitted to the facility on [DATE] with diagnoses including malnutrition, encounter for palliative care, dementia, restless legs syndrome, muscle weakness, and anxiety disorder. R18's Order Summary Report dated April 9, 2025 shows an order for lorazepam (antianxiety medication) every two hours as needed ordered on March 18, 2025. There was no stop date placed on this order. On April 8, 2025 at 11:53 AM, V2 DON (Director of Nursing) said as needed psychotropics/anxiety medications should have a 14 day stop date. Floor nurses have been educated that any time an as needed psychotropic medication is ordered, it needs a stop date. 3. R5's Order Summary Report printed on 4/7/25 showed an order for lorazepam (psychotropic medication) to be given as needed. There was no stop date with the order. 4. R48's Order Summary Report printed on 4/7/25 showed an order for lorazepam (psychotropic medication) to be given as needed. There was no stop date with the order.

Based on observation, interview and record review the facility failed to follow the menu to ensure nutritional adequacy for residents on a pureed diet. This applies to 6 of 6 residents (R5, R18, R27, R34, R48, and R267) reviewed for menus in the sample of 32. The findings include: An undated facility provided list showed that R5, R18, R27, R34, R48 and R267 were on a pureed diet. On 4/7/25 at 10:26 AM, V13 (Cook) made six servings of pureed chicken. V13 placed six pieces of chicken breast, chicken broth and 2 pieces of bread into a blender and pureed it. V13 stated, We mix the bread serving into the meat and vegetables. On 4/7/25 11:08 AM , V13 used an ivory scoop (#10-3.25 ounces) to serve the pureed chicken. V13 stated, I am using a 3 ounce scoop because all residents should get 3 ounces of protein with their meals. The Diet Spreadsheet for the noon meal shows that a #8 scoop (4 ounces) should be used for the chicken breast and a #20 scoop (1 5/8 ounces) for the bread. On 4/9/25 at 9:33 AM, V5 (Dietary Manager) said that the diet spreadsheet should be followed and the staff should be serving what it says on the spreadsheet. V5 said that the spreadsheet and portion size is followed to ensure the resident receives the appropriate amount of protein and vegetables for nutrition. V5 said that since they add the bread serving to the meats and vegetables, they should be making the puree and then measuring the volume and reviewing the chart to determine the appropriate scoop size to use. The Recipe for Pureed Italian Chicken shows that a #8 scoop (4 ounces) should be used and includes the ingredients of: chicken breast, chicken broth and thickener.

Based on observation, interview, and record review the facility failed to ensure medications were administered at the prescribed time. There were 27 opportunities with 6 errors, resulting in a 22.22% error rate. The findings include: 1. R58's Admission Record dated April 8, 2025 shows she was admitted to the facility on [DATE] with diagnoses including pneumonia, metabolic encephalopathy, diabetes mellitus type II, chronic kidney disease, muscle wasting and atrophy, and dementia. R58's Medication Administration Record dated April 1, 2025-April 30, 2025 shows an order for blood sugar checks two times per day at 7:30 AM and 4:00 PM, insulin aspart sliding scale at 7:30 AM and 4:00 PM, insulin 70/30 20 units at 7:30 AM, isosorbide mononitrate extended release scheduled at 8:00 AM and 5:00 PM, metoprolol tartrate scheduled at 8:00 AM and 5:00 PM, and omeprazole delayed release scheduled at 8:00 AM and 5:00 PM. On April 7, 2025 at 9:55 AM (after breakfast) V6 LPN (Licensed Practical Nurse) checked R58's blood sugar level. It was 346. At 10:02 AM, V6 administered R58's insulin, isosorbide, metoprolol tartrate, and omeprazole. 2. R15's Admission Record dated April 8, 2025 shows she was admitted to the facility on [DATE] with diagnoses including idiopathic progressive neuropathy, local infection of the skin and subcutaneous tissue, pressure ulcer of right hip, polyarthritis, personal history of traumatic fracture, alzheimer's disease, age related osteoporosis, and history of falling. R15's Medication Administration Record dated April 1, 2025-April 30, 2025 shows orders for tramadol 50 mg two times a day for pain management scheduled at 7:00 AM and 8:00 PM. On April 7, 2025 at 9:38 AM, V6 LPN went into R15's room. R15 complained of generalized pain. V6 administered R15's 7:00 AM scheduled tramadol. On April 8, 2025 at 11:53 AM V2 DON (Director of Nursing) said medications can be given an hour before and up to a hour after they are scheduled to not be considered late. V2 said omeprazole is typically scheduled at 5:00 AM. V2 said that resident blood sugars should be checked prior to residents eating meals. If the blood sugar is checked after meals, it may be inaccurate. If insulin is given, then it could make the residents' blood sugars go too low. The facility's Medication Pass policy dated February 3, 2019 shows, Medication pass should be completed within one hour before and after scheduled times and document reason for medications that are not given in electronic medical record.

Based on observation, interview, and record review, the facility failed to ensure a resident was placed on enhanced barrier precautions for one of seven residents (R22) reviewed for infection control in the sample of 32. The findings include: R22's Admission Record dated April 8, 2025 shows he was admitted to the facility on [DATE] with diagnoses including heart disease, atrial fibrillation, personal history of urinary tract infections, and alzheimer's disease. On April 7, 2025 at 11:31 AM, V7 and V8 CNAs (Certified Nursing Assistant) went into R22's room to perform peri care. There was a foam dressing in place to R22's sacrum. The bottom end of the foam dressing was not intact to R22's skin. V7 nor V8 had gowns on. There was no isolation signs on R22's door. There was no enhanced barrier precaution sign on R22's door. R22's Order Summary Report dated April 8, 2025 shows an order was placed on April 8, 2025 for enhanced barrier precautions in place due to a wound. R22's Care Plan shows R22 requires the use of enhanced barrier precautions due to a wound. A sign will be placed on resident room door indicating the type of precautions and the required PPE (personal protective equipment). Precautions to remain in place for the duration of the resident's stay in facility or until the resolution of the wound or discontinuation of the indwelling medical device. Staff will wear gowns and gloves during high contact resident care activities which include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. On April 8, 2025 at 11:53 AM, V2 Director of Nursing said that R22 should be on enhanced barrier precautions. V2 said that R22 has a pressure injury to his coccyx. V2 said staff should wear gowns and gloves when doing cares. The facility's Policy and Procedure for Preventing the Spread of Multidrug Resistant Organisms (MDROs) dated January 19, 2025 shows, Nursing home residents with wound and indwelling medical devices are at especially high risk of both acquisition and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Based on observation, interview, and record review the facility failed to assess and obtain an order for a resident to keep medications at bedside and to self-administer medications for 1 of 1 resident (R54) reviewed for self-administering medications in the sample of 32. The findings include: R54's Face Sheet printed on 4/8/25 showed R54 had the following diagnoses: chronic obstructive pulmonary disease, malignant neoplasm of the lungs or bronchus, and pneumoniae. A facility assessment done on 3/28/25 showed R54's cognitive abilities were intact. On 04/07/25 at 9:21 AM, R54 was in his room lying in bed. There were no staff present in R54's room. On the bedside table was an albuterol sulfate inhaler. R54 said the inhaler was kept at his bedside and he uses it as needed. R54 added that he uses the inhaler without staff reminding him. R54 said he started keeping the inhaler at bedside about 1 week ago. On 4/7/25 at 11:28 AM, V9 (Registered Nurse) said she was the nurse taking care of R54 and R54 did not self-administer medications. On 4/7/25 at 1:18 PM, V2 (Director of Nursing) said for a resident to keep medications at the bedside the doctor would assess the resident and staff would obtain an order. V2 added the care plan would also indicate if a resident could keep medications at the bedside. V2 said R54 keeps his inhaler at bedside and uses it as needed. V2 looked at R54's orders and confirmed R54's inhaler was scheduled and not as needed. R54's Order Summary report printed on 4/7/25 at 4:27 PM, showed an order for an albuterol sulfate Inhaler to be taken four times a day for to prevent bronchospasms. R54's Progress Note dated 4/7/25 at 1:34 PM (after the surveyor had observed the medication at bedside), showed the facility contacted R54's Nurse Practitioner to obtain an order for R54 to keep the medication at bedside. On 4/7/25 at 11:30 PM, R54's electronic medical record did not have an assessment to self-administer medications or to store medications at bedside. R54's care plan printed on 4/7/25 did not indicate R54 could keep the inhaler at the bedside. The facility's Self-Administration of Medications policy with a revised date of 3/2/21 showed if the resident wishes to self-administer medications, the facility's interdisciplinary team will assess the resident's cognitive, communication, visual and physical functions to determine if the resident may do so. Should the interdisciplinary team determine that the resident is able to carry out the responsibility, a physician's order will be obtained.

Based on interview and record review the facility failed to ensure a resident was treated in a dignified manner for one of one resident (R6) reviewed for dignity in the sample of 32. The findings include: R6's Admission Record dated April 9, 2025 shows she was admitted to the facility on [DATE] with diagnoses including difficulty in walking, history of falling, and insomnia. R6's MDS (Minimum Data Set) dated March 17, 2025 shows R6 is cognitively intact. R6 requires moderate assistance with toileting hygiene. R6's Care Plan shows R6 requires staff assistance with hygiene/oral care. R6 requires staff assistance for toileting. R6 has bladder incontinence related to history of urinary tract infection, physical limitations related to right hip fracture and recent surgery. R6 uses disposable briefs, change every two hours and as needed, clean peri-area with each incontinence episode. On April 7, 2025 at 10:43 AM, R6 said she was bothered by an incident that happened over the weekend. R6 said her incontinence brief was soaked in the early morning hours of Sunday (April 6, 2025) at about 1:00 AM. R6 said she pressed her call light for assistance, a CNA (Certified Nursing Assistant) came in her room and said she was not R6's CNA so she couldn't change her. R6 said this CNA was rude. R6 said she pressed her call light again a while later and this same CNA came into R6's room and told R6 that R6's CNA was busy so she would change R6. R6 said the CNA was not nice at all. It made me feel so bad and so mad. On April 8, 2025 at 11:53 AM, V2 DON (Director of Nursing) said she got the report of R6 saying she had a rude CNA. V2 said that R6 said the CNA refused to help R6 with personal cares early this passed Sunday morning. V2 said R6 wears an incontinence brief at night because R6 does not want to go to the bathroom during the night. V2 said if staff go into R6's room to check her, R6 can tell them if her brief is wet or not. V2 said that R6 said that she pressed her call light for assistance. This CNA asked R6 what she needed. The CNA told R6 I'm not your CNA and then left R6's room. The same CNA came back a short time later and told R6 that her CNA was busy and changed R6. V2 reported that R6 told her that the CNA was rude. V2 asked R6 for this particular CNA's description. V2 said she believes the CNA was from another hall, but V2 did not know who the CNA was yet. V2 said she was going to find out who the CNA was. V2 said that R6 is alert and oriented. R6's Health Status Note dated April 6, 2025 at 12:14 PM shows, Resident being monitored for increase of trazodone at bedtime, resident tearful this am stating that she had a rough night. Unsure of how she had slept. No adverse reaction noted. The facility's Resident Rights Policy dated November 28, 2016 shows, Employees shall treat all residents with kindness, respect, and dignity. [Facility Name] will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview, and record review the facility failed to ensure a significant medication error did not occur for one of three residents (R58) reviewed for medications in the sample of 32. The findings include: R58's Admission Record dated April 8, 2025 shows she was admitted to the facility on [DATE] with diagnoses including pneumonia, metabolic encephalopathy, diabetes mellitus type II, chronic kidney disease, muscle wasting and atrophy, and dementia. R58's Medication Administration Record dated April 1, 2025-April 30, 2025 shows an order for blood sugar checks two times per day at 7:30 AM and 4:00 PM, insulin aspart sliding scale at 7:30 AM and 4:00 PM, and insulin 70/30 20 units at 7:30 AM. On April 7, 2025 at 9:55 AM (after breakfast) V6 LPN (Licensed Practical Nurse) checked R58's blood sugar level. It was 346. At 10:02 AM, V6 administered R58's insulin. On April 8, 2025 at 11:53 AM V2 DON (Director of Nursing) said said that resident blood sugars should be checked prior to residents eating meals. If the blood sugar is checked after meals, it may be inaccurate. If insulin is given, then it could make the residents' blood sugars go too low. The facility's Medication Pass policy dated February 3, 2019 shows, Medication pass should be completed within one hour before and after scheduled times and document reason for medications that are not given in electronic medical record.

Based on observation, interview, and record review the facility failed to ensure nutritional supplements were provided to a resident. This applies to 1 of 3 residents (R28) reviewed for nutrition in the sample of 32. The findings include: R28's face sheet shows she is a [AGE] year old female with diagnoses including parkinson's,congestive heart failure, depression, anxiety, history of transient attack and cerebral infarction. R28's Nutrition Note dated 10/10/24 shows her weight 117 lb (pounds) BMI (body mass index) 18.9; BMI is within normal but on the low side. R28 would benefit from a little bit more weight gain. Offer extra butter or peanut butter on meal trays. Supplements health shake, whole milk, resident drink with all meals and magic cup with lunch and dinner. R28's Nutrition Note dated 01/09/25 shows her weight 115 lb, BMI-18.6; Supplements health shake, whole milk, resident drink with all meals and magic cup with lunch and dinner. BMI is within normal limits but on the low side, would benefit from more weight gain. R28's diet card shows health shake, magic cup coffee, whole milk and resident drink with meals. The diet card does not show to offer peanut butter or butter with meals. On 4/07/25 at 12:02 PM, R28 was observed during the noon meal. R28 was seated in the main dining room, her eyes were closed with her head down. She was served country fried steak, mashed potatoes and green beans, she ate approximately 20 % of her noon meal. Her fluids were served in a handled cup with a lid and straw. Staff did not assist her during the noon meal or encourage her to eat. She was not provided her magic cup or health shake. On 4/08/25 at 11:35 AM, R28 was in the dining room during the noon meal. R28 was served her noon meal, with juice, health shake and water. She was not served her magic cup or milk. She had tremors to her hands and ate less than 20 % of her meal, staff did not assist her or encourage her to eat. On 4/08/25 at 10:56 AM, V11 (Licensed Practical Nurse-LPN) said R28 is alert to self and forgetful, she has a poor appetite, and needs cueing to eat, she will eat more when staff assist or encourage her to eat. She likes to eat junk food. On 4/09/25 at 9:47 AM, V4 (Dietary Manager) said R28 refuses her magic cup and health shake and would give them to her tablemate's. We don't offer them to her anymore because she would give them away to her tablemate's. On 4/9/25 at 12:11 PM, V4 (Dietitian) said if a resident triggers for weight loss we implement nutritional supplements. She thinks at one point staff verbally reported R26 was refusing some supplements. She will try a different intervention if the resident is not taking a supplement like extra peanut butter or butter with meals and would document what supplements are not working. The staff should still offer the magic cup, health shake and milk if it still listed as a supplement for the resident. R28's weights from October 2024 to April 2025 shows her weight from 117 lb to 113 lb. The facility's Weight Monitoring Policy states, To provide an ongoing evaluation of weight to ensure appropriate and timely nutritional intervention registered dietitian will review weight loss/gains completion during visit each month .Registered Dietitian and Dietary Supervisor will add supplements or calorie dense foods, i.e. whole milk, margarine, extra portions, and/or supplements on an individualized basis.

Based on interview and record review the facility failed to administer the correct medications to a resident. This failure resulted in R1 having to be admitted to the hospital's intensive care unit for intravenous fluids and blood pressure support medications. This applies to one of four residents (R1) reviewed for medications. The findings include: The facility face sheet for R1 shows diagnoses to include atrial fibrillation, Alzheimer's disease and hypertension. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and require the assistance of one staff for care. The facility medication error report dated 3/22/23 shows R1 received another residents medications at 6:30 AM. The medications R1 received in error included allopurinol (a uric acid reducer), aspirin (nonsteroidal anti-inflammatory and blood thinner), diltiazem (for high blood pressure), isosorbide (angina prevention), Jardiance (antidiabetic), lisinopril (antihypertensive), magnesium (dietary supplement), metoprolol (antihypertensive), vitamin B-12 (vitamin supplement), spironolactone (antihypertensive). These medications were meant for R10. The error report also shows a question that asked how could this error have been prevented and the nurse answered double checking resident with medications. On 3/28/23 at 8:45 AM, V3 Licensed Practical Nurse (LPN) said she was the nurse that gave R1 the wrong medications. V3 said she was starting her medication pass early as she has a lot of residents to give medications to. V3 said she was standing outside R1's door with her medication cart but had R10's Medication Administration Record (MAR) open and was answering the COVID monitoring questions. V3 said she then prepared the medication from that MAR but gave the medications to R1 instead. V3 said she did not realize an error had been made at that time. V3 said later in the morning around 8AM, V1 began acting strange while sitting on the toilet with staff in the room. He was having trouble sitting up. V3 said she got R1 back to bed and checked his blood pressure (B/P) which was 66/45. (Normal blood pressure is 120/80) V3 said R1's doctor was in the building, so she went and got him, and he instructed her to monitor the blood pressure, push fluids and keep R1 in bed with his feet elevated. V3 said she did not realize her error until she went to give R10 his medications after 8AM. V3 said she continued to monitor R1's B/P and when it was not coming back to normal, she contacted the doctor and R1 was sent to the emergency room . V3 said R1's B/P remained low and was 78/48 when he left the facility. The hospital records dated 3/23/23 shows R1 was seen at the local hospital emergency room but was then transferred to a hospital with an intensive care unit for closer monitoring. R1 was given intravenous fluids and dopamine (a medication to treat symptoms of shock by improving blood flow). R1 was diagnosed with hypotension (low B/P) secondary to accidental overdose. On 3/28/23 at 12:00PM, V4 LPN said when passing medications, it is important to double and triple check the medications to be given against the resident receiving the medications. On 3/28/23 at 10:05 AM, V2 Director of Nursing said she expects the nurses to give the correct medications to the residents. The nurses should be checking the medications against the MARs numerous times and verifying they have the correct resident before giving any medication. On 3/28/23 at 1:10 PM, V9 Physician Assistant (on call for R1's regular Physician) said when nurses are administering medications to the residents, they need to verify the resident name by checking the MAR, checking name bands and looking at the picture. V9 said the medications R1 received could have caused severe low blood pressure, low blood sugar and heart arrhythmia. R1 required a stay at the hospital due to the accidental overdose of medications not prescribed for him. The nursing progress notes for R1 shows on 3/22/23 the wrong medications were given to R1. Later that same day a nursing note showing R1 was transferred to an intensive care unit due to low blood pressure. The facility policy dated 2/3/2019 for medication pass, right resident, right drug, right time, right route, right dose shows Medication administration: a.) all medications should be checked against the MAR prior to administration .b.) identify resident by picture, name c.) med pass should be completed within one hour before and after scheduled times.

Based on interview and record review the facility failed to ensure a resident was free of a significant medication error. This failure resulted in R1 being hospitalized with [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: The facility's Medication Error Report dated July 27, 2017, showed R1 was given the wrong medication by E1(RN-Registered Nurse). E1 had prepared R1 and R2's medication. E1 administered R2's medication to R1. E2 then gave R2 her medications. R2 stated the medications in the cup did not look right. E1 then realized she had given R1 the wrong medications. R1 was sent to the local emergency room for monitoring due to a low blood pressure. The facility's Incident Report dated July 27, 2017, showed E1 administered R2's 8:00 AM scheduled medications to R1. The medications given to R1 included: one anti-depressant ([MEDICATION NAME]), two diuretics( [MEDICATION NAME] and [MEDICATION NAME]), one hypoglycemic ([MEDICATION NAME] extended release) and three anti-hypertensives ([MEDICATION NAME] extended release, Losartaan Potassium and [MEDICATION NAME] Tartate). R1's blood pressure was running low so she was transported to the local hospital for monitoring and observation. R1's Minimum Data Set, dated dated dated [DATE] shows R1 has [DIAGNOSES REDACTED]. R1's Physician order [REDACTED]. R1's Monthly Weights and Blood Pressures Log for 2017 shows R1's usual blood pressure to be 130's (systolic) / 80's(diastolic). On August 3, 2017 at 10:40 AM, R1 stated, I went to the hospital last week because they (facility staff) gave me the wrong medicines. My blood pressure was low. They also kept checking my blood because my blood sugar was low. They gave me some medicine and an IV (intravenous fluids). I had a headache. It upset me because I had to go to the hospital, it takes so long when your are there. On August 3, 2017 at 10:25 AM, E1(Registered Nurse) stated on the morning of July 27, 2017 she was doing her medication pass. E1 stated,R1 and R2 sit at the same table. I gave R1 what I thought were her medications and then turned and handed R2 her medications. R2 poured out her medication and counted them. R2 said there were not 12 pills. At that point I realized that I gave the wrong pills to R1. I know R2 takes some heavy duty pills for her blood pressure. I checked R1's blood pressure and it was already going down. I called the nurse practitioner and she told me to send her out to the emergency room . R1's blood pressure was 80/54, which is low for R1. E1 was asked what she would have done differently. E1 stated, I should put resident's name on the medication cup so I know whose medications are whose. On August 3, 2017 at 11:40 AM, E2(Director of Nursing) stated, when the nurses are administering medications they are to administer to one resident at a time. The nurse is to check the medication against the MAR-Medication Administration Record. Then give the medication to the resident. Lastly they are to sign out that the medication was given. After that is done then they can move on to the next resident. They should not prepare two residents medication the same time. There is too much room for error. R1 was sent out to the hospital because she was hypotensive. When R1 returned to the facility they were (facility staff) monitoring her blood sugar and blood pressure for any ill effects of the medication error. On August 3, 2017 at 12:09 PM, Z2(Clinical Pharmacist) stated, R1 was not on any anti-hypertensive's or antihyperglycemics. The medications given to R1 accidentally were concerning for lowering her blood pressure and blood sugar. It would take at least 24 hours for the medications to leave her system. [MEDICATION NAME] and [MEDICATION NAME] are long acting medications and would be the most concerning. On August 3, 2017 at 11:50 AM, Z1( Physician) stated, R1 was transferred to the emergency room for a low blood pressure. Her blood pressure initially was in the low eighties. She was given intravenous fluids to raise her blood pressure. We checked the half life of the medications she was given. the half life was 24 - 36 hours for the medications to leave her system, so she was admitted so we could monitor her blood pressure, heart rate and blood sugar. She was placed on a cardiac monitor and blood sugars and blood pressure were monitored. When administering medication to residents it should be done one resident at a time so this kind of thing doesn't happen. R1's hospital admission history and physical dated July 27, 2017 showed R1 was admitted to the hospital with [REDACTED]. R1 is to be observed placed on cardiac monitoring and monitor glucose. R1's hospital discharge history and physical dated July 28, 2017, showed R1's final [DIAGNOSES REDACTED]. R1 was accidentally administered another resident's medication with subsequent weakness, [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. R1 is to be discharged back to the nursing home with the following instructions; monitor for signs and symptoms of [DIAGNOSES REDACTED]. Blood sugars are to be checked every four hours today July 28, 2017. If the blood sugar is less than 100 start sugar feedings and recheck the blood sugar in 30 minutes. If the blood sugar is still less than 100, call 911. Be careful in administering medications.

Based on observation, interview and record review the facility failed to implement planned interventions for a resident with known pressure ulcers, failed to identify a pressure ulcer until it had progressed to a stage 2, failed to perform weekly skin assessments, and failed to identify a resident with incontince and mobility limitations as a high risk for pressure ulcer and implement interventions for prevention of pressure ulcer. These failures resulted with a resident identified at low risk for pressure ulcers to develop a Stage 3 pressure ulcer. This applies to 3 of 5 residents (R3,R10, R11) reviewed for pressure ulcers in the sample of 15. The findings include: 1. The May physician order [REDACTED]. The admission Minimum Data Set (MDS) assessment of March 29, 2016 shows R11 requires extensive assist with two staff for bed mobility and transfer from bed to chair and standing. The Bladder and Bowel assessment for the MDS documents R11 to be frequently incontinent of urine. The March 22, 2016 and the March 29, 2016 Braden scale for predicting pressure sore risk showed R11 to have a score of 20 and 17, a mild risk for acquiring a pressure ulcer. No further weekly Braden assessments were documented. The interim care plan for R11 dated March 22, 2016 documents a potential alteration in skin condition and required skin monitoring and to report red/discolored or broken skin, and turn and reposition every two hours and as needed. The March 22, 2016 admission body audit performed by admission nurse documents R11 had no skin breakdown or open areas. On May 5, 2016 at 3:45 PM, E8 Licensed Practical Nurse (LPN), stated R11 required two assist when she was admitted . E8 said R11 was difficult to keep dry and always seems to have wet incontinence briefs. On May 6, 2016 at 1:00 PM, E9 LPN, stated when R11 was admitted she was unable to move herself in bed and she was always incontinent of urine, she just had no control. The March 22, 2016 admission nursing assessment for R11 documents she required staff for assist bed mobility and to always need help to move up in bed and to sit up. On May 5, 2016 at 3:45 PM, E8 stated R11 was a skilled resident and would have had a skin check daily by the nurse and at least twice a week by the aides during her shower. E8 stated R11 was found to have open areas on her buttocks on April 9, 2016. On May 6, 2016 at 8:00 AM, E3 (Director of Nursing) stated any low risk resident would be one who would be able to ambulate on their own and provide their own care and would not require a daily check. E3 stated any resident who is unable to reposition and is incontinent of urine would be considered a high risk for skin breakdown or pressure ulcers. E3 stated any wound should be identified as redness or bruising before it would open and become a Stage 2 or 3. On May 6, 2016 at 8:10 AM, E4 MDS Coordinator / Registered Nurse (RN), stated she had assessed the wounds on April 10, 2016 and the coccyx was open but would not say the wound was a stage3 but more of a stage 2. E4 stated she should have re-assessed the Braden scale risk assessment weekly after her admission. E4 stated when the wounds were found, R11 was then put on a turn and reposition schedule, but she should have been on a turn schedule prior to the wounds. On April 9, 2016 the nurse's notes showed R11 to have a slit type open area between the buttocks. The wound documentation progress sheet documents the wound to be 1.2 cm x 0.3 cm (centimeters, length by width). No staging of the wound is documented. A second wound is documented as two irregular shaped areas on the right buttock. No wound measurements or staging is documented. On April 11, 2016 a fax request was sent to the physician's office for a referral to the wound clinic for two open areas at a Stage 2. The physician responded he wound assess the wounds on April 13, 2016. The April 13, 2016 physician visit dictation notes R11 had complained of some buttock pain but makes no assessment of buttock wounds. The physician order [REDACTED]. The April 14, 2016 wound nurse assessment documents R11 to have two stage 3 pressure ulcers. The wound on the coccyx measure 2.0cm x 0.7cm. And the left buttock wound measure 4.5cm x 1.1cm. On May 6, 2016 at 8:15 AM, E3 stated R11 was working with physical therapy when she was admitted and was very weak. E3 said R11 would refuse to get up and would always want to stay in her room. E3 said the wounds were not open when they were identified but had progressed to stage 3 over the 5 day period. On May 6, 2016 at 3:15 PM, Z2 (RN) stated she represents Dr. Woods and would respond on his behalf. Z2 stated any resident with incontinence and mobility issues should be considered a high risk for pressure ulcers. And Z2 agreed that with appropriate interventions the wounds could have been avoidable. 2. The March 15, 2016 MDS documents R10 requires extensive assist with 2 staff for bed mobility and is totally dependent upon staff for transferring in and out of bed. The MDS showed R10 to be frequently incontinent of urine. The Braden scale shows R10 to be at a high risk for pressure ulcers. The March 2016 treatment record showed R10 was to have a weekly skin check performed by the nurse on Thursday evening. The record showed no skin check was documented for March 24 or the 31st. R10's nurse's notes for March 29, 2016 document a newly identified wound on the left lower buttock. The wound measured 3.5 cm x 4 cm x 0.5cm. The notes show barrier cream was applied to the sore. The nurse's note for March 30, 2016 documents an open area on the left buttock and is a dime size bruise. No measurements or description of the wound bed or tissues is documented. The March 31, 2016 nurses note documents R10 had a stage 2 pressure ulcer on her left buttock and measured 3cm x 2 cm with drainage. The weekly wound documentation was initiated on March 31, 2016 with the wound as a stage 2. On May 6, 2016 at 10:30 AM, the left buttock wound was observed to be a small open area with pink skin around the wound. No drainage noted, and no odor. E9 noted a new open area on R10's coccyx. E9 stated it was a new area since she had no current treatment orders for this wound. E9 measured the wound as an open stage 2 wound 0.5cm x 0.5 cm. E9 stated this area has opened and closed before and now it has re-opened. E17 Certified Nursing Assistant (CNA) stated she had been putting barrier cream on R10's bottom and she should be turned every 2 hours. On May 6, 2016 at 8:30 AM, E3 stated the buttock was more of a pink area and it was not opened and cannot believe in one day the area opened and had drainage. E3 stated she cannot say the nursing documentation was incorrect. E3 stated the nurse with the initial documentation did not complete a weekly wound sheet as required per protocol. The facility policy for Prevention and treatment of [REDACTED]. Procedure: Prevention of Pressure Ulcers 1. Braden scale will be done upon admission and weekly for the first 4 weeks post admission. 2. Monitoring of skin integrity: b. Weekly skin audits on the bath/shower day will be performed by the Licensed Nurse in conjunction with the nursing assistant. If there is development of a pressure ulcer the following procedure is to be implemented: 10. Initiate weekly wound documentation progress sheet which will include: type of wound, location, date, stage (pressure ulcer only), length, width and depth. 3. March 1, 2016 MDS shows R3's admitted to be February 22, 2016. The same MDS shows R3 to have a [DIAGNOSES REDACTED]. The April 15, 2016 nursing progress notes shows R3 had a open area on his left and right inner buttocks. On April 16, 2016 a blister on his right heel measuring 10 cm (centimeters) was discovered and categorized as unstageable. On May 5, 2016 at 9:00 AM R3 was restless and getting up as soon as the CNA, assisted him in sitting. E16 (LPN) said he (R3) has a stage 2 pressure ulcer on either side of his buttocks. On the same date and time R3 was seen leaning over in his wheelchair and leaning forward, putting pressure on his arms in an effort to relieve pressure off his bottom. On May 3, 2016 at 2:00 PM, E16 LPN applied barrier cream to a stage 2 pressure ulcer that measured approximately 8cm X 3cm on the right side of the buttocks and 5cm X 4cm on the left side of the buttocks. No visible drainage was seen. R3 had a 4cm in diameter blister on his right heel. On May 3, 2016 at 3:30 PM while in bed R3's heels were not being floated. On May 4, 2016 at 9:21 AM R3's heels were not being floated. On May 5, 2016 at 8:15 AM R3 was in bed with heels not floated. On May 4, 2016 at 12:24 PM, E3 said, if R3's physician's orders [REDACTED]. On May 4, 2016 at 9:30 AM R3 was in his wheelchair without his seat cushion. On May 4, 2016 at 12:24 PM, E3 DON said, his (R3) seat cushion not being on his wheelchair was my fault. I transferred R3 into the wheelchair and forgot to put the cushion on. On May 3, 2016 at 9:00 AM R3 said my butt hurts if I sit on it. On May 4, 2016 at 1:48 PM R3 stated, did you know about my back side? My butt really hurts, I have a sore. On May 5, 2016 at 9:14 AM R3 said my butt hurts. On May 4, 2016 at 10:00 AM, E11 RN said she did not assess R3's pain yet and did not give any medication for pain. On May 5, 2016 at 10:00 AM E18 CNA said she did not realize that R3's heels should be floated while in bed. We get information on resident's care in daily report and on communication sheets and floating heels was not on my communication sheet. On May 4, 2016 at 12:24 PM E3 said we are trying to make positive changes in the way information is being passed down to the CNA's after there is a change in care for the residents. On the same date and time E3 said that a pain assessment should be done upon admission and when there is a change in the resident's condition. E3 said a pressure ulcer is a change in condition. R3 had one pain assessment sheet in his chart dated February 2, 2016, but none after that. E3 said weekly wound reports should be completed weekly. R3's buttocks wound was assessed on April 15, 2016 with no other weekly wound reports completed. R3's right heel wound was assessed on April 16, and April 23, 2016 with no other wound reports completed. The June 15, 2012 prevention and treatment of [REDACTED].#5 notify therapy department for seating surface evaluation and possible treatment interventions in other interdisciplinary team members as appropriate. #7 initiate Braden Scale form. #9 update nursing assistant profiles with skin concerns, appropriate risk factors, turning intervals and interventions as appropriate. #11 when a pressure ulcer is present, daily wound monitoring should include; A. An evaluation of the ulcer. E. whether pain is being adequately controlled. The April, 2016 POS shows on April 16, 2016 to float heels in bed and monitor every shift. The TAR (treatment administration record) for May, 2016 shows that heels are to be elevated in bed with no documentation for first shift on the 2, 3, 4, and 5 of May.