Every finding on record at Rosebud Health Care Center

Based on interview and record review, the facility failed to ensure the Medical Director or designee attended Quality Assurance Performance Improvement (QAPI) meetings at least quarterly. This deficient practice limited the Medical Director's ability to fully participate and add value to the QAPI meetings. Findings include:During an interview on 12/17/25 at 3:31 p.m., staff member B stated the Medical Director participated in the QAPI program by notification of the meeting date and time, and was also provided the QAPI meeting documentation. Staff member B further stated that the information was shared with the Medical Director at monthly board meetings and medical staff meetings. Staff member B stated the facility's Medical Director was located in a different area of the state and the Medical Director did not attend the QAPI meetings.During an interview on 12/17/25 at 4:11 p.m., staff member G said he has not attended any of the facility's QAPI meetings. Staff member G stated he was misinformed and did not realize he was supposed to be an active member and participant in the QAPI meetings.Review of the facility's documents titled, QA (Quality Assurance)/ RIP (Rapid Improvement Projects) meeting sign-in sheet, dated June through November 2025, showed the Medical Director did not attend any of the Quality Assurance meetings.

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and dated after the package was opened, failed to ensure food items in the freezer were stored off the floor, and failed to label and date items in the refrigerator in the resident's dining room. This deficient practice increased the risk of food borne illness for all residents who were served food from the kitchen. Findings include:During the initial tour of the kitchen on 12/15/25 at 2:24 p.m., the following were observed:- A plastic bag contained what appeared to be chow mein noodles, located in the dry storage area. The bag was not labeled with the contents and was dated 7/7.- Two plastic bags containing potato wedges were opened and not labeled or dated in the freezer.- A stainless steel pot was observed on the floor of the freezer. The pot was covered with aluminum foil and was torn near the edge of the pot which left the contents of the pot open to air. The pot was labeled, flank steak chili, dated 11/12. - A cardboard box which was labeled, beef, was observed on the floor of the freezer.- Three plates that contained green beans, a dinner roll, and what resembled a casserole were covered in the walk-in cooler and not labeled or dated.During an interview and observation on 12/15/25 at 2:30 p.m., staff member E said food items should not be stored on the floor of the freezer. During an observation on 12/16/25 at 5:24 p.m., six meat sandwiches were observed on a platter in the refrigerator in the dining room and were not labeled or dated. During a return visit to the kitchen on 12/17/25 at 8:39 a.m., the following were observed in the facility's freezer:- Two plastic bags which contained potato wedges were opened and not labeled or dated.- A plastic bag which contained French fried potatoes was opened and not labeled or dated.-A plastic bag which contained potato slices was opened and not labeled or dated.During an interview on 12/17/25 at 8:43 a.m., staff member H stated when food items were opened the bag should be taped closed with a date of when the bag was opened.During a follow-up visit to the kitchen on 12/18/25 at 8:29 a.m. the following were observed:- A bag of sausage crumbles was opened and not labeled or dated.- One bag of potato wedges was open and not labeled or dated.During an interview on 12/18/25 at 8:30 a.m., staff member F stated when food items were opened, the bags should be clipped or taped closed and, usually dated.Review of the facility's policy titled, Proper Storage, revised on 2/8/24, showed, Policy. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard to the food.

Based on observation, interview, and record review, the facility failed to consider a resident's cognitive abilities when obtaining informed consents for influenza vaccinations and failed to ensure the consent forms were completed accurately for 2 (#s 4 and 12). Findings include:1. During an observation and interview on 12/17/25 at 9:44 a.m., resident #4 was dressed and lying in her bed, looking toward the window. Resident #4 could not comprehend the surveyor's question regarding whether she had received an influenza vaccine. Resident #4 stated, Sometimes I get some shots, but was unable to communicate any additional details. Resident #4 stated, I don't know to all additional questions regarding vaccination consents or administration. At the time of the interview, resident #4 also was unable to relay the month of the year, the current season, or her geographic location.During an interview on 12/17/25 at 2:12 p.m., staff member C stated resident #4 was cognitively better in the mornings than the afternoons or evenings.Review of the facility's roster matrix showed resident #4 was identified as having a diagnosis of Alzheimer's/Dementia.Review of resident #4's comprehensive care plan, initiated 9/25, showed the following: . Topic: Cognition . I am at risk for missed care, unmet needs due to declining cognition . Involve my family, POA with all decisions .Review of resident #4's Quarterly MDS assessment, with an ARD of 9/14/25, showed a BIMS score of 7, reflecting the resident had severe cognitive impairment. The MDS assessment was completed two weeks before obtaining the resident's consent for vaccination.Review of a facility document titled Resident Influenza Vaccine Consent 25/26, undated, showed resident #4's written signature next to an x on the resident signature line. The signature was shaky and difficult to read, and appeared to be a partial signature. The signature date line showed 9/28/25 in alternate handwriting. The form did not include a signature of the staff member obtaining consent, and did not include a resident representative's signature.2. During an observation and interview on 12/17/25 at 3:34 p.m., resident #12 was awake and lying in bed. Resident #12 made consistent eye contact throughout the interview, although she remained nonverbal and only nodded affirmatively to confirm her name and whether she was able to hear adequately. Resident #12's nods were delayed responses, and she did not respond to any follow-up questions.During an observation on 12/16/25 at 5:02 p.m., resident #12 was seated in the dining room. Staff member I offered resident #12 her choice of three flavors of ice cream. Resident #12 stared at staff member I and did not answer. Staff member I then stated, Do you want some chocolate ice cream? Resident #12 slowly nodded her head up/down in response with yes. Staff member I stated resident #12 has difficulty processing when given too many choices.During an interview on 12/17/25 at 3:55 p.m., staff member C stated resident #12 sometimes refused to answer questions, but she believed she was able to process thoughts accurately.Review of resident #12's Annual MDS assessment, with an ARD of 6/8/25, showed a BIMS of 00, reflecting the resident had severe cognitive impairment.Review of resident #12's Quarterly MDS assessment, with an ARD of 9/7/25, showed a BIMS of 00, reflecting the resident still had severe cognitive impairment. The 9/7/25 MDS assessment was completed three weeks before obtaining the resident's consent for vaccination.Review of resident #12's Diagnoses list included a diagnosis of Dementia, unspecified severity .Review of resident #12's history and physical exam, dated 8/26/25, showed diagnoses including dementia and CVA. The document showed, She is essentially non-verbal .Review of a facility document titled The Mini-Mental State Exam, dated 9/15/20, showed a score of 0, and reflected severe cognitive disease. Several questions were marked as refused.Review of resident #12's care plan, initiated 7/20, showed the following: . Topic: Cognition . I am at risk for further decline in cognition. My cognition can fluctuate . Review of a facility document titled, Resident Influenza Vaccine Consent 25/26, undated, showed resident #12's written signature next to an x on the signature line. The signature was shaky and difficult to read, and the resident's last name was started, but only contained the first two letters. The signature date line showed 9/28/25 in alternate handwriting. The form did not include a signature of the staff member who obtained consent, and did not include a resident representative's signature.Review of a web article titled, Informed consent FAQs, accessed on 12/22/25, at informed consent FAQs/HHS.gov, showed the following information: .CFR (Code of Federal Regulations) governs informed consent, primarily through 45 CFR Parts 46 and 21 and CFR Parts 50 & 56, requiring Legally Authorized Representatives for those with impaired metal capacity .Review of a facility policy titled, Influenza vaccinations, updated on 2/25/25, showed: . It is the policy of this facility, in collaboration with the medical director, to have an immunization program against influenza disease in accordance with national standards of practice .

Based on interview and record review, the facility failed to complete and submit a revised pre-admission screening and record review (PASARR) for a resident with a newly identified diagnosis of schizophrenia for 1 (#8) of 11 sampled residents. Findings include: Review of resident #8's Annual MDS, with an ARD of 12/4/20, showed no psychiatric or mood disorder diagnoses. The MDS also failed to show hallucinations, delusions, or any behaviors which interferred with the resident's care or safety. Review of resident #8's Quarterly MDS, with an ARD of 8/20/23, showed the presence of hallucinations, depression, and schizophrenia. Review of resident #8's PASARR, completed on admission on 12/23/20, failed to show a diagnosis of schizophrenia. Hallucinations with an unknown history was the only mental health diagnosis documented at the time of resident #8's admission. During an interview on 11/8/23 at 10:07 a.m., staff member C stated she was responsible for submitting the PASARR form, and was not aware a revised form needed to be submitted when there was a newly diagnosed mental health condition. When asked, staff member C was not able to provide documentation of a revised PASARR when schizophrenia was documented on resident #8's medical record.

Based on observation, interview, and record review, the facility failed to identify a concave mattress as a potential restraint, and did not complete a risk assessment, consent, or restraint monitoring for 1 (#5) of 11 sampled residents with a concave mattress in place. Findings include: During an observation on 11/6/23 at 3:15 p.m., a concave mattress was observed on resident #5's bed. During an interview on 11/7/23 at 8:12 a.m., staff member K reported resident #5 had the concave mattress on her bed, for a couple of months now. During an interview on 11/7/23 at 11:12 a.m., staff members B and C reported the concave mattress was not a restraint, and therefore would not require restraint documentation. Review of resident #5's progress notes, fall report, and care plan entry, dated 8/12/23, showed the concave mattress was placed on resident #5's bed on 8/12/23. The progress notes stated resident #5 required a Hoyer lift to get out of bed, but was able to independently reposition herself from side-to-side while in bed. Review of resident #5's medical record failed to show documentation of a restraint risk assessment, written consent, or monitoring for the concave mattress. Review of the facility document titled, Restraint Policy, dated September of 2016, included the statement, RESPONSIBILITIES: Nursing: 1. Completes a Pre-Restraining Evaluation form on admission and obtain consent for use of any device that could be considered a restraint.

Based on interview and record review, the facility failed to implement and utilize a grievance process for the identification, investigation, anonymous submission, and resolution of resident grievances related to care and services for 1 (#3) of 11 sampled residents. Findings include: During an interview on 11/6/23 at 4:34 p.m., resident #3 stated she had been writing complaints about receiving warm milk, as well as eggs she had requested to be cooked over hard, and were served runny with yoke all over her plate. Resident #3 stated she wrote her complaints on a dietary card delivered with her meals, and it was then given to the dietary manager. During an interview on 11/7/23 at 10:50 a.m., staff member B stated she had the facility's formal grievance book, but no grievances had been filed in 2023. Staff member B stated resident #3 had two to three complaints a day regarding her meals. Staff member B stated resident #3 submitted her concerns on a dietary card at the end of her meal, and it was then given to the dietary manager to address. Staff member B stated it would take a full-time person to log resident #3's food complaints. Staff member B stated they did not track the complaints submitted by resident #3. Review of the facility's grievance log failed to show meal complaints, and there were no grievances in the grievance book for 2023. Review of the facility's document titled, Grievance/Complaints-Residents, dated 2/23/17, showed the following: - 1. Resident grievances are documented on the resident grievance form . - 3. The grievance is investigated by the Social Service Director . - 5. Results of the investigation and resolution of grievances will be documented on the grievance form. The Social Service Director will notify DON with outcome of investigation.

Based on observation, interview, and record review, the facility failed to ensure a psychiatric evaluation was performed and documented prior to including a diagnosis of schizophrenia for 1 (#8) of 11 sampled residents. Findings include: During an observation and interview on 11/6/23 at 4:33 p.m., resident #8 was sitting in her recliner with her dog. Resident #8 was well-groomed, and able to participate in the interview without difficulty. Resident #8 stated she had been a little depressed recently, and was taking a medication for it. Resident #8 also stated she was seeing a counselor for her depression. Review of resident #8's medication orders, dated between 6/13/23 and 11/6/23, showed the resident was started on risperdal, an atypical antipsychotic, for depression with psychosis and hallucinations. Review of resident #8's provider progress note, dated 5/11/23, showed the resident expressed concern with worsening depression, requested an antidepressant, and to see a counselor. Review of resident #8's provider progress note, dated 6/12/23, showed the resident reported hearing music and voices again, had a history of hallucinations in the past, and had taken risperdal with good effect. Review of resident #8's provider progress note, dated 7/13/23, showed staff member F and the resident's counselor discussed changing her diagnosis from depression with psychosis to schizophrenia. During an interview on 11/7/23 at 3:36 p.m., staff member F stated she had provided care to resident #8 prior to her admission to the facility in December of 2020. Staff member F stated resident #8 had a history of hallucinations which were effectively managed with risperdal. Staff member F stated the hallucinations returned after the resident was weaned off both risperdal and antidepressant medications. When asked what criteria was used to diagnose resident #8 with schizophrenia, staff member F stated, Her history. Staff member F stated the diagnosis of schizophrenia was added because the resident had a history of hallucinations which were well-controlled with the use of risperdal. During an interview on 11/8/23 9:04 a.m., staff member J, who was responsible for physician oversight of resident #8's care, stated he was not aware the resident had been given a diagnosis of schizophrenia. Staff member J stated schizophrenia was, Not on my (staff member J's) radar. Staff member J stated the diagnosis of schizophrenia may not have been appropriate because the resident was high functioning and the diagnosis of depression with psychosis may have been more accurate. Staff member J stated he would see resident #8 and discuss her diagnoses with her primary care provider (staff member F) and the social worker she (resident #9) was seeing for counseling. Review of resident #8's medical record failed to show a mental health evaluation was performed and documented prior to including schizophrenia as a diagnosis for the resident.

Based on interview and record review, the facility failed to establish a process for when resident should be weighed, and failed to identify and intervene in a timely manner when weights were not completed for 2 (#s 2 and 5) of 11 sampled residents. Findings include: During an interview on 11/6/23 at 4:02 p.m., staff member K stated residents were weighed monthly, and sooner as needed or as ordered by the provider. 1. During an interview on 11/6/23 at 5:15 p.m., staff member D reported resident weights were completed with baths twice weekly, when the resident was out of bed. Staff member D stated resident #2 preferred a bed bath, in which case the staff would try to obtain a weight weekly. Staff member D reviewed the skin assessment log during the interview (11/6/23) and reported no weights for resident #2 had been documented in the medical record since 10/3/23. During an interview on 11/7/23 at 10:23 a.m., staff member L stated residents were weighed when they received a bath. Staff member L stated if the resident received a bed bath or refused a bath, the CNAs would document no weight on the skin assessment form, for the nurse to review. During an interview on 11/7/23 at 3:15 p.m., staff member B stated weights were completed with baths, and documented on the skin assessment form and on the weight graph in the resident's medical record. Staff member B stated the nurses signed off on the skin assessment form and would know the resident did not have a weight completed. Review of resident #2's medical record showed a documented weight on 10/3/23. Resident #2's skin assessment forms, dated between 10/4/23 through 11/7/23, showed the resident received four showers and three bed baths with no weights documented. 2. Review of resident #5's medical record showed no documented weights for the month of September 2023. During an interview on 11/7/23 at 2:34 p.m., staff member B stated resident #5 was being monitored by the facility's Nutrition-At-Risk (NAR) Committee for significant weight loss and provided the committee meeting minutes for review. Review of the facility document titled, NAR Tracking, dated 10/11/23, stated, NO SEPT. WEIGHTS. Review of resident #5's skin assessment forms, dated September of 2023, showed no weights were obtained for the month. A request was made, on 11/7/23, for the facility's weight policy. As of the survey exit on 11/8/23, no weight policy was received.

Based on observation, interview, and record review, a facility staff member left a hot pack on a resident for an extended period of time, and the resident (#7) sustained 1st and 2nd degree burns and increase in pain from the injuries, of 1 sampled resident; and, a resident (#9) was having coughing/choking episodes, for an extended period, which the facility did not address timely or sufficiently, and the resident was hospitalized , of 1 sampled resident. Findings include: 1. Review of resident #7's nursing progress notes, dated 8/6/22, showed, Resident c/o pain to skin on back .8 in x 7 in area of pink to red skin .2 cm x 2 cm fluid filled blister to center of area .CNA did place hot pack at lunch for c/o back pain .area appears to be possible burn from hot pack. Review of resident #7's nursing progress notes, dated 8/6/22, showed the resident was restless, tearful, and complaining of pain every three to five hours, after the burn, earlier that day. Review of resident #7's physician note, dated 8/9/22, showed, Resident was determined to have a 10% skin area of a first degree burn and a 1% skin area with a second-degree burn. During an observation and interview on 8/31/22 at 9:37 a.m., resident #7 had a small, open, oval shaped wound on her lower back. Staff member F applied the Silvadene cream and covered the site with a bandage. She stated the wound was from a hot pack burn. Staff member F believed hot packs needed a doctors' order but was unsure. She stated she had not been oriented on the use of hot packs, in her three-month period of employment at the facility. Staff member F stated she did not know where the hot packs were located in the facility. During an interview on 8/31/22 at 11:02 a.m., staff member C stated after the burn occurred, they had provided staff education for the CNA who placed the hot pack and not reported the hot pack to the oncoming shift. She stated hot packs were now only to be placed and monitored by the nurses. Review of facility standing orders, no date, showed hot packs could be used for pain relief, but showed no update in the scope of their placement or responsibility for their monitoring. During an observation on 8/31/22 at 4:30 p.m., of a facility education sheet posted in the breakroom, titled Application of Hot Packs, undated, did not specify who was able to apply hot packs. 2. During an observation on 8/30/22 at 7:52 a.m., resident #9 was eating breakfast coughing aggressively toward the end of her meal. Review of resident #9's nursing progress notes, from 3/5/22 - 6/16/22, showed the resident had been choking and coughing with food and medications. Further review of resident #9's medical record lacked evidence of a comprehensive assessment related to the residents coughing/choking while eating, and the potential risk of aspiration, and there was a lack of nursing assessments on resident #9's respiratory status after coughing/choking episodes. The medical record also lacked a dietary consultation to evaluate resident #9's appropriateness of the physician ordered regular textured diet. Review of a facility grievance, dated 6/17/22, showed NF3 had been concerned with resident #9's coughing on 5/22/22, 5/26/22, 5/31/22, 6/1/22, 6/3/22, 6/5/22, 6/7/22, and 6/13/22. Review of resident #9's hospital summary, dated 6/17/22, showed the resident was admitted for a UTI and pneumonia. Review of resident #9's nursing progress notes, dated 6/18/22 showed, resident #9 was started on a Level II dysphagia diet on 6/18/22 while in the hospital and she had physician's orders, dated 6/22/22, to have a swallow study completed. Review of resident #9's care plan, dated 12/30/21, showed the plan did not address the choking/coughing concerns sufficiently for staff to have an awareness of the necessary interventions to be used in the event the resident was coughing/choking when eating or taking medications. This failure, contributed to the increased risk for the resident. During an interview on 8/30/22 at 11:57 a.m., NF1 stated, It (care concerns for resident #9) was brought up three different times and nothing was done. This resident was not treated the way she should've been. Refer to F600 - Neglect of Care. During an interview on 8/31/22 at 11:02 a.m., staff member B stated she had talked with resident #9's family, and they did not want a swallow evaluation performed for resident #9 at that time (in May 2022). Although staff member B stated the family was approached on the swallowing concerns, the facility did not implement safety interventions at that time. A review of resident #9's medical record showed there was a lack of documentation related to a swallow evaluation conversation with the family in May 2022, and that family had declined a swallow study before hospitalization . Calls placed to NF3 on 8/30/22 at 9:30 a.m., and 8/31/22 at 10:39 a.m. were not returned. The facility failed to ensure a system was in place to timely identify and address the potential risk factors related to resident #9's choking/coughing and implement interventions to prevent negative outcomes for the resident.

Based on observation, interview, and record review, the facility neglected to act in a timely manner for the assessment and implementation of interventions to address a resident's prolonged coughing and choking episodes, which resulted in the resident's health decline and hospital admission for pneumonia, for 1 (#9) of 1 sampled resident; and, a staff member left a hot pack on a resident (#7) and left without communicating the use and placement of the hot pack to oncoming staff, and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. During an observation on 8/30/22 at 7:52 a.m., resident #9 was coughing during her meal. Review of a facility grievance, dated 6/17/22, showed NF3 had been concerned with resident #9's coughing on 5/22/22, 5/26/22, 5/31/22, 6/1/22, 6/3/22, 6/5/22, 6/7/22, and 6/13/22, but interventions had not been implemented to address the coughing. Review of resident #9's nursing progress notes, from 3/5/22 - 6/16/22, showed the resident had been choking and coughing, specifically with food and medications, for the three months. Review of resident #9's medical record showed a lack of documentation of nursing assessments or documentation to address resident #9's respiratory status after coughing/choking episodes, to include when eating, or a dietary consultation to evaluate resident #9's appropriateness of her physician ordered regular textured diet. Review of resident #9's hospital summary, dated 6/17/22, showed the resident was admitted for a [CONDITION(S)] and pneumonia. Review of resident #9's nursing progress notes, dated 6/18/22 showed, resident #9 was started on a Level II dysphagia diet on 6/18/22, while in the hospital being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/30/22 at 11:57 a.m., NF1 stated NF3 and NF2 had voiced concerns regarding the neglect of care for resident #9. She stated the first-time resident #9's condition was brought to the attention of the facility it had been blown off. NF1 stated, It (care concerns for resident #9) was brought up three different times and nothing was done. This resident was not treated the way she should've been. Review of resident #9's MDS assessments, dated 1/7/22, 4/30/22, and the Significant Change assessment dated [DATE], were all coded as the resident was not showing any signs or symptoms of swallowing difficulty. The facility staff neglected to address concerns with resident #9's choking/coughing, over an extended period of time, although it was brought to their attention on multiple occasions and documented in the medical record. 2. During an observation and interview on 8/31/22 at 9:37 a.m., resident #7 had a small, open, oval shaped area on her lower back. Staff member F stated the wound was from a hot pack burn. Review of resident #7's physician assessment, dated 8/9/22, described the wound as having portions of first and second degree [CONDITION(S)]. During an interview on 8/31/22 at 11:02 a.m., staff member C stated after the burn occurred, they had provided staff education for the CNA who placed the hot pack and not reported the hot pack to the oncoming shift.

Based on interview and record review, the facility failed to document pneumococcal and influenza vaccine education or declination for 3 (#s 4, 9, and 12 ) of 15 sampled residents. Findings include: Review of the vaccination records for resident #s 4, 9, and 12 revealed a lack of documentation of the education regarding the risks versus benefits of the pneumococcal and the influenza vaccinations. The records also revealed a lack of signed refusal for vaccinations by the residents or their representatives. During an interview on 8/31/22 at 12:17 p.m., staff member H stated there was no documented forms for refusals of the pneumococcal or the influenza vaccinations. Staff member H stated, We have never done that. Review of the facility policy titled Immunizations, dated 2/17, showed, All residents admitted to or already in the facility will be given information and the opportunity to receive the influenza and pneumococcal vaccine .If the resident refuses, the reasons will be documented in the resident record.

Based on observation and record review, the facility staff failed to identify, plan, and implement interventions on the comprehensive care plan, for a resident show had problems with choking/coughing with meals and medications, for 1 (#9), of 1 sampled resident. Findings include: During an observation on 8/30/22 at 7:52 a.m., resident #9 was eating breakfast coughing aggressively toward the end of her meal. Review of resident #9's nursing progress notes, from 3/5/22 - 6/16/22, showed the resident had been choking and coughing with food and medications. Review of a facility grievance, dated 6/17/22, showed NF3 had been concerned with resident #9's coughing on 5/22/22, 5/26/22, 5/31/22, 6/1/22, 6/3/22, 6/5/22, 6/7/22, and 6/13/22. Review of resident #9's hospital summary, dated 6/17/22, showed the resident was admitted for a [CONDITION(S)] and pneumonia. Review of resident #9's nursing progress notes, dated 6/18/22 showed, resident #9 was started on a Level II dysphagia diet on 6/18/22 while in the hospital and she had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #9's care plan, dated 12/30/21, showed the plan did not address the choking/coughing concerns sufficiently for staff to have an awareness of the necessary interventions to be used in the event the resident was coughing/choking when eating or taking medications. This failure, contributed to the increased risk for the resident.

Based on interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications were reviewed after 14 days or discontinued, unless a rationale for continuing the medications was documented by a physician, for 1 (#4) of 2 sampled residents. Findings include: Review of resident #4's physician's order, dated 3/22/22, showed, New, haloperidol (Haldol) tablet, 0.5 mg, take one tablet po q6 hrs prn Severe Agitation . No stop date for the PRN psychotropic medication was recorded on the order. Review of resident #4's physician's order, with a start date of 7/21/22, showed, New, haloperidol concentrate, 2 mg/ml, Apply 0.5 ml to inner wrist every 4 hrs. as needed for agitation, transdermal gel . No stop date for the PRN psychotropic medication was recorded on the order. Review of resident #4's monthly pharmacy review reports, dated 5/22 - 8/22, did not show any notations, made by the pharmacy, of the PRN haloperidol orders exceeding the 14-day limit. During an interview on 8/30/22 at 3:43 p.m., staff member H stated the monthly pharmacy review was completed to identify problems with medications and perform monitoring. Staff member H stated she was unaware of a regulation for psychotropic medications being limited to 14 days, or for the medications to be evaluated by a physician, with a documented rationale for continuation. During an interview on 8/31/22 at 9:59 a.m., staff member B stated resident #4 was a hospice resident and the hospice physician renews the medication orders. Review of resident #4's hospice interdisciplinary team review, dated 3/1/22 - 8/27/22, did not show any stop date for the PRN haloperidol orders. No rationale was documented for the continuation of the orders related to a specific diagnosis. Review of the facility's policy, titled Psychotropic Medications, with an effective date of 12/2017, showed: - .PRN orders for psychotropic medications will be limited to 14 days unless the provider identifies the rationale to extend the medication beyond 14 days, and - PRN anti-psychotic drugs will be limited to 14 days and will not be renewed unless the provider evaluates the resident for appropriateness of the medication .

Based on observation, interview, and record review, staff member F failed to adhere to proper infection control practices, during the administration of medications for 3 (#s 1, 3, and 5) of 4 sampled residents. Findings include: During an observation on 8/31/22 at 7:36 a.m., staff member F was preparing medications for administration for resident #1. Staff member F was shaking the acetaminophen 325 mg tablets into the lid of the bottle, to pour into the plastic souffle cup. Staff member F had three tablets in the lid, instead of the prescribed two tablets. Staff member F picked one of the tablets out of the lid with her bare hands and replaced the tablet into the bottle. During an observation on 8/31/22 at 7:48 a.m., staff member F was preparing medications for administration for resident #5. Staff member F shook two tablets of aspirin 81 mg into the plastic souffle cup. Staff member F picked one tablet of aspirin out of the plastic souffle cup, with her bare hands, and placed it back into the bottle. During an observation on 8/31/22 at 7:58 a.m., staff member F was preparing medications for administration for resident #3. Staff member F poured three acetaminophen 325 mg tablets out of the multi-dose bottle and into the lid. Staff member F picked two tablets out of the lid, with her bare hands, and placed them into the plastic souffle cup. During an interview on 8/31/22 at 8:01 a.m., staff member F stated it was hard to not touch the pills, when several pills poured out of the medication bottle at once. Staff member F stated best practice would be to not touch any pills with bare hands. During an interview on 8/31/22 at 9:56 a.m., staff member C stated she would not expect a nurse to touch medications with bare hands, but instead wear gloves.

Based on interview and record review, the facility failed to identify a severe weight loss and implement measurements timely to prevent the continued weight loss for 1 (#22) of 21 sampled residents. Findings include: Review of resident #22's weight change history showed: 2/25/21 - 150 lbs 3/4/21 - 146 lbs 3/15/21 - 139 lbs 4/9/21 - 137 lbs 4/13/21 - 134 lbs 4/23/21 - 128 lbs The resident experienced a severe weight loss from 2/25/21 to 3/15/21 of 7.33 percent in less than one month, and between 4/9/21 and 4/23/21 the resident had an additional severe weight loss of 6.57 percent in less than a month. The total percentage of weight loss between 2/25/21 and 4/23/21 was 13.9 percent. During an interview on 5/26/21 at 3:28 p.m., staff member D stated she monitored the resident's nutritional status at least quarterly with their MDS. She stated she comes to the facility on ce a week. Staff member D stated, As long as a nurse notifies me of a weight change, I will catch it quickly. Staff member D stated she was not sure what caused the weight loss for resident #22. She stated she made notes every quarter with interventions that were tried. She stated, If a weight loss was not relayed to me, I would not know about it. There should be another note between December and April. If there was a significant weight loss I would review the resident more frequently then every quarter. Review of resident #22's Interdisciplinary Progress Note written by staff member D, dated 12/29/20, showed, Resident continues on regular diet. Able to feed self without difficulty or adaptive devices. Weight up about 5# (pounds) over the past 3 months. Intakes average about 75% of meals. No new nutrition concerns. Continue with current nutrition care plan. Continue to monitor at least quarterly. Review of resident #22's Interdisciplinary Progress Note, dated 4/9/21, showed, MDS nutrition notes resident continues on regular diet. Able to feed self without adaptive devices. Intakes vary, averaging about 25% at dinner and 50-75% at breakfast and lunch weight down some over the past 6 months. Totaling about 15#. Unsure of decreased intakes reason. Will monitor weight closely, recommending Ensure supplement when meal intakes <50% be offered. During an interview on 5/26/21 at 4:26 p.m., staff member A stated, staff member B was responsible for notifying the dietitian of a weight loss with a resident. Staff member A stated, I know she reviews the weights but I do not know how often. During an interview on 5/27/21 at 9:15 a.m., staff member B stated it was everyone's responsibility to notify her (staff member B) of a weight loss; it was a group effort. Staff member B stated, If I know of a weight loss, I would then email the dietitian. The resident's care plan would be updated with that information. I was notified of resident #22's weight loss on Monday. We did not catch the weight loss until then. Resident #22 had a Significant Change MDS done on 4/4/21, but I don't think I knew of the weight loss at that time.

Based on interview and record review the facility failed to investigate and follow up on grievances expressed during resident council meetings. This deficiency had the potential to affect any resident with a grievance or those who attended the resident council. Findings include: Review of resident council minutes, dated 2/25/21, showed, The main complaint is the food by the same residents. It's always the same thing, no variety. During an interview on 5/26/21 at 9:55 a.m., staff member A stated staff member C is in charge of the grievance process. During an interview on 5/26/21 at 10:02 a.m., staff member C stated, There has not been any grievances filed within the last six months. Staff member C stated, I do not usually make a grievance for items that have been lost because we usually find them. If the items have been lost for more than a couple days, I might make a grievance. I do not usually do a follow up with the resident to make sure that they are satisfied with the outcome of a complaint. If there is a complaint about food, I would just let dietary know through email. I didn't know I was supposed to follow up with the resident. Review of resident council minutes, dated 3/25/21, showed, The main complaint is the food: No flavor said one resident. All other residents were fine with the food. A variety for breakfast would be great instead of the same old stuff. Review of resident council minutes, dated 4/22/21, showed, Most like the food, a few select ones are not happy with the food. We mainly received positive feedback from those who usually are missing laundry. All laundry has been found. The complaints we did have are the same ones every month and missing items that are not even his and wants to buy new ones. The residents who had the concerns at resident council were not identified. Review of the facility's document, Resident Council Concern/Complaint Follow - Up showed: 2/25/21 - Food is the same, no variety. Referred to dietary, completion date 3/29/21, other comments, will investigate to see what they can do different. 3/25/21 - Food no favor, laundry missing. Referred to Laundry, completion date 4/22/21, other comments missing laundry found. 4/22/21 - No variety in food, no flavor. Referred to dietary. The document failed to show a completion date and the Other Comments section was blank. Review of the facility's policy and procedure titled, Grievance/Complaints - Resident, dated 2/23/17, showed: .3. All resident grievances are investigated by the Social Services Director and reviewed by the DON and every effort is made to resolve resident issues. 4. Findings of the investigation and follow-up to be conducted will be documented on the grievance form within five working days. . Procedure 1. Resident grievance are documented on the resident grievance form. 2. This form is then forwarded to Social Service Director. The Social Services Director will alert DON to the grievance. 3. The grievance is investigated by the Social Services Director. Investigation includes interviewing the resident, family, and staff members as warranted by the grievance. A request was made on 5/26/21 for all grievances submitted in the previous six months, to include documentation of the investigations and follow-up performed. Nothing was received prior to the end of the survey.

Based on interview and record review, the facility failed to ensure services were provided to maintain continence for 1 (#125) of 21 sampled residents. Findings include: During an interview on 5/26/21 at 4:10 p.m., staff member A stated the facility did not have a bowel and bladder training program, and were not doing anything specific regarding maintenance of resident #125's current level of bladder continence. During an interview on 5/27/21 at 8:00 a.m., resident #125 stated she did not have issues with incontinence prior to her hospitalization and admission to the nursing home. Resident #125 stated she had been in the hospital for several weeks before being admitted to the nursing home. Resident #125 stated, When I have to go, I have to go now. Resident #125 stated staff did not always come right away when she put on her call light, and sometimes she had to get up on her own. Resident #125 stated the staff did not come in and offer to take her to the bathroom as written in her care plan. Resident #125 stated she now wears an incontinence brief because she does have accidents when she waits too long. Resident #125 stated she does have a fear of falling and would rather have someone with her when she gets up to the bathroom. During an interview on 5/27/21 at 9:25 a.m., staff member I stated resident #125 used her call light but does not always wait for staff to come in and assist her. Staff member I stated she was not aware resident #125 had been continent prior to her admission to the facility. Staff member I referred to a document which showed resident #125 was both continent and incontinent. Staff member I stated resident #125 voided approximately every hour and was incontinent at least half of the time, requiring her brief to be changed. A review of resident #125's medical record on 5/25/21 showed she had been admitted to the hospital on 4/13/21 and to the nursing home on 4/30/21. A review of resident #125's Incontinence Care Plan, dated 5/2021, showed no goals or interventions associated with maintenance of bladder continence. The care plan showed goals related to maintaining intact skin and not having falls due to incontinence. The interventions showed providing assistance with incontinence supplies, monitoring skin integrity and offer assistance to the bathroom before and after meals, upon arising and at bedtime, and every two hours.

Based on observation, interview and record review, the facility failed to ensure the call light was placed within reach of the resident for 1 (#2) of 21 sampled residents. Findings include: During an observation and interview on 5/25/21 at 9:03 a.m., resident #2 was seen sitting in his recliner watching television. Resident #2 had a purple bruise under his left eye. When asked about the bruise, resident #2 stated he must have fallen, but could not remember when or how. Resident #2 stated the staff did not always help him when he needed it. The recliner was placed on the opposite side of the resident's room near the television. Resident #2's call light was laying on his bed, and not attached to the resident's recliner, within his reach. During an interview on 5/26/21 at 4:10 p.m., staff member A stated resident #2 had an extra long call light cord which was supposed to be attached to his recliner when he was sitting in it while watching television. A review of resident #2's Quarterly MDS, ARD date 4/4/21, showed he required limited assistance and supervision with transfers and ambulation. A review of resident #2's ADL Care Plan, dated 4/2021, showed he was supposed to use his walker at all times, sometimes required reminding to use his walker as he was a fall risk, and should use his call light when in his recliner and feeling weak or sick.

Based on interview and record review the facility failed to update and revise the care plan when a severe weight loss occurred, for 1 (#22) of 21 sampled residents. Findings include: During an interview on 5/27/21 at 9:15 a.m., staff member B stated it was everyone's responsibility to notify her (staff member B) of a weight loss, it was a group effort. Staff member B stated when she became aware of a weight loss she would notify the dietitian by email. The resident's care plan would be updated with the information, either by a floor nurse, or herself (staff member B). Staff member B stated she did not catch resident #22's weight loss until recently. Review of resident #22's weight change history showed: 2/25/21 - 150 lbs 3/4/21 - 146 lbs 3/15/21 - 139 lbs 4/9/21 - 137 lbs 4/13/21 - 134 lbs 4/23/21 - 128 lbs Resident #22 experienced a severe weight loss from 2/25/21 to 3/15/21 of 7.33 percent in less than one month. Between 4/9/21 and 4/23/21 the resident had an additional severe weight loss of 6.57 percent in less than one month. Review of resident #22's care plan, dated 7/2021, showed a goal of, I would like to maintain my weight by 5 +/- % by our next visit. The interventions showed, . I like milk. I like bacon and I am not very picky. Offer me choices within my diet limitations. If you see I am not eating much please offer me a substitute, snack or supplement. Monitor my weights twice weekly with my bath. Dietitian to consult. Monitor how much I eat. Notify the provider and dietitian for any change of 5% +/-. I like milk, bacon, hot [NAME]. Review of resident #22's care plan did not show the resident had a severe weight loss, or any new interventions related to the recent weight loss.

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's change of condition, and supervised for the nutritional care of a resident with severe weight loss for 1 (#22) of 21 sampled residents. Findings include: Review of resident #22's weight change history showed: 2/25/21 - 150 lbs 3/4/21 - 146 lbs 3/15/21 - 139 lbs 4/9/21 - 137 lbs 4/13/21 - 134 lbs 4/23/21 - 128 lbs The resident experienced a severe weight loss from 2/25/21 to 3/15/21 of 7.33 percent in less than one month. Between 4/9/21 and 4/23/21 the resident had an additional severe weight loss of 6.57 percent in less than a month. During a interview on 5/27/21 at 7:52 a.m., staff member A stated, There is absolutely no notes regarding [resident #22] nutrition from staff member J. I looked everywhere. Review of resident #22's medical record on 5/27/21 showed, there were no notes regarding any weight loss or discussion about the resident's nutrition from 1/21 - 5/27/21 by staff member J. Call to staff member J attempted on 5/27/21 at 10:01a.m., no answer, no call back.

Based on observation, interview, and record review, the facility failed to prevent falls with injuries, failed to implement interventions to prevent falls with and without injuires, failed to determine the root cause of falls, and failed to provide adequate supervision for 3 (#s 12, 16, and 17) of 15 sampled residents. This defieciency has the potential to affect all residents. Findings include: 1. During an observation and interview on 8/5/19 at 5:30 p.m., resident #12 was sitting in her wheelchair in the dining room. She was incoherent in her answers and said, I don't really know, or hummed softly. Review of resident #12's Incident Reports showed six falls from 7/4/18 to 5/31/19, three with injuries, including a [MEDICAL CONDITION]. During an interview on 8/6/19 at 10:35 a.m., staff member F said resident #12 needed monitoring due to risk for falls. Review of resident #12's care plans, dated (MONTH) (YEAR) through (MONTH) 2019, did not include any of the six falls, the [MEDICAL CONDITION], or any new fall prevention interventions. The care plan showed, I am at risk for falls due to a hx of fall, some wandering, mildly hearing impaired, hx of cataract. The interventions to prevent falls included: - Keep my environment free of clutter and well lit. - I am encouraged to use my call light for assistance. Answer my call light promptly. - Anticipate my needs and be sure my environment is safe. - Encourage me to use FWW if I am walking and assist x 1-2 or SBA as needed depending on how I am doing. - Encourage restorative to help keep me strong and active and prevent further decline. Interventions did not include increased supervision. Review of resident #12's Incident Reports, dated 7/4/19, 9/13/18, 9/26/18, 1/4/19, 1/20/19, and 5/31/19, showed falls and no change in care plan. Review of resident #12's Incident Reports, dated 7/4/19, 9/13/18, 9/26/18, 1/4/19, and 1/20/19, showed falls and the need for increased monitoring. Review of resident #12's Incident Report, dated 9/26/18, showed she was walking in the hallway, on her way to a bathroom. A staff member witnessed her walking, and attempted to assist resident #12. The staff member was not able to reach resident #12 before she fell . Resident #12 leaned on the wall, slipped, and fell to the floor, hitting her right hip and the back of her head. Analysis and recommendations showed, Due to (diagnosis) of dementia, (patient) unable to follow directions to ask for assistance and unable to make sound judgment . and continue the current care plan. The Accident Prevention Team Recommendations showed, staff needs to monitor more frequently and whereabouts. Review of resident #12's Fall Risk Evaluations, dated 8/16/18, showed resident #12 was at risk for falls. Review of Falls Meeting notes, dated 10/25/18, showed resident #12 had the following concerns: Make sure to monitor resident's whereabouts. Monitor resident more frequently due to her mental status and increased confusion. 2. During an observation on 8/5/19 at 2:35 p.m., resident #16 was lying in bed with a side rail up, and a bed alarm on. Review of resident #16's Incident Reports showed she had falls on 9/21/18, 1/2/19, 1/3/19, 3/2/19, 4/1/19, 5/24/19, and 8/2/19. The fall on 1/3/19 showed compression fractures to lower back; the fall on 3/2/19 showed a pelvis fracture; and the fall on 4/1/19 showed a laceration to the head which required five sutures. Review of resident #16's Incident Report dated 9/21/18, for Accident Prevention Team Recommendations, showed Encourage call light use to ask for help and staff to increase toileting frequently. Review of resident #16's Incident Report dated 1/2/19, for Accident Prevention Team Recommendations, showed Staff to check on her more frequentlly; toilet before and after meals and bedtime. Review of resident #16's Incident Report dated 1/3/19, for Accident Prevention Team Recommendations, showed Staff to anticipate needs. Review of resident #16's Incident Report dated 3/2/19, for Accident Prevention Team Recommendations, showed Toilet every 2 hours, monitor for urine on floor. Review of resident #16's Incident Report dated 4/1/19, for Accident Prevention Team Recommendations, showed Remind resident to ask for help. Know where she is every hour. Review of resident #16's Incident Report dated 5/24/19, for Accident Prevention Team Recommendations, showed Resident had not been toileted since before breakfast. Found to be incontinent of BM. CNAs involved spoken to. All CNAs on floor talked to avoidable fall if resident had been toileted as scheduled. During an interview on 8/7/19 at 9:50 a.m., staff member G stated the high fall risk residents would be identifed on the restorative programs for each resident. During an interview on 8/7/19 at 10:00 a.m., staff member F stated resident #16 remains at high risk for falls. She has had multiple falls and we check on her every 2 hours. Most of her falls are in the morning when she is ready to get up. During an interview on 8/8/19 at 8:50 a.m., staff member I stated residents who use walkers and wheelchairs are at high risk for falls. Resident #16's interventions were alarms. An increase in toileting was not mentioned as an intervention. Review of resident #16's Fall Care Plan did not identify the seven falls. The interventions did not inlcude an increase in toileting needs or more supervision in the morning. Review of resident #16's Falls Meeting note, dated 3/14/19, showed Monitor resident's whereabouts at all times. Toilet resident after meals, before bedtime, and when resident gets up in the morning. Review of resident #16's Falls Meeting note, dated 4/18/19, showed Toilet resident more frequently. Toilet when rounds every 2 hours. Review of resident #16's Falls Meeting note, dated 6/12/19, showed Toilet resident more frequently. Toilet when doing rounds. During an interview on 8/8/19 at 1:45 p.m. staff member B stated the nurses write the incident report after a fall, and any witnesses would write a statement. The facility was working on implementing a fall huddle. The fall team meets once a month to review falls. She stated all residents were at high risk for falls. The nursing staff is responsible for updating the care plans after falls. When asked about the root cause of individual falls, she asked You mean why they fell ? 3. During an observation on 8/6/19 at 10:29 a.m., resident #17 was in her room, sitting in her recliner, watching television. Resident #17 had a wanderguard bracelet on her left wrist and was seated on a sensor pad chair alarm. During an interview on 8/8/19 at 7:59 a.m., NF1 stated she would have liked staff to be more encouraging when resident #17 refused to participate in restorative services. Review of resident #17's Quarterly MDS, with an ARD of 11/25/18, showed one non-injury fall since the last assessment in (MONTH) of (YEAR). Review of resident #17's Significant Change MDS, with an ARD of 2/24/19, showed two or more non-injury falls since the last assessment in (MONTH) of (YEAR). Review of resident #17's Quarterly MDS, with an ARD of 5/26/19, showed two or more non-injury falls since the last assessment in (MONTH) of 2019. Review of resident #17's nursing notes showed falls occurring on 10/3/18, 12/14/18, 12/16/18, 1/13/19, 2/5/19, 2/6/19, 2/19/19 (twice), 3/6/19, 3/8/19, 4/26/19, 4/29/19, and 5/26/19. All of the falls were categorized as non-injury falls. Review of resident #17's admission care plan, dated 5/2018, showed the following interventions: -Help me with all transfers and ambulating. -Answer my call light promptly. -Remind me NOT to get up and walk without your help. -I am VERY independent and don't like to bother you. Review of resident #17's care plans, dated 11/2018 and 2/2019, showed no revisions until 3/8/19. Review of resident #17's care plan, with hand written revisions, showed the following changes: -3/8/19 - Please get me up b/4 (sic) breakfast per family req. (request) -3/14/19 - note regarding multiple falls related to bathroom use, family requested that she not be left alone -5/26/19 - crossed out - Make sure I have my call light nearby at all times and answer it promptly. -5/26/19 - note regarding family request for use of pressure pad alarm -no date - Remind me to ask for help and offer help often -no date - Offer to help me with all transfers and ambulating. SBA (stand by assist) to limited (assist) Review of resident #17's Incident Reports related to falls since 1/1/19, showed the following: -1/13/19 fall to floor in room, no care plan changes, Accident Prevention Team Recommendations - staff to monitor whereabouts, anticipate needs, and offer toileting every 2 hours -2/5/19 fall to floor in room, no care plan changes, Accident Prevention Team Recommendations - remind her to ask for help, staff to anticipate needs -2/6/19 found on floor in room, no care plan changes, Accident Prevention Team Recommendations - monitor whereabouts, offer her help and assistance consistently -3/6/19 fall to floor in room, no care plan changes, Accident Prevention Team Recommendations - staff ambulating with resident to and from meals -3/8/19 found on floor in room, care plan changes dated 3/14/19 to not leave alone in bathroom, Accident Prevention Team Recommendations - toilet every 2 hours -4/26/19 found on floor in doorway of room, no care plan changes, Accident Prevention Team Recommendations - alarm placed in chair per family request -4/29/19 found on floor in room, no care plan changes, Accident Prevention Team Recommendations - alarm placed per family due to impulsiveness -5/26/19 found on floor in room, no care plan changes, Accident Prevention Team Recommendations - remind staff to check on her frequently Review of resident #17's physician's orders [REDACTED]. Review of resident #17's medical record showed no documentation of any falls since 5/28/19, the date when the pressure pad alarm was placed.

Based on staff interview, and record review, the facility failed to protect 3 (#s 2, 13, and 14) of 15 sampled residents from aggression by other residents. Findings include: 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The following was documented in the NN dated 8/26/10 at 6:00 p.m., "Res. called a male Res. (resident #13) a dumb ass and the male Res. hit female in the face. She has bruise under R eye." The facility did separate resident #13 and 14 at the time of the incident. 2. Resident #2 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Nurses notes dated from 5/11/10 through 12/4/10 were reviewed. The nurses documented the following: On 6/25/10, "Elder refused meds, cursing @ staff & other Elders. Hit another Elder @ breakfast."; On 8/2/10, "Elder cursed during Neb TX. Mask held by nurse. Cursed at other female resident who was sitting at table."; On 9/23/10, ". . . . Sticking out her tongue & spitting at staff & female Elder also cursing @ everyone when walked by."; On 9/27/10, "Elder was cursing and banging on table. Another resident told her to stop so she threw her coffee at her. A CNA caught the cup before it hit the other resident. Elder kept cussing and banging on table."; On 10/23/10, "Late Entry for 10/23/10. Elder was caught attempting to hit another Elder with her fist."; On 11/13/10, "Res. very voicetress (sic) at supper. Bounceing (sic) coffee cup on table. Threatening to throw coffee across table at another res."; 11/18/10, "Elder threatened another Elder by saying, 'I am going to throw this at your face,' and the other Elder tried to walk away."; On 11/26/10, ". . . . Now RCA (resident care aide) reported this Elder hit the Elder sitting (next) to her left at the table on her (right) hand (with) her fist."; and On 12/1/10, "Res spitting & yelling at staff & other res." Resident Assessment Protocols dated 8/24/10, for psychosocial well-being, mood state and behavioral symptoms were reviewed. These contained the following, "She uses fowl (sic) language, can hit others." "Staff cannot stop (resident #2's name) fowl (sic) language, combativeness or refusal of meds. Her world is her own and we as staff must prepare ourselves with what (resident #2's name) is capable of." "(Resident #2's name) can and will be verbally abusive toward anyone. She has also been combative with staff." In answer to the question, "What are the effects of these behaviors on others?" "Hurt staff or other residents." However, under Summary/Recommendations, there were no recommendations for protecting other residents from resident #2's aggressive behaviors. The current care plan for resident #2 was printed 10/25/10. There was no topic, concern, or need relating to the resident's aggressive behaviors toward other residents and staff. There were no directions to staff to prevent aggression by the resident. On 12/7/10 at 11:17 a.m., staff member D, the DON, and staff member A, the administrator in training, stated the only Incident Report for the above incidents was on 11/26/10. Staff member D stated the facility did not investigate the incident or update the care plan with interventions on how to approach the resident, or how to keep the other residents around resident #2 safe. Staff member D stated the staff will usually take resident #2 away from the situation to some place quiet, which usually helped the resident settle down. Staff member D stated, "We are used to (resident #2's name) being (resident #2's name)." Staff member A stated, resident #2's family members stated resident #2 has always cursed and acted this way. 3. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The following was documented in the NN dated 8/26/10 at 6:00 p.m., "Res. hit female Res. (resident #14) after she called him a dumb ass".