Every finding on record at Sharon Health Care Willows

Based on interview and record review, the facility failed to prevent resident-to-resident physical abuse for one of three residents (R1) reviewed for abuse in a sample of three. Findings include: R1's current electronic diagnoses sheet includes DiGeorge Syndrome (genetic disorder), Schizoaffective disorder, Major Depression, Anxiety, and Epilepsy. R1's Progress Notes, dated 2/19/26, state that a male peer open hand hit R1 on the left side of her face in the dining room. R1's current care plan documents that R1 is noted with hearing loss. This form also documents that (R1) has DiGeorge Syndrome, causing intellectual and cognitive deficiencies. R2's current electronic diagnoses sheet includes Antisocial Personality and Schizoaffective Disorder, and Post-Traumatic Stress Disorder. R2's current care plan documents a history of battery. This form also documents that R2 can be physically aggressive and cause damage to property due to poor impulse control from schizophrenia and antisocial personality disorder. R2's Progress Notes, dated 2/19/26, documents that this resident (R2) struck another resident (R1). The facility's FRI (facility reported incident) Final Report, dated 2/19/26 at 12:25pm, documents that in the North Dining Room, (R2) hit (R1) on the left side of her face with a closed fist. Residents were immediately separated and counseled. (R1) was assessed and no injuries or complaints of pain noted. (R1) had (R2's) cup and (R2) tried to grab it away from (R1), (R1) is hard of hearing, and they both pulled at the cup, (R2) then hit (R1). (R2) was arrested and cited a ticket with a notice to appear in court. The facility's Incident/Accident Report, dated 2/19/26, documents that R1 stated that She (R1) snatched my cup! I took it from her, she yanked it out of my hand, then I punched her with a closed fist just once in her face. (R1) stated that it was her cup and asked for it back, then (R2) hit her when she was trying to get it back. On 4/8/26 at 2:00pm, V5, Certified Nursing Assistant, stated that she had seen R1 pick up R2's cup, then R2 punched R1 in the face twice. V5 stated that she separated the two, then told the nurse. On 4/8/26 at 2:10pm, V7, Certified Nursing Assistant, stated that R2 took his cup back from R1, then R1 grabbed the cup, and R2 punched her in the face. The facility's Abuse Prevention Program Facility Policy, updated 6/5/25, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This form documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. This form also documents physical abuse, including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview, and record review, the facility failed to prevent physical and sexual abuse for two of five residents (R4 and R6) reviewed for abuse in a sample of seven. 1.On 2/6/26 at 11:00am, R4 stated that she was slapped in the face in the dining room but was unable to give any specific details. At 12:45pm, R4 propelled herself by the nurses' station and stated, He (R7) grabbed my breast in the dining room. (R7) then walked behind R4 and said, Let's go, baby while attempting to kiss the top of her head. R4 yelled at him, and the staff intervened. The facility's Incident Investigation Report, dated 2/6/26, documents that R4 reported that a peer (R7) touched her breast and lower side without her consent. (R4) and (R7) were immediately separated. V9's, Certified Nursing Assistant, statement, dated 2/6/26, documents that she heard R4 yell stop touching me. V9 observed (R7) touching (R4) on her breast and lower back. V9 approached the two, and (R7) walked away. V9 stayed with (R4) to ensure her safety and reported the incident. R4's current care plan documents that R4 has the potential to be verbally and physically aggressive related to Schizophrenia disorder and Bipolar. R7's current care plan documents that R7 has a history of inappropriate sexual behavior, initiated 1/2/23. On 2/9/26 at 12:30pm, V9 verified that she seen R7 touch R4's breast, and he was rubbing her back and sides. V9 stated that he could not hear what he was saying to her. 2.The facility's Incident Investigation Report, dated 1/27/26, documents that at 1:10pm, (R3) hit (R4) on the mouth with an open hand. R3 and R4 were immediately separated. This form documents that (R3) admitted to hitting (R4) because she is always saying Nobody is holy. V4's, Registered Nurse, statement, dated 1/27/26, documented that she heard V4 yell, He hit me. Staff intervened and separated the two. R3's current care plan documents that R3 has a criminal history, including domestic battery, aggravated battery, and battery. R3's interventions are for R3 to search out social services to vent feelings. This form also documents for staff to monitor and redirect R3 from peers with whom he had a conflict. 3.The facility's Incident Investigation Report, dated 12/29/25, documents that at 9:16am in the south dining room, R5 hit R6 in the mouth with a closed fist. The two were separated. V10, Registered Nurse, statement, dated 12/29/26, documents that (R5) hit (R6) in the mouth, (R5) had punched her (R6). This form documents that upon assessment, R6 was noted to have a laceration and swelling to her lip. R5 did not have any injuries. On 2/9/26 at 9:15am, R6 was observed propelling herself around the south dining room. R6 did not display any signs of adverse behaviors. R6 was cooperative with V8, Licensed Practical Nurse, during medication pass. R5 was in her room, yelling out. At 9:40am R5 was in the main dining room, yelling out staff and residents in the area. R5's current care plan documents that R5 has daily behaviors of yelling out in her room and common areas due to hallucinations related to schizoaffective disorder. R5 may be physically aggressive at times and can be resistant to redirection and refuse any medical intervention.On 2/9/26 at 9:15am, V8, Licensed Practical Nurse, stated that R5 has been on one-on-ones since the incident with R6. V8 stated that R5 is very delusional and will yell and hit anyone who is around her. V8 verified that R5 has to be kept away from other residents while in common areas. On 2/9/26 at 1:00pm, V2, Director of Nursing, stated that R7 is going to be moved to the other side of the building for closer monitoring. V2 also stated that R5 has been under one-on-one supervision since the incident with R6. The facility's Abuse Prevention Program Facility Policy, updated 8/1/22, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, and misappropriation of resident property, corporal punishment, and involuntary seclusion. This form documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm. This form also documents that physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Sexual abuse is non-consensual contact of any type with a resident.

Based on interview and record review, the facility failed to notify the local police of allegations of physical and sexual abuse for two of five residents (R4 and R6) reviewed for reporting abuse in a sample of seven. The facility's Incident Report, dated 12/29/25, documents that at 9:15am, (R5) hit (R6) with a closed fist to her face. (R6) sustained a cut on her lip. This form documents that the police were not notified of the physical altercation between R5 and R6. The facility's Incident Report, dated 1/27/26, documents that at 1:10pm, in the North dining room, (R3) hit (R4) in the mouth with an open hand. (R4) alerted staff who separated the two. (R3) admitted to hitting (R4) because she said nobody's holy. This form documents that the police were not notified of the the physicall altercation between R3 and R4. The facility's Incident/Accident Report, dated 2/6/26, documents that (R4) stated that a peer (R7) touched her breast and lower side without her consent. This form has no documentation that the local police were notified of the unwanted touching. On 2/9/26 at 10:30am, V1, Administrator, verified that the police are not notified of any physical or sexual incidents unless there is a serious injury.

Based on interview and record review, the Facility failed to establish procedures to purchase Resident personal items and prevent staff from the unauthorized use/theft of a Resident's debit card, without the Resident's permission, for one of four Residents (R2) reviewed for Misappropriation of Resident property in a sample of four. This failure resulted fraudulent charges on R2's personal financial debit card account causing R2 mental distress.Findings include:The Facility Abuse Prevention Program Policy, updated 6/5/25, documents: this Facility affirms the right of our Residents to be free from abuse and misappropriation of resident property; prohibits mistreatment and abuse; has attempted to establish a secure environment; the Facility is doing all that is within its control to prevent occurrences of mistreatment and abuse of our Residents; pre-employment screening and orienting and training employees; establish an environment that promotes Resident security and prevention of mistreatment; is committed to protecting our Residents from abuse by anyone including but not limited to Facility staff; Misappropriation of Resident property is the deliberate misplacement, exploitation, wrongful/temporary/permanent use of a Resident's belongings or money without the Resident's consent; supervisors will monitor the ability of the staff to meet the needs of Residents; mistreatment or misappropriation of Resident property will be handled through counseling, training or the Facility's progressive discipline policy; and employees of this Facility who have been accused of abuse or misappropriation of Resident property will be removed from Resident contact immediately until the results of the investigation have been reviewed by the Administrator.The Facility Resident Rights Policy, undated, documents the Facility: must provide services to keep your mental health and sense of satisfaction; must not be abused by anyone, financially; must make reasonable arrangements to meet your needs and choices; and the Facility may not become your money manager without your permission.The Facility Activity Director Position Description, undated, documents: escorts Residents to and from special activity areas, to include off campus trips and assists in providing for the personal needs while participating in all aspects of the activity program; and performs other duties as special circumstances demand.V7's (Police Officer) Police Report, dated 9/10/25, documents R2 gave V3 (Activity Director) R2's personal debit card to purchase tobacco products. V3 purchased the incorrect flavor of tobacco and R2 asked V3 to purchase the correct flavor. V3 did not return with R2's debit card and R2 did not see V3 until days later Monday morning (9/8/25), wherein V3 told R2 that the debit card had been lost. The investigation is ongoing. Attempts to contact V7 were unsuccessful.V3's (Activity Director) Personnel File documents a date of hire as 7/20/23, for a Certified Nursing Assistant/CNA position. The Personnel File also documents V3 successfully completed the Activity Director Course on 5/13/25 and assumed the role of the Activity Director. V3's Orientation Information Form, dated 7.20.23, documents V3 received: Code of Contact; Employee Handbook; General Guidelines; Abuse Prevention Policy; and Resident Rights Policy.V3's Core Values Policy, dated and signed by V3 on 10/5/23, documents: provide high quality health care, honesty and integrity; employees Code of Professional Conduct and Work Ethics to foster, maintain, enhance trust, confidence and a culture of safety; provides guidance on how and in which manner should the conduct of the employee be when they are performing work on behalf of the Facility; ethical obligations defined as rules of conduct that are used in regard to behaving correctly and morally in a particular group situation; comply with all applicable laws and regulations; and fraud or the intent to steal, deceive or lie in most cases is criminal and some examples of fraud are misappropriating assets or misusing Facility property and unauthorized handling or reporting of transactions.V3's Receipt/Acknowledgement Form, dated 7/2/25, documents V3 received the Employee Handbook.V3's Personnel File documents V3's Employee Report, dated 9/8/25, as self-discharge from employment after V3 sent a message to V1 (Administrator/ADM) that V3 needed a leave of absence with no advance notice. V1 attempted to contact V3 after the text message and V3 did not respond. V3 took all personal items and left the Facility key, therefore interpreted as self-termination from employment.R2's Contract Between Resident and Facility, dated 7/1/22, documents, Facility Standards are defined as the Rules and Regulations of the local State Agency, applicable Federal Rules and Regulation and the local State Department of Human Services and the Department of Healthcare and Family Services; the Facility shall offer personal care and activities as identified in the Resident's Plan of Care. R2's Facility's local State Agency Final Report/Report, dated 9/17/25, documents on 9/10/25 at approximately 4:00 pm, R2 inquired as to V3's (Activity Director) location. R2 stated that R2 had given R2's debit card to V3 a few weeks prior to do some shopping and to pay R2's court fine. V3 told R2 that V3 lost the debit card and was getting R2 a replacement card. V3 told R2 that V3 paid for R2's court fine and cigarettes with V3's own money until R2 received the new card. On 9/10/25, V15 (Social Service) assisted R2 with checking on the status of the new card and at that time they were informed that a new card had not been requested, and that at that time R2's debit card balance was $2.20.R2's Report also documents that initially when V3 (Activity Director) purchased tobacco products for R2, V3 purchased a menthol flavor and V3 wanted regular tobacco. V3 then left again with R2's debit card to purchase the correct tobacco and during this time V3 took the debit card home, over the weekend, and the debit card was allegedly lost while in V3's possession. At that time, V3 told R2 that V3 ordered a new debit card.R2's Report also documents R2's balance in August 2025, was around $2600.00. R2 stated V5 (R2's Daughter) purchased food and miscellaneous items prior for R2. The local Police Department was notified and initiated an investigation. On 9/10/25, V1 (Administrator/ADM) attempted to contact V3 (Activity Director) and V3 did not answer or return phone calls. On 9/8/25, V1 (ADM) received a cellular text message from V3 stating V3 needed to take two months off suddenly. V3 had cleared out V3's office and returned V3's work keys, and V3 was terminated. R2's Debit Card Statement, dated 6/2025, documents an ending balance of $967.00 and no transactions.R2's Debit Card Statement, dated 7/2025, documents an ending balance of $1,934.00 and one transaction for a deposit of $967.00.R2's Debit Card Statement, dated 8/2025, documents a starting balance of $1,924.00 and an ending balance of $2.92. The Statement documents: 8/8/25, four (local bank) transactions totaling $1012.95; 8/9/25 totaling $61.85 for food purchase (local restaurant) and $89.60 for tobacco; 8/9/25 for tobacco totaling $30.15; 8/11/25, four automated teller machine/ATM transactions totaling $348.20; 8/12/25 for tobacco totaling $120.23; 8/13/25 (local bank) transactions $204.60; 8/13/25 14 transactions to a local video gaming facility totaling $906.88; 8/14/25 online shopping website totaling $15.23; 8/29/25 seven transactions to a (local video gaming facility) totaling $874.51; 8/29/25 transaction for (local clothing store) totaling $177.80; and 8/29/25 transaction for cash purchase at (local gas station) totaling $20.00.R2's Debit Card Statement, dated 9/2025, documents a starting balance of $2.92 and an ending balance of -$1.08.R2's Face Sheet, dated 11/25/25, documents diagnoses including Antisocial Personality Disorder, Schizoaffective Disorder and Post-Traumatic Stress Disorder. On 11/22/25 at 12:34 pm, V6 (R2's friend) stated, (R2) lived with me for two and a half years and I speak with him still. (V3) told me that something happened to his debit card, and he thinks it was (V3) because the money has been missing since he gave it to her.On 11/25/25 at 10:57 am, V14 (R2's friend and insurance company) stated, I used to work at the Facility as a Registered Nurse and I still go and visit. When I talked to (R2) on 9/18/25 at the Facility, (R2) told me about (R2's) debit card getting lost and about all the money (R2) lost. (R2) told me that a few weeks prior, (V3) took his debit card to buy him some cigarettes and ended up taking the card home and apparently losing the card, which is questionable. Right around that time (R2's) account was drained and all these charges for gambling and extra stuff showed up on (R2's) statement. When I worked at that Facility, most of the Residents have psychological needs and are clueless to the financial aspect of their needs, so the staff usually do their shopping for them. There was never a process for taking Resident's money and shopping for them. Some Residents would also use cash and employees would go shop with their cash.On 11/25/25 at 9:44 am, V12 (Office of Attorney General Medicaid Fraud Control Unit) stated, We have a current investigation for (R2) over the debit card transactions. I am still investigating these charges and waiting for further documentation.On 11/25/25 at 8:45 am, V3 (Activity Director) stated, Part of my job duties was to shop for the Resident, I had to shop for many of the Residents tobacco and stuff. I did take (R2's) debit card and I misplaced it over the weekend when I was moving. I do not remember when all this happened, but I think it was a couple weeks before my last day on 9/8/25. On 9/8/25, I had to take a leave of absence for personal issues, and I no longer work there.On 11/22/25 at 9:09 am, R2 stated, I have an active police investigation because a couple months ago, I gave my debit card to (V3) because (V3) was buying my tobacco for me. I really think that (V3) spent my money on that card. There are charges for liquor stores and gambling places. (V3) bought me the wrong kind of tobacco, so (V3) told me that (V3) would just keep the card and go after work and get me the right kind of tobacco, but (V3) ended up taking my debit card home over the weekend and lost it. (V3) told me that (V3) was moving that weekend and does not know where it got lost at. (V3) did not help me get a new card issued, someone else helped after I never got the first one. I had around $2600.00 on that card and after a month it was in the negative. I filed a police report on Wednesday 9/10/25 and (V3) quit shortly after that. My card was never found, but I did get a new card finally. It was so wrong that I could not trust (V3) and it has been a real pain and has caused me many problems. I just want my money back.On 11/23/25, V1 (Administrator) stated, (R2) does not have a community pass and normally does not leave the Facility, so usually (V3) would go shopping for (R2's) tobacco products. A week or so before (V3's) last day (9/8/25), (V3) took (R2's) debit card home over a weekend and lost the debit card. We requested a copy of the debit card statements and there were multiple charges for gambling establishments, clothing, and other business. The police were notified, and the investigation is still ongoing. We have had a hard time getting ahold of (V3) and (V3) is not returning my phone calls. We do not have a safe process in place for our employees to do personal shopping for our Residents. It is probably not a good idea that an employee take cash or a debit card from the Residents.

Based on interview and record review, the facility failed to follow its policy to ensure resident to resident physical abuse did not occur for one resident (R1) reviewed for abuse in a sample of five. Findings include:Facility's Initial and Final Reports to (State Department of Public Health) document: On 6/2/25 (R1) was noted on the patio when his wheelchair tipped back. Initial reports stated (R1) did a wheelie and fell. Further investigation, (R1) stated four residents (R2-R5) hit him multiple times and pulled his wheelchair back. R1 stated he did not fall out of his chair. R1 stated that R4 pulled his/R1's wheelchair backward. Residents (R2-R5) involved were questioned and admitted they hit him/R1. Police were called. R1's Minimum Data Set/MDS dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) of 14 on a scale of 00 - 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) (Documentation shows that R2, R3 and R4 have BIMS of 15; R5 has a BIMS of 13.) R1's current Care Plan documents: (R1) has a history of provoking peers. He requires assist of staff due to weakness/paralysis to left arm and leg related to history of stroke and traumatic brain injury. (R1) has history of behavior of purposely sliding himself down in his wheelchair even immediately after staff has repositioned him. (R1) has diagnosis of epilepsy with no recent episodes noted. (R1) is at risk for falls due to impaired balance and mobility. On 7/16/25 at 12:25pm, R1 stated that during the 6/2/25 altercation with R2-R5, They beat me up; one guy flipped my chair, tilted me back and I couldn't move. They just don't like me. On 7/17/25 at 9:15am, R1 stated that R4 Grabbed my wheelchair and flipped it over. On 7/17/25 at 9:35am, R2 stated regarding the 6/2/25 incident with R1, Everything happened so fast. Minding my own business; (R1) had called my mother a bitch and also called R5 a bitch; I laughed at (R1) about the whole thing and that's what he gets. On 7/16/25 at 12:50pm, R3 stated that on 6/2/25, that he was on the patio for smoking break. R3 stated that he had just gone to court in person today for the incident with R1; and got six months court supervision. R3 stated, I plead guilty to battery. R3 stated R3 was charged with mob action, aggravated battery. R3 stated that R1 got smart and cursed at R3. R3 stated, I have Post Traumatic Stress Disorder/PTSD and I popped (R1) in the mouth. He likes to be in everyone's way out on the patio. Asked him to move and he said to me Fxxx you fat ass, and I punched him in the mouth. There are four defendants including R2, R4 and R5, and we all got charged. On 7/16/25 at 12:50pm, R3 stated that during the incident, R1 was screaming and they/staff heard him. R1 got exactly what the hell he deserves; he bullies and curses everyone, even staff. On 7/16/25 at 1:00pm, R4 stated that he did not know who hit R1 first but did admit to hitting R1 as well. On 7/16/25 at 12:45pm, R5 stated, I hit him (R1) because he kept calling me a bitch, and my mother used to call me that and that triggered me. R5 stated that she did apologize to R1. On 7/17/25 at 12:45pm, V1 Administrator stated that she was surprised she did not hear about the 6/2/25 incident initially as a physical altercation. V1 stated V1 was surprised that R1 nor any of the other residents did not report the altercation. V1 stated, The residents do talk. I did not see R1 trying or attempting to do wheelies on the video (facility camera video of 6/2/25 incident); R1 was moved to the South Hall on 6/3/25 after review of the video; he did not go to the hospital; no injuries. On 7/17/25 at 10:17am, V4 Rehab Social Worker stated that the 6/2/25 altercation with R1 and R2-R5 was on a Monday around 11am; stated that she was outside the facility on her cigarette break and heard R1 yelling ‘Staff'; stated that R1 yells staff all the time, like just to have TV on, to get him a soda. V4 stated that R1 kept yelling and she wondered why. V4 stated that she V4 went inside the building and went to the patio; did not see him at first, that R1 was flipped backwards in his wheelchair. At this same time, V4 stated that when she went to tend to R1 for his yelling, that R2-R5 were laughing--saying that R1 was trying to do a wheelie. V4 stated that she V4 asked the residents why not get help and they said, Because it's (R1). On 7/17/25 at 10:17am, V4 stated that on 6/3/24 when they ran the camera video back, saw that R2 hit R1 first in the face; R5 hit him on his leg and arm, then R3 hit R1 in his face on the right side a couple of times; stated that R4 then hit R1 in the face, got up from R4's own wheelchair, laid the back of R1's wheelchair back and flipped R1 backwards. V4 stated that after the video was viewed, that R2-R5 admitted to hitting R1. V4 stated, R5 was the first one who said she was sorry; and she apologized to R1 before he was moved to the South Side from the North side. R3 was making threats and said he should have done more to R1.The Facility's Abuse Prevention Program Policy Dated 6/3/24, documents: This facility affirms the right of our residents to be from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians., friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.

Based on interview and record review, the facility failed to monitor, supervise, and follow its policy to ensure safe smoking environment for two residents (R1, R4) of five residents reviewed for smoking in a sample of five.Findings include:Documentation and interviews indicated that R1 and R4 were smokers. The facility's Incident Investigation Report Dated 6/2/25 documents both R1 and R4 were on the facility's patio for a smoke break when an altercation occurred involving R1 and R4. 1.R1's current Care Plan documents: (R1) is a level III supervised smoker. Interventions: Staff will remind (R1) about smoking policy and procedures as needed. Staff will supervise and assist (R1) with smoking safely. 2. R4's current Care Plan documents: (R4) is a smoker and requires supervision while smoking to maintain safety. Interventions: Staff will remind resident about smoking policy and procedures as needed. Staff will supervise and assist resident with smoking safely.On 7/16/25 at 12:50pm, R3 stated that there were no staff on the smoking patio prior to (6/2/25 altercation involving R1). R3 stated, After the incident, (R1) was screaming and they heard him; (V4 Rehab Social Worker) heard (R1) and came to the patio.On 7/17/25 at 9:35am, R2 stated that there were no staff on the patio on 6/2/25. R2 stated, They (Staff) came out there right after the mess (altercation involving R1).On 7/17/25 at 9:18am, R5 stated that no staff were out on the patio on 6/2/25 and staff had not been out there for their smoke breaks even prior to the 6/2/25 incident. R5 stated, Now they (Staff) have to be there since the incident.On 7/17/25 at 9:45am, V3 Activity Director stated that Staff were probably not out there on the patio to supervise on the 6/2/25 incident date. V3 stated that independent smokers could have been out on the patio without supervision. V3 stated, (R1) should not have been out there with staff monitoring; he is not independent; (R4) was supervised like (R1).On 7/16/25 at 2:30pm, V1 Administrator stated: There were no staff on the patio to supervise; a staff should have been out there supervising. The Activity Aide (V5) should have been on the patio supervising. He was supposed to be but stepped away to do a one on one when another staff had to step away. Facility's Smoking Safety Policy and Procedure, updated 6/5/25, documents: Supervised Smoking Program: Patients in the supervised smoking program need assistance and monitoring to maintain safety while smoking.The facility's Smoke Pass Times documents: Scheduled resident n times include 7am by designated staff: Security; 9am, 11am, 1pm, 3pm, and 5pm by designated staff: Activities.

4. R10's computerized Medical Record documents that R10 is a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Bipolar Type, Post Traumatic Stress Disorder, Unspecified. R10's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) of 14, indicating (cognition intact). R10 has no extremity impairment, required supervision for eating, is independent for all activities of daily living, bed mobility and transfers. R10 has Delusions, verbal behaviors directed towards others and rejects care. R12's computerized Medical Record documents that R12 is a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Unspecified, Generalized Anxiety Disorder, Paranoid Schizophrenia, and Unspecified Dementia. R12's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) of 9, indicating (moderate cognitive impairment). R1 has no extremity impairment and is independent for all activities of daily living, bed mobility and transfers. R12 has Delusions, verbal and physical behaviors directed towards others. R10's Incident/Accident Report dated 4/4/24 at 9:28 PM, documents (R10) was in the wheelchair on F Hallway, peer (R12) came out of his room and hit (R10) on the left jaw. No apparent injuries noted. R12's Incident/Accident Report dated 4/4/24 at 9:28 PM, documents (R12) noted with agitation, (R12) hit the female (R10) on the jaw. The Incident Investigation Report dated 4/4/24 documents On 4/4/24 at 9:30 PM on F-hall (R12) hit (R10) with a closed fist to the left jaw. No initial injuries were noted. R10's Nursing Note dated 4/4/24 at 9:40 PM, documents (R10) was in her wheelchair in the hallway, male peer (R12) came out of his room yelling and screaming, walked down to (R10) and hit (R10) on the left jaw with closed fist. No apparent injuries, (R10) denies pain or discomfort at this time. The Witness Statements taken by V1/Administrator dated 4/5/25 at 12:25 PM, document (R10) stated she was passing by and (R12) hit her on the left jaw. Unable to interview (R12). (V20/Certified Nursing Assistant/CNA) stated that (R10) was passing in the hallway and (R12) out of nowhere started yelling and hit (R10) with a closed fist to the jaw. (V11/CNA) stated (R12) and (R10) were just passing each other and (R12) hit (R10) before staff could intervene. R10 refused to be interviewed and R12 was unable to answer question appropriately. On 6/16/25 at 11:14 AM V1/Administrator verified that R12 did hit R10 in the jaw on 4/4/24. Based on interview, observation and record review, the facility failed to protect residents from episodes of physical abuse occurring for three of ten residents (R1, R4, and R10) reviewed for abuse in the sample of 12. This failure resulted in R1 being pushed to the ground by R2 causing R1 to experience excruciating pain to her right wrist and sustaining a right wrist fracture. Findings include: 1. R1's computerized Medical Record documents that R1 is a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, Post-Traumatic Stress Disorder, Unspecified, Borderline Personality Disorder, Extrapyramidal and Movement Disorder, Unspecified. R1's MDS (Minimum Data Set) Assessment, dated 4/25/25, documents R1 is cognitively intact. R4's computerized Medical Record documents that R4 is a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Borderline Personality Disorder, and Anxiety. R4's MDS Assessment, dated 4/2/25, documents R4 is moderately cognitively impaired. The Incident Investigation Report, dated 5/12/25, documents On 5/12/25 at 3:15 PM in the North dining room, (R1) approached the table where (R4) was and grabbed (R4's) belongings. (R4) stood up and grabbed her stuff back. (R1) then pushed (R4) and (R4) hit (R1) 2X (two times) in the face (with) closed fist. Residents were separated by staff and first aid administered. (R1) sustained a superficial scratch above her R (right) eye and it was red. Investigation interviews, dated 5/12/25, documents R7 was a witness to the incident on 5/12/25 between R1 and R4. On 6/13/25 at 1:45 PM R7 stated, I witnessed around a month ago (R1) trying to take (R4's) things off the table in the dining room. (R4) was upset because they were her things, so she tried to grab them back and (R1) pushed (R4). (R4) then got mad and hit (R1) twice in the face. On 6/13/25 at 1:51 PM R4 was sitting at the dining room table on north side. R4 stated, (R1) was trying to take my things from the table a while back and she ended up shoving me, so I hit (R1) twice in the face. 2. R2's computerized Medical Record documents that R2 is a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses which included Wernicke's Encephalopathy, Psychotic Disorder with Delusions due To Known Physiological Condition, Major Depressive Disorder, Recurrent, In Partial Remission, and Generalized Anxiety Disorder. R2's MDS Assessment, dated 5/14/25, documents R2 is moderately cognitively impaired. R3's MDS Assessment, dated 3/4/25, documents R3 is moderately cognitively impaired. The Incident Investigation Report dated 5/18/25 documents On 5/18/25 at 12:20 PM in the North Dining Room, (R1) was pushed by (R2) and fell to the ground. (R3) then approached (R2) and grabbed (R2's) shoulders to stop (R2). The Incident/Accident Report dated 5/18/25 at 12:20 PM, documents (R1) approached peer (R2) attempting to retrieve (R2's) snacks. (R1) grabs snacks causing her (R1) and the peer (R2) to begin wrestling the snacks out of (R1's) hands. Ultimately peer (R2) ended up pushing (R1) down to the ground, where (R1) landed on her buttocks. Investigation Interviews, dated 5/18/25, documents R3 was a witness to the incident on 5/18/25 between R1 and R2. This same interview documents R3 stated, I tried to stop (R2) from hitting (R1). Investigation Interviews, dated 5/18/25, documents V15/RN (Registered Nurse) was a witness to the incident on 5/18/25 between R1, R2, and R3. This same interview documents V15 stated, I saw (R1) grab (R2's) snack on the floor. Both residents (R1 and R2) then started wrestling the snack out of each other's hands. Then (R2) pushed (R1) making (R1) fall on her buttocks. Both residents then separated then (R3) approached (R2) and grabbed (R2) by his arm/shoulder that seems like (R3) is stopping (R2) from what he (R2) had done (to R1) then both residents (R2 and R3) were separated. R1's Progress Note, dated 5/18/25 and signed by V12/RN, documents (R1) approached peer (R2) attempting to retrieve his snacks. (R1) grabs snacks causing her and the peer (R2) to begin wrestling the snacks out of (R1) hands. Ultimately peer (R2) ended up pushing (R1) to the ground, where she landed on her bottom. R1's Progress Note, dated 5/19/25 and signed by V17/LPN (Licensed Practical Nurse) documents Nurse noted (R1's) right hand and wrist to be swollen and (R1's) complaint of pain. When asked what happened, (R1) states she fell yesterday. (V16/R1's Primary Physician) notified and new order received to obtain a right-hand x-ray with 3 (three) views. R1's Right Hand X-Ray Report, dated 5/20/25, documents Impressions: Displaced fracture distal radial metaphysis. On 6/14/25 at 10:14 AM V1/Administrator verified R1's right wrist fracture was caused from R2 pushing R1 down on 5/18/25. On 6/14/25 at 11:25 AM V15/RN stated, I was in the dining room on North Side passing medications. I witnessed (R1) and (R2) fighting over (R2's) snacks. (R1) and (R2) both were tugging on the snack at the same time, then when they both let go of the snack, (R2) pushed (R1) down to the ground. (R1) landed on her buttocks. I immediately separated them. On 6/14/25 at 1:52 PM R1 was sitting in her room on her bed. R1's right wrist was observed to have a brace on. R1 stated her wrist hurts bad. 3. The Incident Investigation Report dated 5/22/25, documents On 5/22/25 at 2:55 PM in the North main Dining Room, (R2) pushed (R1), who fell to the ground. (R2) stated (R1) went towards his cup so he (R2) pushed her (R1). Nursing assessed and no injuries were noted. Investigation Interviews, dated 5/22/25, documents V13/CNA (Certified Nursing Assistant) was a witness to the incident on 5/22/25 between R1 and R2. This same interview documents V13 stated that V13 was walking through the dining room area when V13 witnessed R2 pushed R1 down to the floor. Investigation Interviews, dated 5/22/25, of R2 documents that R2 stated R1 went for his cup so R2 pushed R1 so R1 could not get it (the cup). On 6/14/25 at 10:58 AM V13/CNA stated, I was in the North Side dining room. (R1) walked up to (R2) and grabbed (R2's) cup, so as I walked by, I witnessed (R2) push (R1) down. The facility's Abuse Prevention Program Facility Policy, dated 6/5/25, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. The facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction on injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to prevent a fall for one resident (R5) of 3 residents reviewed for falls in the sample of 12. This failure resulted in R5 sustaining a fractured femur, causing R5 significant pain and required surgery. Findings include: R5's computerized Medical Record documents that R5 is a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Metabolic Encephalopathy, Disorientation, Acquired Absence of Kidney, and Presence of Right Artificial Shoulder Joint. On 5/8/25 the diagnosis of Unspecified Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing was added. R5's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) of 13, indicating (cognition intact). R1 has delusions, verbal abuse and other behaviors not towards others. R5 has an upper extremity impairment on one side, requires supervision for all activities of daily living/toileting, is independent with bed mobility, and is occasionally incontinent. R5's Care Plan documents (R5) is at risk for falls, (R5) ambulates independently but has a history of wheelchair use. On 6/13/25 at 10:12 AM R5 was sitting in her wheelchair at a table located in the north side dining room. R5 was dressed and groomed appropriately and had non-skid shoes on. R5 stated When I fell and broke my leg, I was trying to go to the bathroom in my room. I only have one kidney so as soon when I have to go to the bathroom I have to go. I went to stand up to go to the bathroom and I slipped on water that was on the floor, fell and hurt my right leg. I went to the hospital after that and had surgery. R5 then lifted her right pant leg and showed where R5 had surgery on her right leg. R5's Fall Screening dated 4/5/25 at 11:20 PM, documents that R5 was walking, slipped on a wet surface and lost her balance. The Witness Statement given by V10/Certified Nursing Assistant/CNA dated 4/5/25 at 11:20 PM, documents (V10/CNA) stated she was walking by (R5's) room and (R5) was in bed. (V10) noticed a large puddle on her (R5's) floor. (V10) went to go get something to clean up the floor and (R5) must have stood up while (V10) was gone. When (V10) returned (R5) was on the floor and couldn't move her leg. The Witness Statement given by R5 dated 4/5/25 at 11:20 PM, documents that R5 stated she slipped when R5 got up to use the bathroom. R5's Incident Investigation Report dated 4/5/25 documents Potential Contributing Factors: Wet floor, (R5) is impulsive - did not wait for staff to clean up floor. On 4/5/25 at 11:20 PM in (R5's) room (R5) was noted by staff lying on the floor. Upon assessment (R5) was unable to bend her right leg without significant pain and (R5) was unable to bear weight. (R5) stated she lost her balance getting up to go to the bathroom. Results from the hospital indicated (R5) fractured her femur. R5's Nursing Note dated 4/6/25 at 4:36 AM, documents (R5) was observed by this nurse lying on the floor in her bedroom in a supine position after being summoned by direct care staff. Further assessment indicates that (R5) is unable to bend her right leg without significant pain which renders her unable to attempt to bear weight. R5 was sent to the Emergency Department for evaluation and treatment. R5's Hospital X-ray Report dated 4/6/25 documents Impression: Acute comminuted and displaced distal femur fracture extending to the articular surface of the knee. Findings: Acute comminuted fractures involving the distal femoral diaphysis and extending to the articular surface of the trochlea. One of the dominant fracture lines extends from the medial aspect of the metaphysis obliquely towards the trochlea with a small fracture line extending into the lateral femoral condyle. A second dominant fracture line extends obliquely across the diaphysis to the metaphysis. The distal fracture fragment is displaced posteriorly by half a shaft width. There is also impaction of the fracture fragments. Moderate-sized lipohemarthrosis. Edema in the musculature surrounding the fracture. R5's Hospital Discharge summary dated [DATE] documents that R5 was in the hospital from [DATE] to 4/10/25. R5 was admitted to the hospital on [DATE] from (the facility) due to a ground level fall resulting in a right Femur fracture. (R5) was having right knee pain and found to have distal right femur fracture. (R5) was admitted for further management. On exam (R5) does have right thigh tenderness and knee tenderness. X-ray of the right leg shows distal femur fracture. Acute commuted and displaced distal femur fracture extending to the articular surface of the knee. (R5) had an ORIF (Open Reduction and Internal Fixation) surgery on 4/6/25. On 6/13/25 at 12:37 PM, V10/CNA stated I walked past (R5's) room and saw there was water all over (R5's) floor. (R5) had a large cup that must have spilled. I don't know how long the water had been there. (R5) was in her bed that was in a low position. When (R5) saw me come into the room (R5) started talking about vaping (using electronic cigarettes) and rolling in bed like she was trying to get up. (R5) gets adamant about when she wants to vape (smoke). I told (R5) to stay in bed and not to get up because there was water on the floor. (R5) was still trying to get up but (R5) needs help to get up from the low bed so I didn't think (R5) could get up. I went through the bathroom that was between (R5's) room and another resident's room to get some extra pads in the other room to absorb the water. Before I got back to the room (R5) had got up and fell. The other resident was talking to me, but I was only gone for a few minutes. I kept telling (R5) not to get up. It depends on (R5's) mood if she listens or not. V10 was asked if she thought she should have done anything different. V10 stated I would have had someone stay with (R5). On 6/17/25 at 2:45 PM, V1/Administrator verified that R5 fractured her femur when R5 fell. V1 stated I talked to (V10/CNA) about (R5's) fall and told (V10) that she should have stayed with (R5) and put the call light on until someone came to clean up the water so (R5) would not have got up and fell. The Fall Policy dated 6/5/25 documents It is the policy of this facility to prevent falls and serious injury outcomes by recognizing multi-factional risk and causes, and institute recommendations for falls prevention and management consist with clinical practice guidelines and standards of care. Nursing Care Strategies General safety precautions and fall prevention measures that apply to all patients: Assess the patient care environment routinely for extrinsic risk factors and institute appropriate corrective action.

Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse for one of four residents (R5) reviewed for abuse in a sample of seven. Findings include: R2's current Face Sheet documents R2 admitted to the facility on [DATE] with the following diagnoses, but not limited to: Unspecified Dementia (without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety), Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. R2's MDS (Minimum Data Set) Assessment, dated 5/6/25, documents R2 is cognitively intact and ambulates without assistance. R2's current Care Plan documents, (R2) has a history of inappropriate sexual behaviors. R5's MDS Assessment, dated 4/8/25, documents R5 is cognitively intact. On 5/19/25 at 12:55 PM R5 was sitting in the south dining room at a table in a chair. R5 was visibly upset and stated, (R2) constantly sexually assaults me and I don't like it at all. (R2) intentionally comes over by me and does sexual gestures with his fingers (makes his pointer finger and middle finger into a V shape, puts them up by his mouth, and sticks his tongue in and out). (R2) is trying to say he wants to do something sexual to me. (R2) is always saying directly to me I want to have sex with you just me and you me and you forever and let's go have sex. I have told him multiple times I don't like it, and he won't quit. I have PTSD (Post Traumatic Stress Disorder) because I was raped as a child. I have reported what (R2) has said and done to me to (V1/Administrator) a few months ago and multiple times before that including different staff members, but (V1/Administrator) says there is nothing they (the facility) can do besides re-direct (R2). R5 stated R2 just did the same sexual gestures to her last week and said again let's have sex to her in the dining room. On 5/19/25 at 1:02 PM V10/Restorative Aide stated, (R2) talks inappropriate to (R5) a lot. I think he does it to (R5) because he knows she does not like it. I have witnessed (R2) make sexual gestures to (R5) with his fingers and say things to her like let's have sex. (V1/Administrator) is aware of (R2) talking inappropriately to (R5) and just tells us too re-direct (R2). I don't know if I reported it myself to (V1), but I know she is aware of it. On 5/20/25 at 2:43 PM V15/Social Services stated, It was reported to me by (V17/Housekeeper) that he saw (R2) standing at (R5)'s table in the dining room and overheard (R2) telling (R5) and her boyfriend (R8) that if (R8) would have slept in a little longer, he would have had (R5) down to his room having sex with her. On 5/21/25 at 10:06 AM V17/Housekeeper stated While (R5) and (R8) were sitting at a table in the dining room (a month or two ago) I saw (R2) go over to their table and tell them both that if (R8) wouldn't have gotten up so early and down to the dining room with (R5), that he would have taken (R5) back to his room to have sex with her. (R5) was upset with him saying that. I reported it to (V15/Social Services) right after it happened. On 5/21/25 at 12:33 PM V1/Administrator verified (R5) did report to her around two months ago that (R2) was making sexual gestures with his hands directly to her constantly and that she didn't like it. V1 also verified R5 has reported to her in the past (could not remember exactly how long) that R2 kept telling R5 that he wanted to have sex and R2 asked him to stop, and he wouldn't stop asking her. V1 stated, I did not document when (R5) and I had these conversations and should have. The facility's Abuse Prevention Program Policy, dated 6/3/24, documents Abuse means any physical or mental injury or sexual abuse inflicted upon a resident other than by accidental means. Abuse is the willful infliction if injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault.

Based on interview and record review, the facility failed to report potential resident to resident sexual abuse allegations to the Administrator and state agency for one of four residents (R5) reviewed for abuse in a sample of seven. Findings include: R2's current Face Sheet documents R2 admitted to the facility on [DATE] with the following diagnoses, but not limited to: Unspecified Dementia (without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety), Bipolar Disorder, Major Depressive Disorder, and anxiety disorder. R2's MDS (Minimum Data Set) Assessment, dated 5/6/25, documents R2 is cognitively intact and ambulates without assistance. This same MDS also documents R2 is cognitively intact and ambulates without assistance. R2's current Care Plan documents, (R2) has a history of inappropriate sexual behaviors. R5's MDS Assessment, dated 4/8/25, documents R5 is cognitively intact. As of 5/19/25, the facility's reports in the last four months to the local State Agency did not contain documentation of R2 potentially sexually abusing R5 as being reported. On 5/19/25 at 12:55 PM R5 was sitting in the south dining room at a table in a chair. R5 was visibly upset and stated, (R2) constantly sexually assaults me and I don't like it at all. (R2) intentionally comes over by me and does sexual gestures with his fingers (makes his pointer finger and middle finger into a V shape, puts them up by his mouth, and sticks his tongue in and out). (R2) is trying to say he wants to do something sexual to me. (R2) is always saying directly to me I want to have sex with you just me and you me and you forever and let's go have sex. I have told him multiple times I don't like it and he won't quit. I have PTSD because I was raped as a child. I have reported what (R2) has said and done to me to (V1/Administrator) a few months ago and multiple times before that including different staff members, but (V1/Administrator) says there is nothing they (the facility) can do besides re-direct (R2). R5 stated R2 just did the same sexual gestures to her last week and said again let's have sex to her in the dining room. On 5/19/25 at 1:02 PM V10/Restorative Aide stated, (R2) talks inappropriate to (R5) a lot. I think he does it to (R5) because he knows she does not like it. I have witnessed (R2) make sexual gestures to (R5) with his fingers and say things to her like let's have sex. (V1/Administrator) is aware of (R2) talking inappropriately to (R5) and just tells us too re-direct (R2). I don't know if I reported it myself to (V1), but I know she is aware of it. I should have reported it to (V1). On 5/20/25 at 2:43 PM V15/Social Services stated, It was reported to me by (V17/Housekeeper) that he saw (R2) standing at (R5)'s table in the dining room and overheard (R2) telling (R5) and her boyfriend (R8) that if (R8) would have slept in a little longer, he would have had (R5) down to his room having sex with her. I did not report this to (V1). I am still new, so I didn't even think about reporting it. On 5/21/25 at 10:06 AM V17/Housekeeper stated While (R5) and (R8) were sitting at a table in the dining room (a month or two ago) I saw (R2) go over to their table and tell them both that if (R8) wouldn't have gotten up so early and down to the dining room with (R5), that he would have taken (R5) back to his room to have sex with her. (R5) was upset with him saying that. I reported it to (V15/Social Services) right after it happened. I did not report it to (V1/Administrator) or anyone else and should have. On 5/21/25 at 12:33 PM V1/Administrator verified (R5) did report to her around two months ago that (R2) was making sexual gestures with his hands directly to her constantly and that she didn't like it. V1 also verified R5 has reported to her in the past (could not remember exactly how long) that R2 kept telling R5 that he wanted to have sex and R2 asked him to stop, and he wouldn't stop asking her. V1 stated, I did not document when (R5) and I had these conversations and should have. I did not report to the state agency what (R5) reported to me what (R2) was doing to her. If anyone is aware or witnesses any type of abuse, including sexual abuse they should immediately report it to me. The facility's Abuse Prevention Program Policy, dated 6/3/24, documents Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. VIII. External Reporting: A. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public health's regional office shall be informed by telephone of fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigation. This report shall be made immediately, but not later than two hours after the allegation is made, if the event that cause the allegation involve abuse or resulted in serious bodily injury.

Based on record review and interview, the facility failed to ensure an investigation was completed after potential resident to resident sexual abuse allegation was reported for one of four residents (R5) reviewed for abuse in a sample of seven. Findings include: As of 5/19/25, the facility's investigations for allegations of abuse did not contain documentation of R5 being sexually abused by R2. On 5/19/25 at 12:55 PM R5 was sitting in the south dining room at a table in a chair. R5 was visibly upset and stated, (R2) constantly sexually assaults me and I don't like it at all. (R2) intentionally comes over by me and does sexual gestures with his fingers (makes his pointer finger and middle finger into a V shape, puts them up by his mouth, and sticks his tongue in and out). (R2) is trying to say he wants to do something sexual to me. (R2) is always saying directly to me I want to have sex with you just me and you me and you forever and let's go have sex. I have told him multiple times I don't like it and he won't quit. I have PTSD because I was raped as a child. I have reported what (R2) has said and done to me to (V1/Administrator) a few months ago and multiple times before that including different staff members, but (V1/Administrator) says there is nothing they (the facility) can do besides re-direct (R2). R5 stated R2 just did the same sexual gestures to her last week and said again let's have sex to her in the dining room. On 5/21/25 at 12:33 PM V1/Administrator verified (R5) did report to her around two months ago that (R2) was making sexual gestures with his hands directly to her constantly and that she didn't like it. V1 also verified R5 has reported to her in the past (could not remember exactly how long) that R2 kept telling R5 that he wanted to have sex and R2 asked him to stop, and he wouldn't stop asking her. V1 stated she did not document when her and R5 had those conversations, nor did an investigation regarding the alleged allegations. The facility's Abuse Prevention Program Policy, dated 6/3/24, documents Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. A. All incidents will be documented whether abuse, neglect, exploitation, mistreatment, or misappropriation of resident property occurred, was alleged or suspected. B. Any incident or allegation, involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. D. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewed. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents.

Based on record review, and interview, the facility failed to ensure a resident was free from abuse for one (R2) of three residents reviewed for abuse in a sample of four. Findings include: The facility's Incident Investigation Report, dated 3/30/25 at 12:08 PM by V1 Administrator, documents: On 3/30/25 at 12:08 PM in the North Dining Room, (R2) wheeled up to the table where (R1) was sitting. (R1) stated (R2) kept running into his wheelchair. (R1) then hit (R2) in the back of the head with an open hand. R1's Nursing Progress Notes, dated 3/30/25 at 12:08 PM by V3 RN/Registered Nurse, documented the incident as follows: Staff alerted this RN to the dining room due to an altercation with peer resident (R2). Per staff witness, peer resident (R2) was wheeling himself in the dining room when he went to (R1's) table. (R1) told peer (R2) that he did not want him sitting in his table then he hit peer (R2) resident on his head. Residents then separated. Per resident (R1), peer (R2) resident keeps on backing his wheelchair into his wheelchair. (R1) told peer (R2) resident to stop but peer (R2) resident continued doing so. (R1) then hit peer (R2) resident on the back of his head. (R1) educated on calling staff for assistance if there is any misunderstanding with peers and avoid physical contact with peers. (R1) verbalized understanding. On 4/10/25 at 2:05pm, V1 Administrator verified R1 hit R2 in the back of the head with an open hand on 3/30/25 while in the Dining Room. On 4/11/25 at 11:50am, V3 RN/Registered Nurse stated she was the Nurse on duty for R1 and R2 at 12:08pm on 3/30/25. V3 stated this is when R1 hit R2 in the back of the head with an open hand while in the Dining Room. V3 stated V3 reported the incident to V1/Administrator/Abuse Prevention Coordinator. On 4/11/25 at 1:50pm, V5 Security stated he was in the Dining Room and saw R1 hit R2 in the head with an open hand when R2 was attempting to sit at R1's table. The facility's Abuse Prevention Program Facility Policy, undated, documents the following: Abuse means any physical or mental injury or sexual abuse inflicted upon a resident other than by accidental means. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

Based on interview, observation and record review, the facility failed to protect residents from episodes of physical abuse occurring from 10/29/24 - 02/25/25 for seven (R1, R2, R4, R6, R7, R12 and R14) reviewed for abuse in the sample of 16. Findings include: The facility's 'Abuse Prevention Program Facility Policy' (updated 06/03/24) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This same policy documents, The facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This policy also documents, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction on injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 1. The facility's Incident Investigation Report (dated 10/29/24) documents the following: On 10/29/24 at 09:10 AM on H Hall, (R4) and (R1) were physically aggressive toward one another, hitting each other with closed fists. Residents were separated and counseled. No injuries were noted, (R4) was sent to the hospital for a psychiatric evaluation, and he was asking to go stating he wasn't feeling well. (R4) thought (R1) was going to hurt him so he hit (R1) first. Police involved in transport. This same investigation documents the following Action Plan: Care Plans updated and staff reminded to use hands-on assistance to redirect (R1) from peers rooms. (R4) reassured and reminded of alternate ways to handle situations. On 03/20/25 at 08:20 AM, V7 (Housekeeping) stated she witnessed the 10/29/24 altercation between R1 and R4. V7 stated, (R1) was following me around in the hall while I was cleaning. He always walks with me. I had pushed my (housekeeping) cart down the hall and had stopped it near (R4's) room. (R1) was standing in the hall in front of the doorway to (R4's) room. (R1) must have been in (R4's) view because I turned around for a second to grab something from my cart, and when I turned back around, (R4) was punching (R1). I called for help and (R1 and R4) were separated. R1's Minimum Data Set Assessment (dated 12/23/24), Section C, documents a Brief Interview of Mental Status assessment was not able to be conducted on R1 due to R1's impaired cognition (rarely/never understood). This same section also documents R1 has a short- and long-term memory problem. On 03/19/25 at 01:20 PM, R1 was wandering throughout the H hallway carrying an empty disposable plastic cup. R1 was dressed and groomed and was wearing nonskid socks. R1 appeared to be pleasantly confused and was cooperative at this time. R4's current medical record documents R4's diagnoses to include Anxiety Disorder, Delusional Disorder, and Disorientation. On 03/20/25 at 10:10 AM, R4 was lying in bed watching television. R4 was dressed and groomed, and a wheeled walker was nearby his bed within his reach. R4 denied ever having any altercations with anyone at the facility at this time and stated, I get along with everyone. On 03/20/25 at 08:40 AM, V1 (Administrator) stated that R1 and R4 did have a physical altercation on 10/29/24. V1 stated, (R1) was walking in the hallway and stepped in view of (R4's) doorway, and that's when (R4) approached him and started hitting him. V1 then stated R1 has a diagnosis of Dementia and frequently wanders throughout the facility. 2. The facility's Incident Investigation Report (dated 11/02/24) documents the following: On 11/02/24 at 12:50 AM on G Hall, (R1) and (R9) ran into one another causing both to fall to the floor. (R9) then hit (R1) in the forehead twice with a closed fist. Residents were separated and staff assessed for injuries- none noted. When nurse expressed to (R9) that the collision was an accident, (R9) apologized to (R1). This same investigation documents the following Action Plan: Staff reminded to redirect (R1) from other halls and intervene proactively. (R9's) care plan updated, and staff re-educated to intervene early if agitated- remind him to walk slowly toward corners of halls. R1's Progress Note (dated 11/02/24) documents the following: This resident was struck by another resident twice in the forehead after apparently tripping over him and taking both to the floor in the hallway of G-Hall. Full body assessment reveals no signs or symptoms of injury at this time. Resident placed on head protocol. (V6, Medical Director) and (V1, Administrator) notified and family notification pending. On 03/26/25 at 11:40 AM, V2 (Director of Nursing) stated she obtained a statement from V14 (Registered Nurse), who was the individual that responded to the 11/02/24 altercation between R1 and R9. V14's statement, which was documented by V2 and included in the facility's incident investigation, documents the following: (V2) Spoke with (V14)- he stated that (R1) was walking up the hall on G Hall, when he tripped and fell into (R9). (R9) then struck (R1) before (V14) could get to them. (R1) was struck in the head two times. On 03/26/25 at 09:00 AM, V1 (Administrator) confirmed R9 physically abused R1 on 11/02/24. V1 stated R9 is no longer residing at the facility because he refused to return to the facility after he was sent to a local hospital for evaluation following an incident that occurred on 11/18/24. 3. The facility's Incident Investigation Report (dated 11/10/24) documents the following: On 11/10/24 at 02:10 PM, in the main dining room, (R1) was pushing (R3's) wheelchair which upset him (R3). (R1) didn't understand (R3) wanted his chair back. (R3) hit (R1) in the face with a closed fist. Staff immediately separated and counseled the residents. This same investigation documents the following Action Plan: To prevent further abuse, (R3) was reminded to resolve conflict and that physical aggression can hurt himself and others. Staff reminded to redirect (R1) when noticing he has something of a peers. R1's Progress Note (dated 11/10/24 and timed 02:23 PM) documents, Resident was noted pushing a wheelchair around facility. Resident peer noticed that it was his wheelchair and wanted it back. An argument ensued and then this resident was hit several times in the face with a closed hand. R1's Progress Note (dated 11/10/24 and timed 09:45 PM) documents, Resident continues to wander and needs frequent redirection from entering peers' rooms. He becomes agitated with staff during redirection and starts pushing staff and attempts to strike staff. He refuses to go to bed at night and when he does go to bed, he only stays in the bed a short time and gets back up wandering again. He remains on H.P. (head protocol) with no s/s (signs and symptoms) neurological deficits. On 03/18/25 at 02:40 PM, V4 (Certified Nursing Assistant) stated the following in regards to the 11/10/24 incident involving R1 and R3: I remember (R1) was pushing a wheelchair and we had taken it away from him. He wandered and found another wheelchair. We had seen him pushing it and wondered whose wheelchair it was. Then I heard some commotion and (R3) was hitting (R1). I ran to break it up. (R3) had punched (R1) in the face at least three times before I had got to them. On 03/19/25 at 01:45 PM, R3 was seated on his wheeled walker against the back wall in the dining room. R3 was dressed, groomed, and was drinking a can of soda, and stated he purchased the soda from the vending machine. R3 stated he has had, Some disputes with a few (residents), in the past, but that ain't no big deal now. On 03/18/25 at 02:05 PM, V1 (Administrator) confirmed that (R3) physically abused (R1) on 11/10/24. 4. The facility's Incident Investigation Report (dated 11/12/24) documents the following: On 11/12/24 at 09:15 AM in the main dining room, (R5) went behind (R6's) wheelchair, grabbed the handlebars and tipped (R6's) chair backwards causing (R6) to fall. (R6) did not hit her head and she got up on her own. No injuries noted. Both residents were 'talking nonsense' per witnesses. Staff separated and monitored the two women. This same investigation documents the following Action Plan: To prevent further abuse, staff were educated to monitor (R5) and (R6) in common areas and redirect them from one another/other peers who may trigger them. R5's Progress Note (dated 11/12/24) documents the following: Per witness resident (R16), (R5) was yelling/arguing with staff and female peer (R6). This resident (R5) noted to ambulate over to (R6), grabbed handles of wheelchair causing foot to base of wheelchair tilting wheelchair causing peer (R6) to fall from wheelchair. Both residents continue to argue as staff separated. Resident (R5) refuses to have vital signs done and full assessment. No apparent injuries noted. No complaints voiced. (V6, Medical Director), administrative staff notified. On 03/20/25 at 01:20 PM, R16 was sitting in his wheelchair near the window in the dining room. R16 was moving chess pieces around on a chess board, and recalls witnessing the 11/12/24 altercation that occurred between R5 and R6. R16 stated, They sit at different tables in the dining room, but they began arguing. (R5) got up and walked over to (R6). R16 then motioned his hands mimicking gripping an object, pulled his hands back toward his chest and explained as he mimicked R5 grabbing R6's wheelchair and tipping R6 wheelchair over backwards while R6 was sitting in it. R5's current medical record documents R5's diagnoses to include Major Depressive Disorder, Frontotemporal Neurocognitive Disorder, and Schizoaffective Disorder. On 03/20/25 at 02:25 PM, R5 was lying in bed with the hood of her shirt covering her head. R5 was mumbling incomprehensible phrases when greeted by this surveyor, and eventually stated, Get out. You need to get the hell out of here. R5 was not interviewed due to refusal. R6's current medical record documents R6's diagnoses to include Schizoaffective Disorder Bipolar Type, and Post Traumatic Stress Disorder. On 03/20/25 at 01:05 PM, R6 was propelling her wheelchair toward the vending machines in the dining room. When this surveyor approached and attempted to speak to R6, R6 began waving her left hand in the air above her, refused to speak with this surveyor and yelled the following nonsensical phrase: Nope! One went to heaven, and one went to hell, and I don't really care about any of it. On 03/20/25 at 12:40 PM, V1 (Administrator) confirmed R5 physically abused R6 on 11/12/24 when R5 deliberately tipped R6's wheelchair causing R6 to fall. 5. The facility's Incident Investigation Report (dated 11/13/24) documents the following: On 11/13/24 at 12:10 PM in the main dining room, (R8) was rolling up to a dining room table when (R7) started backing into her wheelchair. (R8) grabbed (R7's) arm and bit her. Redness was noted and ice was applied. Residents were separated to different tables and (R8) was counseled. (R8) has a diagnosis of Dementia and was confused as to what (R7) was doing. This same investigation documents the following Action Plan: Care Plan updated. To prevent further abuse, staff to intervene and assist (R8) proactively to address her needs (i.e. assist her to dining table). R7's Progress Note (dated 11/13/24) documents the following: (R7) noted arguing with peer (R8) over seating in dining room. Peer (R8) was pulling on (R7's) right arm and proceeded to pull her hair and bite her right forearm. Residents were separated and placed at different tables. Ice applied to (R7's) forearm. POA (Power of Attorney) contacted with no answer, left voicemail. Notified (V6, Medical Director) of incident. V11's written statement (dated 11/13/24) documents, Observed residents in dining room having an altercation. (R8) was pulling on the right forearm of (R7) and proceeded to bite her right forearm. (R7) was observed trying to pull arm back from (R8). This RN (Registered Nurse) did a head-to-toe assessment on both residents, separated them at dining tables. RN (Registered Nurse) placed ice on (R7) and received order for PRN (as needed) ice pack to site. V11 was not able to be interviewed due to currently being out of state on vacation. On 03/24/25 at 09:25 AM, R7 was sitting in her wheelchair at a table in the dining room with her eyes closed. R7 was dressed and several food particles and crumbs were covering her lap. R7 was confused and could not recall the 11/13/24 incident when she was bitten by (R8). On 03/24/25 at 08:55 AM, V2 (Director of Nursing) stated R8 is currently not in the facility. V2 stated R8 was admitted to the local hospital, and was discharged from the facility because, She was sent to (sister facility) for physical therapy. She has since been sent back to the hospital due to pulling out her PICC (peripherally inserted central catheter) line. I believe she pulled it out on Friday. On 03/24/25 at 08:45 AM, V1 (Administrator) stated, If I recall, (R8) didn't like (R7) at her table. The two began arguing, and (R8) pulled (R7's) hair and bit her. 6. The facility's Incident Investigation Report (dated 11/18/24) documents the following: On 11/18/24 at 11:45 AM in the Main Dining Room, (R9) was walking through and hit (R1) in the face with a closed fist which caused him to fall to the ground. No initial injuries were noted. Incident was unprovoked. Non-emergency police were called and consulted with psychiatrist. (R1) went to the hospital for evaluation; (R9) went to (local hospital) for psychiatric evaluation. This same investigation documents the following Action Plan: (R1) returned with no injuries and was placed on 1:1 monitoring for 72 hours. (R9) refused to return to the facility from the hospital and was discharged . R1's Progress Note (dated 11/18/24) documents the following: (R1) was walking past (R9), (R9) turned and punched (R1) in face, staff immediately separated residents, full body assessment implemented, assisted into a chair, vitals obtained, (R1) complains of jaw pain, (V6, Medical Director) notified. (R1) sent to (local hospital) for evaluation and treatment, bed hold policy sent with resident, Power of Attorney notified, and writer received no answer, message left on voicemail. On 03/24/25 at 11:15 AM, V9 (Front Desk) stated he vaguely recalls the incident that occurred between R1 and R9 over four months ago on 11/18/24. V9 verified his witness statement included in R1 and R9's 11/18/24 Incident Investigation and stated the following, A lot of time has passed since then. I believe (R9) was sitting at a table, and when (R1) walked by, (R9) suddenly got and punched him in the face pretty hard. I started heading toward them when I saw (R9) stand up, and got there to catch (R1) and assist him to the floor. On 03/24/25 at 11:35 AM, V1 (Administrator) confirmed R9 physically abused R1 on 11/18/24. V1 stated, We sent (R1) to the hospital to get checked out because he was hit very hard in the face. The (local police) came and spoke with (R9) and gave him the option to go to the hospital, or they would be taking him to jail. (R9) agreed to go to the hospital and when he was ready to be discharged , he refused to return to the facility. (R9) was his own POA (Power of Attorney). We notified (V6, Medical Director) who gave the okay for (R9) not to return. 7. The facility's Incident Investigation Report (dated 12/01/24) documents the following: On 12/01/24 at 02:02 PM in the main dining room, (R2) and (R1) were by the vending machines. (R2) was passing by (R1) and they began yelling at each other. (R1) hit the top of (R2's) head with a cup he was carrying. (R2) had a small laceration to his head. (V6, Medical Director), (V1, Administrator), responsible parties notified. (R2) was sent to the emergency room for evaluation. Returned with triple antibiotic ointment and a band-aid. On 03/18/25 at 02:20 PM, R15 stated he witnessed the incident between R1 and R2 on 12/01/24. R15 stated he recalls observing (R1) strike (R2) with a cup, but cannot recall much more, That was a long time ago. (R1) wanders around and does go into people's rooms. (R2) yells a lot. Due to R1's impaired cognition, he was unable to be interviewed about the 12/01/24 incident that occurred with R2. R2's Progress Note (dated 12/01/24 and timed 02:05 PM) documents the following: (R2) hit on the head with a cup by (R1) at the vending machine, (R2) sustained a little cut on the head that measures 0.5 centimeters by 0.2 centimeters with minimal bleeding. Area cleaned. Power of Attorney notified. (R2) placed on Head Protocol monitoring. Vitals as follows T (temperature) 97.6, (pulse) 78, R (respirations) 18, B/P (blood pressure) 140/81, SPO2 (pulse oximetry) 98. (V6, Medical Director) notified; order received to send (R2) to (local emergency department). (Emergency transport) here and resident taken to (local hospital). R2's Progress Note (dated 12/01/24 and timed 06:58 PM) documents the following: Resident returned from (local emergency department) with Triple Antibiotic Ointment and band-aid on the wound (abrasion), no new orders. Power of Attorney notified of his arrival. Will continue to monitor. On 03/19/25 at 01:35 PM, the door to R2's room was open approximately 6 inches. R2 was lying in a low bed with a fall mat in place and a bedside table positioned near the side of his bed. R2 was partially covered with a sheet, and was wearing a gown and an incontinence brief. An indwelling urinary catheter drainage bag was positioned inside of a dignity bag secured to the lower aspect of R2's bed. R2's call light was clipped on his bedding and within his reach. This surveyor knocked on R2's door and introduced herself. R2 became visibly upset and yelled, What are you doing? What do you want from me? R2 was not able to be interviewed regarding the 12/01/24 incident due to R2 becoming visibly upset upon greeting. On 03/18/25 at 02:30 PM, V1 (Administrator) confirmed that R1 physically abused R2 on 12/01/24 and stated, It happened. V1 then stated that staff were re-educated to remove objects from (R1) if he is carrying things in the facility, He has a tendency to take things of others that do not belong to him, and if staff see him carrying an item such as a cup, they should be intervening. 8. The facility's Incident Investigation Report (dated 12/05/24) documents the following: On 12/05/24 at 08:31 AM, (R2) was noted with bruising to his left eye. Upon investigation, (R10) admitted to hitting (R2) overnight. (R10) was receptive to counseling and requested a room move. (V6, Medical Director), (V1, Administrator) and responsible parties notified. Head protocol was initiated for (R2). This same investigation documents the following Action Plan: Care Plan updated for (R10) to seek out staff for help when bothered by peers/upset. Staff reminded to monitor (R2) if yelling at night to ensure safety and prevent abuse. On 03/19/25 at 03:35 PM, V5 (Certified Nursing Assistant) stated the following regarding the 12/05/24 incident involving R2 and R10: I had worked second shift on 12/04/24, and had put (R2) to bed. I worked day shift the following morning of 12/05/25, and when I went into (R2's) room to get him up for the day, I noticed (R2) had a black eye that he did not have when I put him to bed the night before. I reported it to (V1, Administrator). (R2) didn't say what happened when I asked him about his black eye. I talked to (R10), who had a shared bathroom with (R2) at that time. At first, (R10) tried to tell me he didn't know what happened to (R2), but then (R10) told me he went through the bathroom into (R2's) room during the night and punched (R2) because (R2) wouldn't stop hollering. R2's Progress Note (dated 12/05/24) documents the following: Resident (R2) noted with bruising to left eye (purplish). (R2) unable to fully recall how bruising occurred. Vital signs: blood pressure 134/78, temperature 98.2, 78 pulse, 20 respirations. Perl (Pupils equal and reactive to light) and no signs or symptoms of neurological deficits and no complaints voiced. No other apparent injures noted. Head protocol initiated. All appropriate parties notified. R10's Minimum data Set Assessment (dated 01/28/25) documents a Brief Interview of Mental Status score of 14, indicating R10 is cognitively intact. On 03/24/25, R10 declined to be interviewed. On 03/24/25 at 03:30 PM, V1 (Administrator) stated R10 physically abused R2 sometime between the night of 12/04/24 and morning of 12/05/25 when R10 entered R2's room through the shared bathroom. V1 then stated R10 admitted to punching R2 because R2 was yelling for an extended period of time. 9. The facility's Incident Investigation Report (dated 12/20/24) documents, On 12/20/24 in the South Main Dining Room, (R11) hit (R12) with a closed fist to the mouth, causing her lip to bleed. (R12) was (repeatedly) running her wheelchair into the table at dinner which bothered (R11). Staff intervened and separated the residents. (R11) calmed with counseling. This same investigation documents the following Action Plan: Care Plans updated for staff to assist (R12) into a regular chair during meal service. Staff re-educated and (R11) received counseling about aggressive behaviors. R11's Progress Note (dated 12/20/24) documents the following: (R11) was reported by staff that he hit (R12). When asked, he answered, I hit her with my right fist. (R12) kept coming back to (R11's) table while he was still eating his meal. Plan of care to place (R12) on a chair while other residents are still eating. (R11) and other residents will be away from being bothered by (R12) while eating. On 03/25/25 at 10:30 AM, V1 stated V10 (Registered Nurse), who witnessed the 12/20/24 incident between R11 and R12, is currently out of the country on vacation and will not be able to be reached for interview. V10's written witness statement (dated 12/20/24), which was included in the 12/20/24 Incident Investigation, documents the following: This nurse was alerted that (R12) was hit by (R11). When asked, (R11) stated, 'Yes I hit her.' (R12) was removed from (R11's) table. Prior to that this nurse was getting the medication of other residents to pass. (R12) was done with her dinner and she kept doing it (banging into R12's dining table with her wheelchair) where staff were redirecting her. She was hit on her lower lip that caused it to bleed. (R12) was removed away from (R11) and applied ice pack on her lower lip. (V2, Director of Nursing), (V1, Administrator), and (V6, Medical Director) notified. (R12) was seated on the chair. Power of Attorney notified. R11's Minimum Data Set Assessment (dated 02/11/25) documents a Brief Interview of Mental Status score of 15, indicating R11 is cognitively intact. On 03/25/25 at 12:40 PM, R11 was lying in bed covered with a blanket. R11's glasses and his call light were within his reach on a nearby bedside table. An indwelling urinary catheter drainage bag was secured to the lower aspect of R11's bed. R11 stated he recalls the 12/20/24 incident that occurred with R12. R11 stated, (R12) was banging on the tables (with her wheelchair) and was trying to run into people. She almost knocked two people over. I finally had enough and told her to knock her sh#t off. R11 lifted his right hand and made a fist, and then explained he did strike R12 in the face on 12/20/24 and stated, I'd had enough so I popped her in the mouth. I haven't had any issues since then, but she still bumps the tables. She knows exactly what she's doing. The staff come and take care of it when she is doing it. R12's Minimum Data Set Assessment (dated 03/04/25) documents a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. On 03/25/25 at 01:00 PM, R12 was sitting in her wheelchair alone at a table in the dining room. The arms of R12's wheelchair were padded, and R12 had bilateral forearm sleeves in place. R12 had her head placed down on the table. R12 raised her head upon greeting. R12 was able to answer a few simple yes/no questions, but then began verbalizing nonsensical words. R12 then began repeatedly moving her wheelchair back and forth striking the dining table she was seated at. R12's Progress Note (dated 12/20/24) documents, At 06:25 PM while in the dining area, (R12) was hit by (R11) on her lower lip that caused it to bleed. She kept hitting (R11's) table while he was eating. She was redirected many times and kept away from resident's table. When asked, (R11) he answered, 'I hit her with my right fist.' They were separated right away by staff. Head to toe assessment done. (V6, Medical Director), (V2, Director of Nursing), (V1, Administrator) notified. R12's Power of Attorney was notified too. V6 advised ice pack PRN (as needed), Tylenol PRN and neuro (neurological) checks. Care plan was updated to place (R12) on a chair during mealtime. Placed her on a one on one after she was back in her wheelchair when all residents are done with their meals. On 03/25/25 at 10:25 AM, V1 (Administrator) verified R11 struck R12 in the face on 12/20/24. V1 stated, (R12) has a history of repeatedly running her wheelchair into things. On 12/20/24, she was repeatedly running her wheelchair into the dining table where they (R11 and R12) were sitting. This upset (R11), and he hit (R12). We now transfer (R12) into a regular chair for meals. 10. The facility's Incident Investigation Report (dated 02/13/25) documents the following: On 02/13/25 at 11:00 AM in the North Dining Room, (R14) was yelling for a staff member as the staff member was exiting the bathroom. Before the staff member could get to (R14), (R13) approached (R14) and hit him in the face two times with a closed fist. Staff immediately intervened and separated the pair. Counseling provided. No injuries noted. This same investigation documents the following Action Plan: (R13) received counseling and care plan updated for (R13) to have patience with others' behaviors and allow staff to intervene without becoming aggressive. (R14) was reminded that yelling can bother peers and cause conflict. On 03/25/25 at 03:00 PM, V12 (Certified Nursing Assistant) stated she witnessed the 02/13/25 incident between R13 and R14. V12 verified her written statement included with the facility's Incident Investigation, and then stated the following: I ran to use the bathroom real quick. (R14) was yelling my name, which he frequently does when he sees me. One of his behaviors is yelling out. When I exited the bathroom, I could still hear (R14) yelling my name. As I was approaching, I saw (R13) propelling his wheelchair toward (R14), and before I had reached them, (R13) punched (R14) twice in the face pretty hard with a closed fist. (R13 and R14) were immediately separated. R13's Progress Notes (dated 02/13/25) documents the following: CNA (Certified Nursing Assistant) came to this nurse stating that (R13) and another resident (R14) got into a physical altercation. CNA stated that (R13) rolled up in his wheelchair on peer resident (R14) and proceeded to hit peer resident in his jaw two times with a closed fist. (R13) stated he hit (R14) in the face because he was yelling. Residents were moved to different parts of the dining room. Residents were reeducated on knowing how to avoid conflict with peer residents that share the same living environment. On 03/26/25 at 09:55 AM, R13 was sitting in a high-back wheelchair on the smoking patio smoking a cigarette. R13 was wearing a coat and stocking hat, and a full mechanical lift sling was in place underneath of him. R13 stated he has lived at the facility for [AGE] years, and gets along with 'most' residents. R13 stated he punched R14 in the face on 02/13/25 and added, (R14) is one I don't like. He's a pedophile, and I came unglued that day. R14's Minimum Data Set Assessment (dated 03/10/25) documents a Brief Interview of Mental Status score of 15, indicating R14 is cognitively intact. R14's Progress Note (dated 02/13/25) documents the following: CNA (Certified Nursing Assistant) came to this nurse stating that (R14) and another resident (R13) got into a physical altercation. CNA stated that peer resident (R13) rolled up in his wheelchair on (R14) and proceeded to hit (R14) in his jaw two times with a closed fist. Peer resident (R13) stated he hit (R14) in the face because (R14) was yelling. Residents were moved to different parts of the dining room. Residents were reeducated on knowing how to avoid conflict with peer residents that share the same living environment. On 03/26/25 at 09:40 AM, R14 was lying in bed watching television. R14's call light was within his reach, and R14 was sparsely covered with a blanket. R14 stated he recalls the 02/13/25 incident that occurred with R13 and stated, (R13) hit me in the jaw. Sometimes he be acting crazy. I was ok, and we haven't had problems since. On 03/25/25 at 03:15 PM, V1 (Administrator) confirmed R13 struck R14 in the face with a closed fist on 02/13/25. V1 stated, (R14) is one that yells out, and it can upset his peers. 11. The facility's Incident Investigation Report (dated 02/25/25) documents the following: On 02/25/25 at 06:55 PM in the dining room after dinner, (R5) grabbed the wheelchair handle bars behind (R6) and pulled her to the floor. Staff immediately intervened and separated the women. (R5) said that (R6) said something to her. Residents were redirected without further incident. (R6) sustained no injuries. This same report documents the following Action Plan: Residents were redirected to separate areas of the building and CNAs (Certified Nursing Assistants) on halls were instructed to monitor/keep them separate. No further issues occurred. R5's Progress Note (dated 02/25/25) documents the following: This resident (R5) was talked to negatively and confronted by a peer resident (R6) which caused her (R5) to tilt peer's wheelchair backwards, leaving it propped on the handles. Resident (R5) assisted to room for de-escalation. (V6, Medical Director) notified, guardian notified. No further action required. R6's Progress Note (dated 02/25/25) documents the following: Resident (R6) was talking negatively and being confrontational to another resident peer (R5). Resident (R5) then proceeded to tilt (R6's) wheelchair backwards, causing her chair to land on the handles propping the resident (in her wheelchair) upwards. (R6) never hit the floor no apparent injuries noted, full body assessment done. (V6, Medical Director) notified, guardian notified, no other concerns at this time. On 02/25/25 at 03:30 PM, V13 (Certified Nursing Assistant) stated she witnessed the 02/25/25 altercation that occurred between (R5) and (R6). V13 stated, (R5) got up from the table quickly, approached (R6), grabbed the handlebars to (R6's) wheelchair and pulled it backwards until the handlebars landed on the ground. (V6) did not hit her head. I believe (R5) was upset because of something (R6) said to her. On 03/27/25 at 09:15 AM, V1 (Administrator) verified R5 became upset and proceeded to tip R6's wheelchair backwards causing R6 to fall after R6 had verbalized something that upset R5.

Based on interview, observation and record review, the facility failed to implement behavioral interventions to prevent episodes of physical abuse for seven residents (R1, R4, R5, R6, R9, R11 and R12) reviewed for abuse in the sample of 16. Findings include: The facility's Abuse Prevention Program Facility Procedures policy (updated 06/03/24) documents the following: As part of the resident social history evaluation and Minimum Data Set assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. The facility's Behavior Monitoring policy (updated 06/05/24) documents the following: At any time the IDT (Interdisciplinary Team) may initiate resident checks for increased monitoring, either on an hourly, 15 minute or one-to one staff basis. This same policy documents, 'IDT will review residents on an increased monitoring and may discontinue checks at any time if they determine the monitoring is no longer necessary. This policy also documents, If a resident displays an increase in behavioral disturbances, his/her treatment plan will be reviewed and modified by the interdisciplinary team as needed. Any identified resident may be referred to the Psychiatrist for a medication efficacy review and adjustment as indicated. 1. R4's medical record documents R4's diagnoses to include: Anxiety Disorder, Delusional Disorder, and Disorientation. R4's Progress Note (dated 10/28/24) documents the following: (R4) noted in dining room. Approached female peer grabbed/placed hands to jawline of female peer in attempt to kiss peer then bit her on the left cheek. Both residents immediately separated. No injuries noted. Resident counseled regarding behavior. Family, administration and (V6, Medical Director) notified. R4's Progress Note (dated 10/28/24) documents the following: (R4) noted with increased mood swings with behavioral deficits. Attempted to hit a male peer with no provocation. (R4) counseled and begin to further become irate, expressing delusional comments related to events that are happening now. (R4) counseled by male staff member (R4) then expressed feeling of needing more medication. (Local mental health provider) here for weekly rounds and recommended to evaluate medication therapy for increased behaviors. R4's Progress Note (dated 10/28/24) documents the following: Assessed by (local mental health provider) today. New orders received to increase Seroquel (antipsychotic) to 100 milligrams by mouth every bedtime and start Seroquel 75 milligrams by mouth every morning, Depakote level in AM (morning). R4's Progress Note (dated 10/28/24) documents the following: (R4) was very agitated and was in a verbal altercation with a peer during breakfast approximately 08:45 AM this morning. (R4) was asked to calm down, (R4) abruptly left the dining room for approximately 10 minutes and returned still angry with the peer. R4's Progress Note (dated 10/29/24) documents the following: Summoned to hall per staff. (R4) noted in doorway of room having a physical altercation with another male resident (R1). Both parties immediately separated. (R4) refused vital signs and full body assessment. Per observation no physical injuries noted. No complaints voiced. (R4) counseled per psychiatric social department. Family, administrative staff and (V6, Medical Director) notified. The facility's Incident Investigation Report (dated 10/29/24) documents the following: On 10/29/24 at 09:10 AM on H Hall, (R4) and (R1) were physically aggressive toward one another, hitting each other with closed fists. Residents were separated and counseled. No injuries were noted, (R4) was sent to the hospital for a psychiatric evaluation, and he was asking to go stating he wasn't feeling well. (R4) thought (R1) was going to hurt him so he hit (R1) first. Police involved in transport. This same investigation documents the following Action Plan: Care Plans updated and staff reminded to use hands-on assistance to redirect (R1) from peer's rooms. (R4) reassured and reminded of alternate ways to handle situations. R4's current Care Plan documents the following focus: (R4) has a criminal background with charges of Aggravated Battery in 1994, Carry and Possess Firearm & Battery and Assault in 1985. (R4) may become physically aggressive with peers at times. This same care plan documents the following interventions were in place at the time of R4's altercation with R1 on 10/29/24: Encourage (R4) to participate in activities to increase positive peer interaction; Explain to (R4) the legal consequences of any new incidents of his previous offense; If staff notice (R4) in close proximity to a peer, staff to redirect and reassure his actions will not turn to physical aggression; Refer (R4) for Psychiatric consult as needed for increased agitation or aggression; Staff to intervene proactively when (R4) is becoming agitated with staff or peers to assist, reassure and redirect. R1's Current Care Plan documents the following focus: (R1) wanders throughout the facility, up and down halls and in common areas. (R1) may enter one of his peers' rooms without knowing due to Alzheimer's Disease. (R1) may pick up/mess with peers' belongings. This same care plan documents the following intervention was in place at the time of R1 and R4's 10/29/24 altercation: Staff will assist (R1) in maintaining appropriate boundaries between himself and peers/redirect from peers' rooms. On 03/20/25 at 08:40 AM, V1 (Administrator) stated that R1 and R4 had a physical altercation on 10/29/24. V1 confirmed R4 was never placed on 15-minute checks and stated, We can implement 15-minute checks or 1:1 monitoring with an increase in behaviors, and (R4) was having an increase in behaviors at that time. Looking back, we probably should have put him on 15-minute checks before the altercation with (R1) occurred, and staff should have redirected (R1) away from the doorway of (R4's) room. 2. R5's current medical record documents R5's diagnoses to include: Major Depressive Disorder, Frontotemporal Neurocognitive Disorder, and Schizoaffective Disorder. The facility's Incident Investigation Report (dated 11/12/24) documents the following: On 11/12/24 at 09:15 AM in the main dining room, (R5) went behind (R6's) wheelchair, grabbed the handlebars and tipped (R6's) chair backwards causing (R6) to fall. (R6) did not hit her head and she got up on her own. No injuries noted. Both residents were 'talking nonsense' per witnesses. Staff separated and monitored the two women. This same investigation documents the following Action Plan: To prevent further abuse, staff were educated to monitor (R5) and (R6) in common areas and redirect them from one another/other peers who may trigger them. R5's current care plan documents the following focus: (R5) has daily behaviors of yelling out in her room and common areas due to hallucinations related to Schizoaffective Disorder. (R5) may be physically aggressive at times. She can be resistive to redirection and refuses any medical intervention. This same care plan documents the following intervention was implemented on 11/12/24: Staff to monitor (R5) in common areas and redirect her from other residents whose behaviors may trigger her. R6's current Care Plan documents the following: (R6) experiences auditory hallucinations and has delusions that she is dead. (R6's) delusional comments may negatively impact others at times. This same care plan documents the following intervention was implemented on 11/12/24: Staff to monitor (R6) in common areas and redirect her from other residents whose behaviors may be triggered. The facility's Incident Investigation Report (dated 02/25/25) documents the following: On 02/25/25 at 06:55 PM in the Dining Room after dinner, (R5) grabbed the wheelchair handlebars behind (R6) and pulled her to the floor. Staff immediately intervened and separated the women. (R5) said that (R6) said something to her. Residents were redirected without further incident. (R6) sustained no injuries. This same report documents the following Action Plan: Residents were redirected to separate areas of the building and CNAs (Certified Nursing Assistants) on halls were instructed to monitor/keep them separate. No further issues occurred. On 03/27/25 at 09:15 AM, V1 (Administrator) stated that on 02/25/25, R5 became upset and proceeded to tip R6's wheelchair backwards causing R6 to fall after R6 had verbalized something that upset R5. V1 stated this is the second occurrence in which R5 has grabbed and tipped R6's wheelchair over in the dining room, and staff should be monitoring R5 and R6 closely when they are within close proximity of each other. 3. The facility's Incident Investigation Report (dated 11/02/24) documents the following: On 11/02/24 at 12:50 AM on G Hall, (R1) and (R9) ran into one another causing both to fall to the floor. (R9) then hit (R1) in the forehead twice with a closed fist. Residents were separated and staff assessed for injuries- none noted. When nurse expressed to (R9) that the collision was an accident, (R9) apologized to (R1). This same investigation documents the following Action Plan: Staff reminded to redirect (R1) from other halls and intervene proactively. (R9's) care plan updated and staff re-educated to intervene early if agitated- remind him to walk slowly toward corners of halls. R1's Current Care Plan documents the following focus: (R1) wanders throughout the facility, up and down halls and in common areas. (R1) may enter one of his peers' rooms without knowing due to Alzheimer's Disease. (R1) may pick up/mess with peers' belongings. This same care plan documents the following intervention is currently in place: Staff to redirect (R1) from other halls and escort him to his room as needed. R9's most recent Care Plan documents the following focus initiated on 06/21/23: (R9) has a diagnosis of Paranoid Schizophrenia and Major Depressive Disorder. (R9) has been observed to make delusional statements and respond to auditory hallucinations. He may be physically aggressive related to his paranoia. This same care plan documents the following interventions were in place at the time of R9's altercation with R1 on 11/02/24: (R9) has specific peers who trigger his delusional thought process. Staff to proactively intervene to prevent altercations; Encourage (R9) to vent his feelings when he feels uncertain or upset for any reason at any given moment; Observe (R9) to find what may trigger hallucinations/delusions to eliminate behaviors; Remind (R9) of potential legal consequences of physical aggression toward peers; Remind (R9) to get staff if peers are in his space/bothering him; Staff to intervene proactively if noticing (R9) is agitated by peers that may trigger aggression; Staff to provide 1:1 counseling to reassure paranoid thoughts. On 03/26/25 at 09:00 AM, V1 (Administrator) confirmed R9 physically stuck R1 in the face on 11/02/24. V1 stated at the time the 11/02/24 incident occurred, R1 was ambulating in a hall in which he did not reside, and staff should have redirected R1 out of the hall he was wandering in at that time. 4. The facility's Incident Investigation Report (dated 12/20/24) documents, On 12/20/24 in the South main Dining Room, (R11) hit (R12) with a closed fist to the mouth, causing her lip to bleed. (R12) was (repeatedly) running her wheelchair into the table at dinner which bothered (R11). Staff intervened and separated the residents. (R11) calmed with counseling. This same investigation documents the following Action Plan: Care Plans updated for staff to assist (R12) into a regular chair during meal service. Staff re-educated and (R11) received counseling about aggressive behaviors. R11's current Care Plan documents the following focus: (R11) has potential to be physically aggressive and may be easily agitated by peers. This same care plan documents the following intervention was in place at the time of the 12/20/24 incident that occurred between R11 and R12: 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. On 03/25/25 at 12:40 PM, R11 was lying in bed covered with a blanket. R11's glasses and his call light were within his reach on a nearby bedside table. An indwelling urinary catheter drainage bag was secured to the lower aspect of R11's bed. R11 stated he recalls the 12/20/24 incident that occurred with R12. R11 stated, (R12) was banging on the tables and was trying to run into people. She almost knocked two people over. I finally had enough and told her to knock her sh#t off. R11 lifted his right hand and made a fist, and then explained he did strike R12 in the face on 12/20/24 and stated, I'd had enough so I popped her in the mouth. I haven't had any issues since then, but she still bumps the tables. She knows exactly what she's doing. The staff come and take care of it when she is doing it. R12's current Care Plan documents the following focus: (R12) displays attention seeking behavior by running her wheelchair into staff, peers, and objects. This same care plan documents the following intervention in place (initiated 06/25/23): Staff will redirect (R12) when she is displaying behaviors of running her wheelchair into doors, walls, staff and her peers. On 03/25/25 at 01:00 PM, R12 was sitting alone in her wheelchair at a table in the dining room. The arms of R12's wheelchair were padded, and R12 had bilateral forearm sleeves in place. R12 had her head placed down on the table. R12 raised her head upon greeting. R12 was able to answer a few simple yes/no questions, but then began verbalizing nonsensical words and began repeatedly moving her wheelchair back and forth striking the dining table she was seated at. On 03/25/25 at 10:25 AM, V1 (Administrator) verified R11 struck R12 in the face on 12/20/24. V1 stated, (R12) has a history of repeatedly running her wheelchair into things. On 12/20/24, she was repeatedly running her wheelchair into the dining table where they (R11 and R12) were sitting. This upset (R11), and he hit (R12). We now transfer (R12) into a regular chair for meals. Staff was re-educated to intervene when (R11) becomes agitated with a peer, and to redirect (R12) when she is displaying behaviors of running her wheelchair into objects that disrupt her peers.

Based on interview and record review, the facility failed to ensure resident to resident physical abuse did not occur for two residents (R2, R3) reviewed for abuse in a sample of four. This failure resulted in R2 being transported to the Emergency Department; and R2 sustaining a nasal fracture. Findings include: R2's diagnoses include Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Bipolar Disorder, Major Depressive Disorder. R2's Minimum Data Set/MDS assessment dated [DATE] documents R2 as cognitively intact. R2's current Care Plan documents, (R2) has had verbal aggression that has escalated to physical threats of aggression towards staff and peers. R3's diagnoses include Schizoaffective Disorder Bipolar Type. R3's Minimum Data Set/MDS dated [DATE] documents R3 as cognitively intact. R3's current Care Plan documents: (R3) may be physically aggressive with peers at times. The facility's Initial and Final Reports to (State Agency) for R2 and R3 document, Incident Description: On 11/8/24, (R2 and R3) were noted on the ground on the outside patio engaged in a physical altercation with one another. (R2) sustained injuries to his hand, nose, and back of head. (R3) had no visible injuries. The facility's Information Report Dated 11/8/24 documents V6 Certified Nursing Assistant/CNA stated that R8 said fight and she ran out to the patio. V6 stated that R3 was on top of R2 hitting R2 in the face with a closed fist; and V6 stated that she got R3 up. V6 then stated that she did not know what started the fight. The facility's Information Report Dated 11/8/24 also documents, (V2 Assistant Director of Nursing/ADON) was alerted to the facility's South smoking patio by the staff; and once outside, (R2) was noted on his hands and knees calling for help. R2 was assisted up by staff and (V2) assessed (R2) and noted a 0.5 centimeter/cm laceration across the bridge of (R2's) nose and a 1.0 cm laceration to the back/center of his head. Orders were given for (R2) to be sent to the hospital for further evaluation. Police were contacted and gave (R3) a choice of going to jail or the hospital. (R3) was resistive to both, so the police took him to jail. The facility's Information Report Dated 11/8/24 documents: (R2) said (R3) pushed (R2) and just started hitting (R2) to the ground. (R2) didn't know why. R2's Hospital Notes Dated 11/8/24 documents: Diagnoses, Closed fracture of nasal bone, initial encounter; Assault. On 11/26/24 at 2:05pm, R2 stated that he was sent to the Emergency Department at the local hospital after the 11/8/24 incident with R3 and arrived back at the facility the same day. R2 stated that the hospital staff said he had a broken nose, and it still hurts. At this same time, R2 stated: He's (R3) a troublemaker; I am glad he's gone. On 11/27/24 at 10:30am, V6 Certified Nursing Assistant/CNA stated that on 11/8/24 she was sitting at the nursing station; stated that (R8) was near the patio door and shouted fight. V6 stated that R2 and R3 were on the ground in a physical altercation. V6 stated V6 immediately went to intervene between R2 and R3, separating the two residents. On 11/27/24 at 9:55am, V1 Administrator verified the physical altercation on 11/8/24 between R2 and R3. V1 stated the local police were notified and R3 was arrested. The Facility's Abuse Prevention Program Policy Dated 6/3/24, documents: This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians., friends, or any other individuals. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Based on observation, interview and record review, the facility failed to ensure use of a safe sanitation solution, record sanitation solution checks, ensure kitchen trash bins were kept away from food preparation areas and covered, maintain clean floors in the kitchen, and ensure the ice machine scoop was handled and stored appropriately to avoid cross contamination in the facility's kitchen. This failure has the potential to affect all 115 residents living in the facility. Findings include: The facility's Sanitation Checks, dated October 2024, documents Take the designated bleach bucket and fill with luke warm water (70 degrees). Using dispenser add bleach water and mix. Test solution if it is not 100 ppm (parts per million), add more bleach, mix and test. Record results and initial. Procedures are to be done at least prior to the start of each meal. Buckets are changed more often if needed. On 10/15/24 at 10:00 AM, V9 (Dietary Manager) confirmed the facility's sanitizing bucket is used to wipe food preparation surfaces in the kitchen and the solution should be at least 100 ppm but not higher than 200 ppm. V9 then took a solution test strip and tested the sanitizing bucket solution and result was 10 ppm. V9 stated It is too weak for solution at 10 ppm. It should be at 100 ppm and will need remade. On 10/16/24 at 11:00 AM, V9 checked the sanitation solution, and it measured above 200 ppm. V9 stated The solution is too high and needs remade. At this time V9 provided the October 2024 Solution Check list. This checklist did not document any sanitizing solution checks were completed on 10/16/24. The facility's Waste Disposal policy, dated 2017, documents Garbage will be disposed of and as needed throughout the day and at the end of each day. Procedure: Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered when not in use. On 10/15/24 at 9:30 AM, three large barrel trash cans were present in the facility's kitchen. All of the cans were not covered/open to air and placed in random walkways of the kitchen. On 10/15/24 at 11:45 AM, a open large barrel trash can that contained food waste and trash was sitting in the facility's kitchen within two feet of the facility's steam table, which contained prepared food for the noon meal. Another open large barrel trash can containing food and product packaging waste, was directly next to the kitchen's grill where food was being prepared. On 10/16/24 at 11:00 AM, three open large trash barrel trash cans were observed in the kitchen. One was sitting by the reach in cooler and two were located against the wall between the steam table/serving window and the dishwashing machine. All three barrels contained trash, liquid splatter and food contents. At this time V9 stated We should have some lids for those. V15 (Dietary Aide) stated We don't have lids for those. In the five years I have worked here, I have never seen lids on them (kitchen trash cans). The facility's General Sanitation of Kitchen policy, dated 2017, documents Food and Nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. On 10/15/24 at 9:30 AM, a tour of the facility's kitchen was conducted. During this tour the kitchen floor was observed to be dirty with dirty grout and particle debris on the floor in several areas including corners and along the edges of the walls. The floor was also noted to be sticky when walking. During the tour V9 (Dietary Manager) confirmed the floors sticky feeling and debris throughout and stated They (the facility) are looking to replace the floor in here, but it should be getting cleaned multiple times throughout the day. On 10/16/24 at 11:00 AM, the facility's kitchen floor was observed to have debris and particles scattered in several areas of the kitchen. The floor in the juice machine area contained a yellow shiny slime-like substance under the machine, around the cart and by the wall. This same area of floor also contained a brown, thick, gritty substance around the juice cart and against the wall. Two drink sweetener paper packets and approximately one fourth of a full orange was on the floor near the wall. At this time, V9 confirmed the condition of the floor near the juice cart and made kitchen staff aware, stating There is an orange against the wall over here! The facility's Ice policy, dated 2017, documents Ice will be provided and handled in a manner to keep it free from contamination. Ice will not be handled with bare hands, but rather with a sanitized scoop and container for transport and distribution. On 10/16/24 at 11:00 AM, V9 (Dietary Manger) stated the kitchen does not have an ice machine so any ice for the food tables and resident drinks would be obtained from the resident F-hall ice machine and transported to the kitchen via a cooler and cart. At this time V9 walked to the North side nurses' station where halls F, G and H are located. V9 pointed to a cart at the nurses' station and stated it contains the ice scoop and cooler used for kitchen purposes. The second level of this cart contained an ice scoop open to air and resting on a surface with unknown particles, brown specs and debris. V9 grabbed a brown tray from the dining area and placed the scoop on the tray then stated, I will get a bag to cover that (ice scoop). V9 confirmed this ice scoop is the only one used in the ice machine, ice cooler and for kitchen ice purposes. On 10/16/24 at 11:15, R6 walked up to the ice cooler cart and grabbed the ice scoop with bare hands, filled a personal cup and then walked away leaving the scoop on the cart. V22 (Certified Nursing Assistant) was the only staff in the area at this time and confirmed R6 is a resident who resides in the H-hall.

Based on observation, interview, and record review, the facility failed to update a care plan to include targeted behaviors and non-pharmacological interventions for two (R7 & R51) of 23 residents reviewed for care plan revision in a sample of 30. Findings include: Facility policy Care Plan Policy, updated 6/5/24, documents Patients receive care and treatment based on an assessment of their needs. The data is used to determine and prioritize the patient's plan of care. 1. R7's medical record documented R7 was alert and oriented, admitted to the facility on [DATE], and had Schizophrenia. R7's current physician orders for October 2024 documents R7 takes the following: Lorazepam 1 MG (milligram) by mouth two times a day for anxiety started 2/17/24; Zoloft 200 mg by mouth at bedtime started 2/27/24; Risperidone (antipsychotic) 5 mg by mouth two times a day started 2/28/24; Olanzapine (antipsychotic) 20 mg by mouth at bedtime started 5/28/24; and Trazodone (antidepressant) 50 mg by mouth at bedtime started 2/16/24. On 10/15/24 and 10/16/24 between the hours of 9 AM and 2 PM multiple observations were made of R7 in her room and in the dining room with no behaviors noted. On 10/17/24 at 11:10 AM, R7 was coming out of her room, no behavior noted, and stated she has hallucinations a lot that tell her to harm herself, and her hallucinations are from the past and present. R7's current care plan has no behaviors identified or documented with interventions, and no non-pharmacological interventions listed. On 10/17/24 at 11:20 AM, V3 RN/Registered Nurse Care Plan Coordinator verified R7's care plan does not have targeted behaviors with interventions, or non-pharmacological interventions listed and should. 2. R51's medical record documents R51 had Schizoaffective Disorder and Altered Mental Status, and did not take any Psychological medications. On 10/15/24 at 9:41 AM, R51 was yelling out in her room, surveyor went in the room to introduce herself, resident told surveyor to Get the hell out of my room, I don't want to talk to you and then slammed her door shut and continued yelling in her room. On 10/17/24 between 11:44 AM and 11:50 AM, R51 was yelling out in her room while lying on her bed. No staff members were present or went into R51's room. On 10/17/24 at 11:50 AM, V12 CNA/Certified Nurse Aid stated She (R51) always yells out, sometimes it is in the dining room and we have to take her to her room, that is her behavior. R51's current care plan had no behaviors identified or documented with interventions, and no non-pharmacological interventions listed. On 10/17/24 at 11:20 AM, V3 RN/Registered Nurse Care Plan Coordinator verified R51's care plan did not have targeted behaviors with interventions, or non-pharmacological interventions listed and should.

Based on Observation, Interview and Record Review the facility failed to ensure a range of motion program was in place for residents with functional limitations in range of motion for three of five residents (R8, R47, R90) reviewed for range of motion in the sample of 30. Findings include: The facility's Restorative Program Policy, dated 6/6/24, documents It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the individual's comprehensive assessment, to achieve and maintain the highest practicable outcome. Our goal is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible, and to achieve and preserve their highest level of mental, physical and psychosocial functioning. Restorative nursing is available seven days a week and is provided for the residents with assessed needs according to program criteria. Purpose: The restorative nursing program is designed to Preserve function, Promote optimal improvement, Increase independence, self esteem and dignity, Promote safety, Minimize deterioration within the limits of normal aging and/or recognized disease process. This same policy documents An individualized program will be developed based on the resident's restorative needs, and include the restorative program on the care plan. 1. On 10/15/24 at 10:10 AM, R8 was observed in bed sleeping in a contracted like fetal position. R8's Minimum Data Set assessment, dated 8/28/24, documents R8 has limits in range of motion with Impairment to bilateral (both sides) lower extremities. R8's current Care Plan does not document a plan of care for R8's range of motion limitations or interventions/programming to prevent further decline. 2. On 10/15/24 at 10:05 AM, R47 was in her room in a bariatric bed. R47 stated she relies on staff to get in and out of bed. R47 denied doing exercises or having staff complete range of motion in her hips, knees or ankles. R47's Minimum Data Set assessment, dated 8/19/24, documents R47 has limits in range of motion with Impairment to bilateral lower extremities. R47's current Care Plan does not document a plan of care for R47's range of motion limitations or interventions/programming to prevent further decline. 3. On 10/15/24 at 11:50 AM and 10/16/24 at 10:45 AM, R90 was observed in common resident areas in her wheelchair. R90's arms were frequently in the bent (contracted at the elbow) position and movements of R90's arms and legs appeared spastic at times. R90's Minimum Data Set assessment, dated 9/16/24, documents R90 has limits in range of motion with Impairment to bilateral upper and lower extremities. R90's current Care Plan, dated 6/13/24 documents R90 has diagnoses of Huntington's Disease and Primary Osteoarthritis. This care plan does not document a plan of care for R90's range of motion limitations or interventions/programming to prevent further decline. On 10/17/24 at 10:30 AM, V19 (Rehabilitation Aide/Certified Nursing Assistant (CNA)) confirmed she is the one who over sees the restorative program for CNAs and Range of Motion therapies. V19 stated she receives the list of residents who are in need of restorative from V20 (Licensed Practical Nurse/Assistant Director of Nursing) and R8, R47 and R90 are not on the list. V19 stated Those three residents are not receiving any active or passive range of motion that I am aware. On 10/17/24 at 10:30 AM, V19 (Rehabilitation Aide/Certified Nursing Assistant (CNA)) confirmed she is the one who over sees the restorative program for CNAs and Range of Motion therapies. V19 stated she receives the list of residents who are in need of restorative from V20 (Licensed Practical Nurse/Assistant Director of Nursing) and R8, R47 and R90 are not on the list. V19 stated Those three residents are not receiving any active or passive range of motion that I am aware.

Based on observation, interview, and record review, the facility failed to implement non-pharmacological interventions, and failed to identify, document or track behaviors for one (R7) of six residents reviewed for psychotropic medications in a sample of 30. Findings include: Facility policy Psychotropic Medication, undated, documents Each psychotropic medication is tracked for behaviors, mood/depressions. Psychotropic medications are used when non-pharmacological approaches have previously failed. Identify target symptoms/behaviors. R7's medical record documents R7 was alert and oriented, admitted to the facility on [DATE], and has Schizophrenia. R7's current physician orders for October 2024 documents R7 takes the following: Lorazepam 1 MG (milligram) by mouth two times a day for anxiety started 2/17/24; Zoloft 200 mg by mouth at bedtime started 2/27/24; Risperidone (antipsychotic) 5 mg by mouth two times a day started 2/28/24; Olanzapine (antipsychotic) 20 mg by mouth at bedtime started 5/28/24; and Trazodone (antidepressant) 50 mg by mouth at bedtime started 2/16/24. On 10/15/24 and 10/16/24 between the hours of 9 AM and 2 PM multiple observations were made of R7 in her room and in the dining room with no behaviors noted. On 10/17/24 at 11:10 AM, R7 was coming out of her room, no behavior noted, and stated she has hallucinations a lot that tell her to harm herself, and her hallucinations are from the past and present. R7's medical record has no behaviors identified or documented, and no non-pharmacological interventions implemented for the use of psychotropic medications. On 10/17/24 at 11:20 AM, V3 RN/Registered Nurse verified R7's medical record does not have targeted behaviors, or non-pharmacological interventions and should. On 10/17/24 at 11:30 AM, V12 CNA/Certified Nurse Aid stated We chart behaviors in our (online) charting system, it walks us through the system.

Based on observation, interview and record review, the facility failed to ensure a resident's leg wounds were protected from cross contamination during scheduled dressing changes for one of four residents (R47) reviewed for skin conditions in the sample of 30. Findings include: The facility's Treatments policy (undated), documents The treatment will be carried out in accordance with physician orders, pharmacy recommendations and CDC (Centers for Disease Control) guidelines, using universal precautions. The facility's Skin Treatment Protocol, dated 6/5/24, documents The facility strives to ensure that each resident receives care and services necessary to attain and maintain the highest practicable overall well-being, in accordance with the comprehensive assessment and plan of care. This policy also documents when treating a wound: Sterile technique is not necessary, unless ordered by a physician. Clean technique is used for all other dressings and universal precautions are adhered to. If clean, un-sterile dressings are used, then measures must be taken to prevent contamination of unused dressings. R47's current care plan, dated 9/7/23, documents R47 has actual impairment to skin integrity related to occasional urinary incontinence and limited mobility. Right lower lateral leg (wound measurement)7 cm (centimeters) x 2 cm x 0.1 cm. Right posterior lateral thigh (wound measurement) 1.5 cm x 10.5 cm x 0.2 cm. Right lateral calf (wound measurement) 0.9 cm x 0.5 cm x 0.1 cm. This same care plan contains a historical active plan of care that documents (R47) is being treated with antibiotic therapy for a wound on her right thigh. Antibiotic order date 8/22/24-9/5/24. Maintain universal precautions when providing resident care. On 10/17/24 at 10:00 AM, V21 (Registered Nurse (RN)) and V3 (RN/Infection Control Preventionist) went into R47's room to complete wound care to R47's right leg wounds. R47 rolled in bed to her left side for treatments to begin. A moderate amount of brown smeared stool was noted in the center of R47's buttocks when she rolled over. V21 placed a disposable drape on R47's bed under her buttock and hip. V21 then took bandage scissors and cut R47's hip/thigh dressing and without sanitizing, then used the same scissors to cut the lower leg gauze wrap off. A strong odor was noted from lower leg when dressing was removed. After cleansing R47's hip wound, V21 used same (un-sanitized) scissors to cut three pieces of Puracol (collagen treatment) and applied them to R47's hip/thigh wound. V21 used the same (un-sanitized) scissors to cut strips of calcium alginate and then applied them to the hip/thigh wound. While V21 waited for V3 to open a bandage, one square of calcium alginate fell on to the drape (where R47's soiled buttocks was laying) three times. Each time V21 picked up the calcium alginate and reapplied it to the wound before then covering the entire wound with a bandage. V21 proceeded to use the same scissors (still un-sanitized) to cut strips of Puracol for R47's calf wound and applied two cut pieces to the lateral calf wound. After the wound care was completed V21 stated to R47 We are done. I will send (Certified Nursing Assistants) in to get you cleaned up (from stool). On 10/17/24 at 10:12 AM V21 stated the scissors used during R47's wound care are V21's and she did not think about sanitizing them between use when completing R47's wound cares. V21 confirmed that a piece of calcium alginate fell on top of R47's disposable drape three times during her treatment and R47's feces soiled bottom was laying on this drape. V21 stated I think R47 was having a bowel movement during her cares. At this time V21 confirmed the stool should've been cleansed to keep a clean field before performing wound care to avoid wound contamination.

Based on interview and record review, the facility failed to prevent a resident injury by not keeping the bed in low position before leaving a resident unattended for one of three residents (R2) reviewed for falls in the sample of eight. This failure resulted in R2 falling out of bed, hitting his head causing decreased level of consciousness/unresponsiveness, a four cm (centimeter) hematoma on his forehead with a two cm laceration requiring four staples, requiring hospitalization for five days with a primary diagnosis of Traumatic Subarachnoid Hemorrhage (brain bleeding) of the frontal lobe. Findings include: The facility's Fall Prevention policy (undated), states, It is the policy of this facility to prevent falls and serious injury outcomes by recognizing multi-factorial risks and causes, and institute recommendations for fall prevention and management consistent with clinical practice guidelines and standards of care. R2's Minimum Data Set assessment dated [DATE], documents R2 requires total assistance of two staff for bed mobility and transfers. R2's Incident Report dated 4/2/22, documents R2 fell out of bed. R2's Care Plan last revised on 6/21/22, documents R2 has a history of falling out of his bed and wheelchair (prior to 5/20/22). R2's Incident/Accident Report dated 5/20/22 at 1:40 p.m., documents R2 fell out of his bed and hit his left forehead on the floor causing a 2 cm laceration, 4 cm hematoma and decreased level of consciousness. This same report documents R2 was sent to the local hospital. R2's Incident Investigation Report dated 5/20/22 at 1:40 p.m., documents, (V8/CNA) changing (R2) soiled depend, noted stool on sheet. (V8) Stepped into hallway to get a clean sheet. Upon entering (R2's) room, (V8) witnessed (R2) roll off his bed and onto floor. Hit head on floor. Action Plan: Ensure that bed is in the lowest possible position before leaving bedside. R2's Hospital History and Physical dated 5/20/22, documents images from the Computed Tomography (CT) dated 5/20/22, shows a Traumatic Subarachnoid Hemorrhage (brain bleeding) of the frontal lobe due to a fall from (R2's) bed. R2's CT scan dated 5/20/22, documents R2 had left frontal lobe acute Subarachnoid hemorrhage. R2's Hospital Progress Note dated 5/25/22, documents R2 was hospitalized for 5 days after being admitted for Traumatic Intracerebral Hemorrhage (HCC). This same note states, Plan to return (R2 to the facility) with Hospice, anticipate discharge (5/26/22); transitioned to comfort-focused care today. R2's Progress Note dated 5/26/2022 at 7:20 p.m., documents R2 was readmitted from the hospital; R2 was non-verbal with, eyes open looking around; 4 staples to left forehead; R2 is 100% dependent for all cares; R2 assessed by Hospice for admission. On 6/25/22 at 7:02 p.m., V8 stated, I was changing (R2) and he messed his sheets with (feces). I left him in his bed, in high position, to go and get clean sheets. When I came back in the room he was falling out of the bed. (R2) was on the floor, face down with blood coming out of his head. I didn't move (R2) and called the nurse for help. I was given a counseling form (by administration) for leaving (R2's) bed up in a high position and leaving him unattended. I know now to always lower the bed before leaving a resident or call for assistance. On 6/25/22 at 6:34 p.m., V1 (Administration) stated that immediately after R2's fall on 5/20/22, V8 (CNA/Certified Nurse Aide) was reprimanded. V1 stated V8 left R2 unattended with the bed in the highest position to go get clean linens in the hall. V1 stated when V8 walked back into the room, R2 was falling out of bed and landed face down causing head trauma and a brain bleed. V1 stated R2 did have a significant injury from that fall on 5/20/22. V1 stated the fall resulted in R2 becoming unresponsive and having a laceration to his head requiring staples, being hospitalized until returning to the facility on [DATE], and admitted to Hospice care. V1 stated V8 and all nursing staff were educated on not leaving residents unattended without lowering the bed and putting any safety interventions required in place. V1 stated the staff may even call for extra assistance if needed rather than to leave a resident at risk for injury.

Based on observation, record review and interview, the facility failed to identify residents as being at risk for pressure ulcer development, timely obtain pressure ulcer treatment orders from a Physician, perform routine skin assessments, implement pressure relieving interventions, and perform proper hand hygiene during wound care, for three of seven residents reviewed (R21, R40, R66) for pressure ulcers in a sample of 40. These failures resulted in R21 developing a Stage 4 pressure ulcer on right ankle and right first toe, R66 developing a Stage 4 pressure ulcer on the right hip, and R40 developing a Stage 3 pressure ulcer on the right ischium. Findings include: The facility's Skin Treatment Protocol (undated) documents, Decubitus ulcers are commonly referred to as bedsores or pressure sores. Pressure sores are usually formed when the skin breaks down because the resident remains in the same position for an extended period of time. When a resident remains in the same position for an extended period of time, there is a loss of circulation to that area, which destroys the tissues. The most common site of pressure sore is where the bone is near the surface of the body. These include the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, toes, and under the breasts. The comprehensive assessment and plan of care determines the amount of care needed by each individual resident to ensure that a resident who enters the facility without a pressure sore does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable, and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Clinical conditions may demonstrate pressure sores were unavoidable only if preventive care was provided. Adequate preventive care includes turning and proper positioning, application of pressure relief devices, providing clean and dry bed linens, and maintaining adequate nutrition. Resident assessment (Braden Scale) identifies residents at risk of developing pressure sores and routine preventive care is provided. Based on the outcome of the comprehensive assessment and as change warrants, skin deficits are addressed as appropriate with the Physician. Treatment is provided as prescribed and a plan of care is developed. For a resident who upon admission to the facility did not have a pressure sore and now has one, resident assessment determines if the pressure sore was unavoidable, such as: 1. Was the resident identified as being at risk for pressure sores? 2. Was routine preventive measures and care specific measures to addressing the resident's unique risk factors identified? For all residents who have pressure sores identify: 1. Are measures to assist healing necessary (relieving pressure, moving the resident without casing shearing, applying a medicated dressing)? 2. Are measures to prevent infection necessary? 3. If the pressure sore is not healing, is getting larger, and/or signs of additional skin breakdown are evident, have alternative interventions been considered or attempted? Preventions of Pressure Ulcer: 1. Assess for risk of pressure ulcer development by completing the Braden Assessment. a. For those residents identified at moderate or high-risk preventative care plan measures will be put in place and the skin observation tool will be performed on a weekly basis. 2. Assess and identify complicating conditions that may contribute to pressure ulcer development. 3. Identify additional risk factors that may exist and address as needed on the care plan. 4. Explain care plan approaches to the resident. 9. Use pressure reducing or relieving devices as necessary. 10. Establish a turning and positioning routine in bed and chair to meet the resident's needs. 11. Position with appropriate surfaces to protect bony prominence's. Pressure sores are the most serious skin condition for the resident. Report any signs of a developing pressure sore to the staff/charge nurse immediately. 1. The Electronic Medical Record documents R21 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set assessment, dated 5/22/20, documents R21 has inattention and disorganized thinking, requiring the physical assistance of one person for dressing, hygiene, bathing and transfers. Progress notes dated 3/13/20 document R21 developed a scabbed area on the right outer ankle that measured 0.1 cm (centimeters) x 0.2 cm, along with another scabbed area to the top of the right foot, that measured 0.2 cm x 0.1 cm. Treatment Administration Records document those areas as being treated with skin prep once daily until they healed on 3/25/20. Progress Notes dated 9/15/20 document R21 developed another area near the arch of his right foot, measuring 2.0 cm x 0.1 cm, which was treated with [MEDICATION(S)] and covered with a foam dressing daily (from 9/16/20 to 10/12/20), and R21 was educated on the importance of not sleeping with socks and shoes on. R21's Plan of Care at the time of both occurrences failed to identify R21 as at risk for impaired skin integrity, that R21 developed actual skin impairment on his right foot, or that R21 was to not sleep with his socks and shoes on. On 10/28/20, Progress Notes document, noted an open area to (R21's) right heel. Upon assessment this writer noted resident in bed asleep (with) shoes and socks on. This writer educated resident on importance of not sleeping in footwear to which (R21) replied 'it's too hard to take my shoes on and off.' This writer re-educated resident on use of call light and importance of asking staff for assistance. Resident has what appears to be an unstageable pressure ulcer to right ankle that measures at 3 x 2 cm. An Initial Wound Evaluation and Management Summary, dated 10/29/20 by V8 (Wound Doctor), documents R21 as having a wound determined to be from pressure, described as unstageable (due to necrosis) of the right, posterior ankle, measuring 2.0 cm x 1.3 cm x unmeasurable depth. V8 instructed staff to clean the wound, dry, apply Calcium Alginate with Silver and cover with a border foam dressing daily, off-load wound and utilize a sponge boot. Nursing Progress Notes, Skin Observation Tools or Skin/Wound Notes do not document further assessment of R21's right posterior ankle wound until over two weeks later, on 11/16/20. The 11/16/20 Skin Observation Tool documents R21's right ankle wound as 1.5 cm x 1.0 cm, and identifies a new wound on the right great toe measuring 0.4 cm x 0.4 cm. There is no documented evidence that the Physician was notified of the development of a new wound on the right great toe, or that a treatment was initiated at that time. A Wound Evaluation and Management Summary, dated 11/19/20 by V8, documents R21 as having a Stage 4 Pressure Wound on the right posterior ankle, measuring 1.5 cm x 1.0 cm x unmeasurable depth, and a unstageable pressure ulcer of the right, dorsal, first toe, which measured 0.4 cm x 0.4 cm x unmeasurable depth. V8's documentation indicates both wounds required surgical debridement at that time, and treatment was changed to applying collagen sheets daily to the wounds, with instructions to continue to use a sponge boot and off-load R21's wound. R21's Plan of Care failed to identify that R21 developed actual skin impairment on his right foot, was to not sleep with his socks and shoes on, was to utilize a sponge boot and off-load the wound. On 12/03/20, documentation indicates a Plan of Care was developed related to R21's pressure ulcers on the right ankle and right first toe, with the following interventions: Staff will assess wounds routinely, document and notify (Physician) of change in condition, Staff will complete treatments as they are ordered by the wound (Physician), Staff will ensure that (R21) is wearing clean socks with properly fitting footwear. On 12/18/20, a Wound Care Telemedicine Follow Up Evaluation, documents R21's right ankle wound as a Stage 4, measuring 1.9 cm x 1.5 cm x unmeasurable and the unstageable pressure ulcer of the right, dorsal, first toe, measuring 0.4 cm x 0.4 cm x unmeasurable. R21's Plan of Care still failed to identify that R21 was to not sleep with his socks and shoes on, was to utilize a sponge boot and off-load the wound. The most recent Wound Evaluation and Management Summary by V8, dated 4/22/21, documents R21 now has the following wounds on the right foot: 1. Stage 4 Pressure wound of the dorsal first toe (0.3 cm by 0.3 cm by unmeasurable depth), 2. Wound of the medial heel (0.7 cm x 1.0 cm x unmeasurable depth), 3. Wound of the lateral heel (0.2 cm x 0.1 cm x 0.1 cm). Documentation further indicates the right first toe and medial heel required surgical debridement on 4/22/21 and V8's recommendations for the Plan of Care was to Off-load wound; Sponge boot. On 4/26/21 at 10:11 am, R21 was sleeping in bed with shoes on his feet, which were resting directly on the mattress, with no off-loading. On 4/28/21 at 1:11 PM, R21 was sleeping in bed wearing dirty socks and his feet resting directly on the mattress. R21 stated he tries to not wear his shoes to bed anymore and denies ever having a sponge boot to wear. On 4/29/21 at 08:50 am, V9 (Licensed Practical Nurse) stated R21's wounds were created by pressure from sleeping in bed in his shoes. V9 stated R21 has never had a sponge boot for the right foot. At that time, V9 performed wound care to the right great toe and right heel. V9 identified three new open areas on the right foot, located on top of the second and third toe and the top of the foot near the ankle. On 4/29/21 at 9:40 am, V3 (Assistant Director of Nursing) stated it was determined that R21's right foot pressure ulcers were caused by R21 sleeping in his shoes. V3 stated R21 should have been identified as at risk for the development of pressure ulcers, due to his admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 concluded that R21 should have had a Plan of Care with pressure ulcer prevention interventions developed in March of 2020 when R21 first developed open wounds on his feet. V3 stated the Treatment Nurse is typically responsible for developing a Plan of Care related to skin issues. V3 stated R21 never had a sponge boot or off-loading measures implemented for the right foot, as ordered by V8 on 10/29/20. V3 was unaware that V8 wanted R21 to have a sponge boot for the right foot and explained that up until recently she and V2 (Director of Nursing) did not have access to V8's documentation. 2. R66's Nursing Note dated 7/30/2020 at 11:28 PM documents, (R66) admitted to the hospital for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R66's Nursing Note dated 8/10/2020 at 3:18 PM documents, (R66) readmitted to facility after return from the hospital post left hip arthroplasty (surgical hip repair). R66's Minimum Data Set assessment dated [DATE] documents R66 required extensive assistance of one person physical assist for bed mobility, extensive assistance of two person physical assist for transfers, was not a risk for development of a pressure ulcer, did not have a pressure reduction device to the bed or chair, and was not on a turning and repositioning program. R66's Braden Scale for Predicting Pressure Sore Risk dated 8/10/20 (After sustaining the right hip fracture) documents R66 is not at risk for developing a pressure ulcer. R66's Medical Record dated 8/10/20 (date of re-admission) through 11/12/20 does not include R66 having a turning and repositioning program until 11/12/20. R66's Plan of Care dated 4/8/20 through 10/20/20 does not include pressure reducing interventions or wound treatment interventions until 10/20/20. R66's Wound Evaluation and Management Summary dated 10/08/20 and signed by V8 (Wound Physician) documents, (R66) has a stage two pressure wound of the right hip for a least one day in duration. Wound size 3.0 cm (centimeters) x 4.0 cm x 0.1 cm. Exudate: Light sero-sanguineous. R66's Wound Evaluation and Management Summary dated 10/16/20 and signed by V8 documents, Unstageable (due to necrosis) pressure ulcer of the right hip. Wound size 4.0 cm x 6.5 cm x non measurable depth. Exudate: Moderate sero-sanguineous. Necrotic tissue 70 percent. Wound progress: Deteriorated. R66's Wound Evaluation and Management Summary dated 4/22/21 and signed by V8 documents, Stage four pressure wound of the right hip. Etiology: Pressure. Minimum Data Set stage: Four. Duration: Over 193 days. Wound Size: 0.5 cm x 0.5 cm x 0.2 cm. Slough: 20 percent. Indication for Surgical Excisional Debridement Procedure: Remove necrotic tissue and establish the margins of viable tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, a blade was used to surgically excise 0.05 cm of devitalized tissue including slough. On 04/27/21 at 09:34 AM V12 (Agency LPN) removed R66's pressure ulcer dressing and then cleansed R66's right hip pressure ulcer with wound cleanser. R66's pressure ulcer dressing contained a moderate amount of reddish-yellow drainage. R66's right hip pressure ulcer was yellow in color and measured 0.5 cm (centimeters) x 0.5 cm x 0.2 cm depth in the center with 3.5 cm deep red colored scar tissue surrounding the ulcer. V12 then applied calcium alginate to the wound and covered the wound with a bordered gauze. R66 stated, I got the sore from laying in bed too long on that side. I broke my hip and could not move. It hurts. On 04/27/21 at 11:40 AM (V3) (Assistant Director of Nursing/ADON) stated, (V8) documented (R66's) wound to the right hip was due to pressure. The Braden Score assessment dated [DATE] was inappropriately coded and should have been scored at a 14 which would have indicated that (R66) was at moderate risk of developing a pressure ulcer. (R66) should have been put on a turning and re-positioning every two hours program and weekly skin checks should have been done after (R66) returned from the hospital with a hip fracture. On 04/28/21 at 08:53 AM V3 stated, No pressure relieving interventions were implemented to prevent pressure ulcers after (R66) broke his hip until after he developed the pressure ulcer. On 04/27/21 at 02:13 PM V1 (Administrator) stated, (R66) was not put on a turning and repositioning program until 11-12-20 after the pressure ulcer already developed. 3. R40's Braden Scale for Predicting Pressure Sore Risk assessment, dated 2/15/21, documents that R40 is at risk for developing pressure ulcers. R40's Skin Observation Tool, dated 2/15/21, documents, (R40)'s skin is warm, dry, intact. No new skin issues noted. R40's Electronic record has no documentation of a skin check being completed on R40 until 3/11/21. R40's Skin/Wound Note, dated 3/11/2021 at 3:23 PM, documents, New pressure wounds to right ischium and buttock. R40's Wound Evaluation and Management Summary, dated 3/12/21, documents, Stage 3 pressure wound of the right ischium measuring 1.8 cm (centimeter) x 1 cm x 0.2 cm. R40's TAR (Treatment Administration Record), dated 3/2021, documents that a treatment was not initiated until 3/13/21 for R40's pressure ulcer. R40's Wound Evaluation and Management Summary, dated 4/22/21, documents, Stage 3 pressure wound of the right ischium measuring 0.5 cm (centimeters) x 0.3 cm x 0.2 cm for greater than 38 days. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommendations: Off load wound; Reposition per facility protocol.) R40's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/28/21 at 10:17 AM, V7 (LPN-Licensed Practical Nurse) removed a border foam dressing from R40's right ischium dated 4/27/21. R40 had a small irregular shaped open area with depth with reddened surrounding tissue. The skin between R40's right and left buttock was significantly reddened. V7 cleansed R40's right ischium again with normal saline. V7 proceeded, with the same gloves on, to apply antifungal cream to her fingertips and apply the cream to R40's reddened right and left buttocks area. Then, V7 removed her gloves and applied a new pair without washing/sanitizing her hands. V7 applied a square piece of calcium alginate with silver to R40's right ischium and covered it with a border foam dressing. On 04/28/21 at 10:45 AM, V7 stated, I didn't wash my hands when I changed my gloves since I was working with the same resident. On 04/29/21 at 08:44 AM, V3 (Assistant Director of Nursing) stated that skin checks should be done weekly and that was not occurring for (R40), and if they were the pressure ulcer could have been identified prior to being a Stage 3 (pressure ulcer). V3 also stated that a Physician ordered treatment should have been initiated when (R40's) pressure ulcer was identified.

Based on interview and record review, the facility failed to thoroughly investigate a fall and implement interventions to prevent further falls for 2 of 3 residents (R64 and R65) reviewed for falls in a sample of 40. These failures resulted in R65 experiencing subsequent falls leading to a nondisplaced fracture involving the fibular tip. Findings include: The Facility's Resident Accident/Incident Safety Policy, undated, documents the following: It is the policy of (the facility) to provide a safe environment for all residents. We understand there will be times when best efforts will not be enough. Accidents will happen. Residents will fall. For any incident/accident, involving a resident, the following protocol will be followed: Complete an incident/accident report. This includes an investigative report, and for falls, a fall assessment. The report is presented to the DON (Director of Nursing) for further investigative review, and initiation of additional measures as necessary. The Facility's Procedure for Responding to a Resident Fall, dated 7/18/2019, documents the following: Once the resident's immediate needs have been attended to, document the incident by reporting the facts. Record all objective data including the time the resident was discovered, the resident's condition, who was notified and when, and the follow up treatment. Also, record any subjective data concerning the fall, such as comments made from the resident and witnesses verbatim and attribute them accordingly. An incident report should be made according to facility policy. The nursing staff should notify the facility's supervisor of the fall so he or she can direct staff to implement interim interventions to protect the resident from another fall or injury. This information should be documented in the resident's record. IDT (Interdisciplinary team) will complete the thorough investigation to determine contributory causes for the fall and what actions should be taken to minimize the risk of a future fall, review care plan and make revisions if needed. R65's quarterly and annual MDS (Minimum Data Set) assessment dated [DATE] and 12/30/2020 document R65 has a BIMS (Brief Interview of Mental Status) of 6 (scale of 0-15, 15 being mentally intact). R65's Incident Investigation Report dated 12/24/2020 documented the following: (R65) noted on the floor on D hall. Wheelchair behind him. He stated he was picking up something from the floor and fell from his wheelchair. This report does not include root cause analysis or interviews from staff. R65's Incident report dated 12/30/2020 documents the following: (R65) was noted on the floor lying on his back. He stated he was trying to lay in his bed. This same form documents the following: Action Plan: follow any recommendations from the hospital upon return. This investigation did not include interviews, root cause determination of R65's fall or interventions to prevent further falls. R65's Incident Report dated 4/13/2021 documents the following: Nurse noted (R65) with pain and swelling to left ankle. Non Displaced fracture involving the fibular tip. (R65) reports that he injured ankle when he transferred self from wheelchair to bed. Intervention: Refer to (local orthopedic doctor wrap with bandage) until further recommendations are received. Follow all recommendations. This report did not document an intervention to prevent further falls or interview to determine the root cause. R65's X-ray dated 4/13/2021 documents the following: Impression: Nondisplaced fracture involving the fibular tip. R65's current fall care plan was reviewed and did not include interventions to prevent further falls for R65's falls dated 12/30/2020 and 4/13/2021. On 4/28/2021 V3 ADON (Assistant Director of Nursing) stated the following regarding R65's falls on 12/30/2020 and 4/13/2021: There were no immediate interventions put in place to prevent further falls nor were additional interviews to determine root cause were not conducted. 2. On 04/26/21 at 10:48 AM, R64 stated, I had to go to the restroom really bad one night. I was going to soak everything. I had my call light on in the night waiting for help. There isn't enough staff to help. You're lucky to get help. I had to go to the bathroom so bad I couldn't wait any longer so I tried to get into my wheelchair on my own. I fell trying to get into my wheel chair. I called for help when I was on the floor, and it took a while for them to get to me. I wet myself waiting for the staff to come to me when I was on the floor. I couldn't get myself up without help. I ended up breaking my left ankle. The facility's Incident Report Telephone to State Agency, dated 1/25/21, documents, R64 reported that she had a fall during the night of 1/24/21. Reported pain 10/10 to the left side, left hip and left ankle. Nurse reported no [CONDITION(S)] other than baseline [CONDITION(S)] to left ankle. Noted small amount of bruising to left upper thigh. R64 requested X-ray of her left hip and left ankle. Type of Injury: Fracture: Left lateral and medial malleolus. R64's Left Ankle X-ray Report, dated 1/26/21, documents, Impression: The visualized osseous structures demonstrate acute fractures involving the left lateral and medial malleolus. Associated soft tissue swelling is noted. Continued close clinical correlation is advised and orthopedic consultation is recommended. R64's Incident Investigation Report, dated 1/27/21, documents that R64 reported the fall on 1/24/21 at 12:34 p.m. Injuries: pain/bruising. R64 reported fall during the night and reports pain to left hip. X-ray obtained. Fall reported on 1/25/21. The investigation report had no documentation of staff and/or resident interviews nor of a new fall intervention. R64's care plan, dated 3/11/21, has no documentation of a fall intervention to prevent future falls for R64 following the fall on 1/24/21. On 04/29/21 at 09:07 AM, V3 (Assistant Director of Nursing) stated that (R64) would have needed help to get up from the floor, (R64) can't get up without help. I questioned this when (R64) told me she fell the night before and no one knew anything about it. I didn't document any staff interviews nor did I interview any residents either. On 04/29/21 at 9:28 AM, V6 (Care Plan Coordinator) stated that R64 did not have a new intervention implemented after her fall with a fracture.

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidance to assign dedicated staff to work only in the COVID-19 unit and to exclude symptomatic healthcare personnel from work until a confirmation molecular test (PCR) is performed. The facility also failed to follow the CDC, Federal, and Local Health Department guidance for frequency of testing based on county level positivity rates. These failures have the potential to affect all 154 residents in the facility. These failures resulted in staff being tested on ly one time per week instead of two and symptomatic staff who tested negative on a Point of Care (POC) test during a high county level positivity rate greater than 10% (percent) to work preparing food, provide direct resident care and also work in close contact with residents instead of being excluded from work pending a confirmatory PCR test. These failures also resulted in nursing staff providing direct resident care for COVID positive residents and COVID negative residents during the same shift. These failures resulted in an immediate jeopardy. While the immediacy was removed on 1/6/21, the facility remained out of compliance at Severity level 2 while the facility is in the process while the faiclity continues to monitor for full complaince and updates current infection control policies in their facility policy to include all current guidance from CDC and CMS. A CDC Symptoms of Coronavirus guidance dated 5/13/20 states, People with COVID-19 have had a wide range of symptoms reported, which may include cough, muscle, body aches, congestion or runny nose, fatigue, headache, and fever. A CDC Considerations for Use of [DIAGNOSES REDACTED]-CoV-2 (COVID-19) [MEDICATION NAME] Testing in Nursing Homes dated 12/10/20 states, As the sensitivity of [MEDICATION NAME] tests is generally lower than RT-PCR (molecular), FDA EUA (Food and Drug Administration Emergency Use Authorization) recommends that negative POC (point of care) [MEDICATION NAME] tests be considered presumptive (possibly positive or negative). This guidance also instructs that when testing symptomatic healthcare personnel (HCP), If an [MEDICATION NAME] test is presumptive negative, perform RT-PCR immediately (e.g. within 48 hours). Symptomatic residents and HCP should be kept in transmission-based precautions or excluded from work until RT-PCR results return. A CDC Guidance for Expanded Screening Testing to Reduce Silent Spread dated 12/3/20 states, Persons with asymptomatic and presymptomatic infection are significant contributors to community [DIAGNOSES REDACTED]-CoV-2 (virus causing COVID-19 infection) transmission and occurrence. This guidance also states, plan for expanded screening testing for [DIAGNOSES REDACTED]-CoV-2 to prevent or reduce silent spread of [MEDICAL CONDITION]. Jurisdictions should consider implementing an expanded screening testing strategy to rapidly identify people without symptoms (asymptomatically or presymptomatically infected with [DIAGNOSES REDACTED]-CoV-2) who are contributing to the silent spread of infection, because they are unaware they are infectious. A CMS (Centers for Medicare and Medicaid) Updates COVID-19 Testing Methodology for Nursing Homes dated 9/29/20 states, Under guidance CMS issued on August 26, 2020, nursing homes must test staff at a frequency of once monthly if the facility's county positivity rate is less than five percent (%). Staff testing frequency increases to once weekly if the county positivity rate is between five and ten percent. Finally, testing frequency increases to twice weekly if the county positivity rate exceeds 10 percent. A CDC Responding to Coronavirus (COVID-19) in Nursing Homes guidance dated 4/30/20 states, Assign dedicated HCP (healthcare professional) to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. A facility Novel Coronavirus/COVID-19 policy (3/13/20) states, Every attempt will be made to assign designated staff to work with the residents in isolation. Likewise, those in quarantine will have staff members dedicated to work with them. This same policy documents it was last updated 7/23/20 and includes infection prevention and control processes that are incorrect or outdated based on current CDC guidance. A Resident Room Roster dated 12/21/20 documents there are three hallways on the North wing of the facility with 30 COVID-19 positive residents residing on the North G wing and non-COVID positive residents residing on the North F and H wings. Facility Resident Room Roster's dated 12/21/20, and 12/29/20 and a daily nurse and certified nurse aide (CNA) hall assignment sheets dated 12/1/20, to 12/29/20 documents that the facility is divided in to three resident halls on the North, and five resident halls on the South wing. The resident room rosters indicate one of the three halls (G hall) on the North wing is where the COVID-19 positive residents reside and shows the designated non-COVID halls (F and H hall) assigned to each nurse. The daily nurse and CNA (Certified Nurse Aide) hall assignment sheets document there are only two nurses to provide care for the residents on the COVID-19 G hall and the other two non-COVID halls on the North side of the building. Daily nurse and CNA hall assignments dated 12/1/20, prior to the resident outbreak of COVID-19, to 12/22/20 document no more than two nurses are scheduled on the North hall on days, and evenings; and only one nurse is scheduled to care for all of the North wing COVID and non-COVID residents at night. On 12/21/20 at 10:50a.m. V7 and V8 (CNAs) were seated at the North hall nurses' station. V8 stated that she was assigned to the H hallway where residents are not infected with the COVID-19 virus. V8 stated she and V7, who was assigned to the F hall, were currently filling in for the CNAs assigned to the COVID-19 unit while they were gone for lunch in addition to caring for the non-COVID residents on their own hallways. V8 stated that all staff working on the North COVID, and non-COVID halls use the same nurses' station, break room, and restroom. V8 stated that staff enter and exit the COVID-19 unit through double doors which open toward the nurses' station from the COVID-19 resident hall. V8 stated that there are two nurses working on the COVID positive G hall. V8 stated that one nurse takes one side of the hall while the other nurse cares for residents on the other side of the G hall. V8 stated that one of those nurses also cares for residents on the non-COVID North F hall and the other nurse cares for residents on the non-COVID North H hall. On 12/21/20 at 11:00a.m. V9 (CNA) was standing behind the nurses' station wearing a surgical mask. V9 stated that she is assigned to care for residents on the North G COVID-19 unit today but helps care for non-COVID positive residents on the North F and H halls during the same shift, as needed. On 12/21/20 at 11:10a.m. V10 (Licensed Practical Nurse/ LPN) exited the double doors where the COVID-19 unit is located. V10 stated there are only two nurses working on the North hallway today, himself and V20 (LPN). V10 stated that he was providing care for residents on one side of the COVID-19 hall and all of the non-COVID residents on the F hall. V10 stated that V20 was providing care for the other half of the COVID positive residents on the G hall and all of the COVID negative residents on the H hallway. V10 also stated the facility is currently testing staff for COVID-19 only one time per week. V10 stated staffing in the North hall was at its usual level or the same as before the outbreak of COVID-19. On 12/21/20 at 2:30p.m. V14 (LPN) stated that she is one of two evening shift nurses on the three North halls. V14 stated that during her current shift she is providing care for one half of the residents on the G COVID-19 unit and all of the non-COVID residents on the H hall located to the right of the North nurses' station. V14 stated that her current resident assignment is what is usual during the evening shift, even before the facility had COVID positive residents. A facility COVID-19 testing schedule dated 12/21/20 documents facility staff have been or will be tested for COVID-19 on 11/18/20, 11/19/20, 11/23/20, 12/1/20, 12/2/20, 12/7/20, 12/14/20, 12/23/20, 12/24/20. A CMS.gov (Centers for Medicare and Medicaid) COVID-19 Test Positivity Rates documents that the facility's county level positivity rate for the week ending 11/18/20 was 12.3%, for week ending 11/25/20 was 11.7%, for week ending 12/2/20 was 11.7%, for week ending 12/9/20 was 11.8%, for week ending 12/16/20 was 11.2%. All of these weekly positivity rates indicate the facility should be testing staff two times weekly. A County Test Positivity Seven (7) Day Rolling Average log, provided by V1 on 12/22/20 to verify the facility has been monitoring the county positivity rate, documents the county in which the facility is located has had a 7-day rolling average above 10% since 11/18/20. On 12/21/20 at 9:25a.m., 3:14p.m., 3:58p.m., 12/22/20 at 1:20p.m., 12/23/20 at 10:48a.m., and 12/24/20 at 1:40p.m. V1 (Administrator) stated the facility is testing staff one time per week. V1 stated that although the testing schedule shows more than one testing date per week, the extra dates are to make sure all staff can make time to be tested on e time during that week. V1 stated the testing schedule is based on direction from the facility's corporate office who has been directing the facility on how many times per week testing should occur. V1 stated the facility performs its own COVID-19 testing and uses both the PCR test, which is sent off to a lab, and a point of care (POC) or [MEDICATION NAME] test which doesn't require a lab and gives the facility the results very quickly on the same day. V1 stated that usually the PCR test for COVID-19 is performed one time per week on a specific date, and the point of care or the [MEDICATION NAME] tests are given for the rest of the week or when staff and residents have COVID-19 symptoms requiring immediate testing. V1 stated the only contact he has had with his local health department (LHD) is when he sends in the facility's COVID-19 test results. V1 stated he has also received CDC and State Agency COVID-19 guidance from V30 (LHD contact). V1 stated that although V2 (Director of Nurses) and V34 (Assistant Director of Nurses/ADON) are currently considered the facility's infection control nurses, the facility does not have an infection preventionist on-site who has been trained, but instead, the facility relies on a Corporate Nurse to provide guidance for COVID-19. V1 stated that when staff complain of COVID-like symptoms, they are tested using the facility's point of care or [MEDICATION NAME] testing. V1 further stated that if a symptomatic staff member tests negative using the POC test, they can remain at work to provide resident care. V1 stated that there is no confirmatory PCR test for symptomatic staff who test negative on the POC test unless the PCR test happens to be scheduled on the same date they had the POC test. V1 stated there is no log of employee illnesses beside the COVID-19 POC testing sheets which record employee symptoms, when they last worked, and the results of the test. V1 stated that the employee POC testing sheets, which show the employee had symptoms but tested negative, indicates the staff members were allowed to stay at work unless the sheet shows the staff person tested positive. V1 stated the facility currently has COVID positive residents on the G hallway on the North wing of the building. V1 stated those COVID positive residents do not have dedicated staff, but instead, staff may care for COVID positive residents on the North G hall and COVID negative residents on the North F or H halls at the same time. V1 stated the facility's first case of a COVID-19 positive resident was on 12/6/20. V1 stated that based on the facility log of residents who tested positive for COVID-19 dated 12/2020, residents initially began testing positive 12/6/20 with the COVID-19 unit being established 12/9/20 and without dedicated nursing staff assigned to COVID positive residents. V1 stated the facility has continued to have more COVID-19 positive residents which were either identified during weekly testing or using the POC test when those residents had symptoms. V1 stated he has not had enough staff to dedicate nurses only to the COVID-19 unit. V1 stated that V2 (Director of Nurses) has tried to schedule extra nurses from nursing agencies without any success. A facility log of residents who tested positive for COVID-19 dated 12/2020 documents that since 12/9/20, when the COVID-19 unit was established, until 12/20/20 there have been 21 new COVID-19 cases among residents, 20 of whom resided on the North hall where nurses cared for both COVID positive and negative residents during the same shift. V18's (Dietary Aide) POC testing sheet dated 12/14/20 documents V18 had the COVID-like symptoms of headache and body aches on 12/14/20 and was tested by the facility on that date using a POC rapid test which was negative. V18's timecard documents V18 worked at the facility on 12/15/20, 12/16/20, 12/18/20, 12/19/20, 12/20/20. On 12/23/20 at 10:00a.m. V5 (Assistant Dietary Manager) stated that V18 also worked on 12/21/20 but was sent home when she tested positive on a POC test administered on that date, while she was at work. V5 stated V18's kitchen duties include all aspect of food preparation for all facility residents. V19's (CNA) POC testing sheet dated 12/13/20 documents V19 had the COVID-like symptoms of congestion and headache on 12/12/20 and was tested by the facility on 12/13/20 which was negative. This same document shows that V19 was administered the POC test on 12/13/20 while she was at work. V19's PCR test which was not administered until 12/17/20 with results reported on 12/19/20 showed V19 was positive for COVID-19. V19's timecard documents V19 worked at the facility providing resident care following COVID-like symptoms on 12/13/20, 12/15/20, and on 12/17/20. On 12/23/20 at 9:05a.m. V19 stated that she resigned from the facility after she last worked on 12/17/20. V19 stated the facility did not notify V19 of her positive PCR test results and only found out today, 12/23/20, when she was interviewed by a State Agency Surveyor. V19 verified working at the facility providing direct care to residents on 12/13, 12/15, and 12/17/20 after having new onset of COVID-like symptoms on 12/12/20 and after being tested as negative by the facility using a POC [MEDICATION NAME] test on 12/13/20. V19 stated she continued to have symptoms after she tested negative on the POC test but, since the facility told her she was negative, V19 thought she was stressing over COVID-19. V2's POC testing sheet dated 12/18/20 documents V2 had the COVID-like symptoms of congestion and a headache on 12/18/20 and was tested by the facility on that date which was negative. V2's PCR test dated 12/17/20 shows V2 was administered the test on 12/17/20 with results reported to the facility 12/19/20. V2's timecard documents V2 worked at the facility on 12/17 and 12/18/20 following complaints of COVID-like symptoms. On 12/21/20 at 10:15a.m., 3:34p.m. and on 12/23/20 at 1:05p.m., V2 verified that on 12/18/20 V2 had the COVID-like symptoms of congestion and headache, V2 was tested as negative using the POC test at the facility, and V2 remained at work while having symptoms on that date. V2 stated that she is performing the COVID-19 POC and PCR testing in the facility. V2 verified that staff are tested on e time per week either with the PCR or the POC test. V2 also verified that there is no on-site trained infection preventionist. V2 stated the lab results for the PCR testing is currently taking approximately two to three days to provide the facility with results. V2 stated she has reached out to some contracted nursing agencies in the past but that V25 (Human Resources) has taken over that role. V21's (Housekeeping) POC testing sheet dated 12/17/20 documents V21 had the COVID-like symptoms of headache and body aches on 12/17/20 and was tested by the facility on 12/17/20 which was negative. V21's PCR test results document V21 was tested on [DATE] with the results not reported to the facility until 12/19/20. V21's timecard documents V21 continued to work while waiting for the PCR test results on 12/17, 12/18, and 12/19/20. On 12/23/20 at 9:31a.m. V21 stated that on 12/17/20 he reported to V2 that during his days off he had been exposed to two different people who tested positive for COVID-19 from the previous weekend and from the previous day. V21 stated that he was also having a new onset of COVID-like symptoms of body aches and an upset stomach. V21 stated he also had a runny nose which is not uncommon for him. V21 stated he asked V2 to provide him with a POC test. V21 stated that, initially, V2 refused because V2 said V21 didn't have enough symptoms to justify getting a POC test. V2 stated he continued performing his work as a housekeeper cleaning residents' rooms and hallways until the facility finally gave him a POC COVID-19 test later in the day 12/17/20 which was negative. V21 stated he continued to work with symptoms after the negative POC test on 12/17, 12/18, and 12/19/20, and without being sent home to quarantine related to his COVID-19 exposure. On 12/23/20 at 1:11p.m. V25 (Human Resources) stated she has been setting up contracts with nursing agencies for the facility since 12/18/20. V25 stated the facility had only one previous contract with a nursing agency, but that V25 has signed additional contracts with four other agencies over the last few days. V25 stated the latest nursing agency contract was signed today, 12/23/20. V25 stated the facility notified her with a needs list indicating the facility needed agency CNA staff for 12/25/20. V25 stated that an agency offered staff to fill those openings but V25 had to decline the agency because the facility filled those openings with their own staff. V25 stated that during the previous week, the facility asked her to fill six to eight shifts for nurses needed from 12/18/20 to 12/23/20. V25 stated that she ended up not needing to call the agencies because those nurses' shifts were filled internally. V25 stated the facility also asked her to fill another nurse's shift for 12/31/20 but it also was filled internally when a nurse agreed to work a double shift for that date. V25 stated that the facility did not ask for nursing staff to fill any opening for 12/21/20, when observations were made of non-dedicated nursing staff working on the North hall COVID-19 and non-COVID halls. V25 stated the facility had requested another agency nurse for 12/23/20 but that request was also removed from the staffing needs list by the facility. V25 stated she presumed the 12/23/20 nursing shift was filled internally. On 12/23/20 at 1:52p.m. V26 (Helping Hands Staffing Agency Director of Nurses) stated the facility signed a contract with them 10/2020 and had used some of their agency staff for a limited period. V26 stated her agency had not been contacted by the facility for additional staff until the week of 12/21/20. On 12/23/20 at 1:57p.m. V27 (Horizon's Healthcare Staffing Agency) stated the facility reached out to her agency for nursing staff for the first time on 12/21/20. On 12/23/20 at 2:07p.m. V29 (Staff of Life Staffing Agency) stated the facility just finalized a contract with them 12/18/20. V29 stated the facility's staffing needs list only included one nurse on one shift for 12/25/20, and multiple CNAs. On 12/23/20 at 12:07p.m., V30 (Local Health Department) stated the facility should have been testing staff two times weekly for as long as the county positivity rate has been above 10%, which has been since 11/2020. V30 stated the facility should have sent home any symptomatic staff pending a confirmatory PCR test following a negative POC test. V30 stated the facility should have dedicated staff on their COVID-19 unit who do not also care for non-COVID residents during the same shift. V30 stated that the facility has not requested assistance with staffing from the local health department. V30 stated that V31 (Facility Chief Operating Officer) contacted him today, 12/23/20, and mentioned their staffing concerns are related to not having extra staff to enter PCR/POC test results into the computer and because of this the facility is only going to test staff one time per week instead of the required two times per week based on the county positivity rate being above 10%. V30 stated that V31 gave as another reason for not testing staff two times per week as the facility's lab was taking too long to return the PCR test results. V30 stated the facility is only testing staff one time per week but should be able to test two times per week because they also have the ability to use the POC test to supplement the PCR test. V30 stated he instructed the facility they could use the POC rapid [MEDICATION NAME] test in addition to the PCR tests so they could perform two tests per week. V30 stated he has provided the facility with CDC and State Agency guidance for COVID-19 for nursing homes multiple times, including testing based on positivity rates, the steps for mitigating staffing shortages, how to use POC testing during high county positivity levels including presumptive negative results for symptomatic staff. V30 stated he sent the facility guidance which specifically states to follow up a negative POC test for symptomatic employees with a PCR test and to send that employee home until the PCR results are known. V30 stated his primary contact with the facility has been through V31 instead of V1 or the facility's infection preventionist. A Facility Census and Condition of Residents form dated 12/23/20 and signed by V1 (Administrator) documents that at the time of the survey 154 residents resided in the facility. An Immediate Jeopardy was identified on 12/21/20 at 11:10a.m. The Immediate Jeopardy began 12/9/20 when the facility's COVID-19 North wing G hall was designated as the COVID-19 hall with positive residents moved to that hall and with hall assignments indicating nursing staff were not dedicated to the COVID-19 unit. Instead only two nurses were scheduled to provide care for the three halls on the North wing which includes the COVID unit on days and evenings and only one nurse was scheduled to provide care on the night shift from 12/9/20 through 12/22/20. The North wing nursing staff was confirmed through observations, and interviews to be providing care for COVID positive and COVID negative residents during the same shift. This Immediate Jeopardy also includes the facility's failure to perform routine COVID-19 testing for staff two times weekly based on the county level positivity rate greater than 10%, and because the facility failed to exclude staff with COVID-like symptoms from work following a negative POC test and without a confirmatory negative PCR test. On 12/24/20 at 4:58p.m. the facility was notified of the Immediate Jeopardy situation. On 1/6/21 at 9:20a.m. the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Employees who have any contact with residents who are in quarantine due to potential exposure to someone who is COVID positive will be instructed to wear N95 mask, gloves, and eye protection whenever entering a Quarantine room. Additional signage has been posted regarding quarantine PPE protocols. 2. Testing is now being done 2X (Two times)/ weekly via PCR tests. If test results do not return within 48 hours, supplemental POC rapid testing will be done. 3. The following website is being utilized for positivity data: https://data.coms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg 4. To prevent the possibility of cross-contamination (dirty to clean) a designated medication cart as well as housekeeping supply cabinet have been added to the COVID Unit (G Hall). 5. Additional hand sanitizing stations have been added throughout the building to ensure they are readily available. 6. Four industrial size S400 air purifiers are being utilized, two for the North Unit and two for the South Unit, as well as electrostatic disinfectant spraying devices are used for disinfection spraying of all hard and high touch surfaces throughout the building. 7. All staff are screened prior to entering the building prior to their shift, including temperature and symptom check. Fatigue has been added to the list of symptoms. Staff who are symptomatic will have a rapid test along with a PCR test performed immediately and will be prohibited from working until the time specified in the CDC guidelines has passed. 8. The facility now has two trained Infection Preventionists for on-site management of COVID prevention and response activities. 9. Every attempt will be made to assign dedicated staff to work with those residents in isolation, including without limitation attempting to obtain additional staff through six agencies with which the facility has now contracted, alternative work hours and scheduling (including where possible eliminating contact with residents/staff in non-COVID areas after working in the COVID unit), and additional pay incentives. 10. Daily monitoring of hand hygiene and PPE compliance. 11. On a daily basis, staff will be informed as to who is and remains on isolation for being COVID positive and who is and remains in quarantine. 12. Residents' families and representatives will be notified at least weekly or by 5:00p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.

Based on observation, interview, and record review, the facility failed to use appropriate (facial coverings) Personal Protective Equipment/PPE, cohort COVID positive residents, dedicate nursing staff to care for COVID positive residents and affix isolation signs on the door of residents on transmission based precautions. These failures have the potential to affect all 149 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 12/11/20, the facility remains out of compliance at a severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the implementation of protocols and oversight visits. Findings include: Facility Resident Room Roster, dated 12/4/20, documents 149 residents residing in the facility. The Roster documents that nine residents are COVID positive: R1, and R10 reside on the F Hall. R4, R5, R7, R8, and R9 reside on the G Hall. R3, R6 reside on the H Hall; and R2. The Resident Room Roster documents that these residents are in Contact/Droplet Transmission based precautions. On 12/7/20, V1 (Administrator) confirmed that nine COVID positive Residents (R1, R3, R4, R5, R6, R7, R8, R9, R10) are residing in the facility. Facility Novel Coronavirus/COVID 19 Policy, undated, documents: that COVID-19 is transmitted primarily through droplet particles and through indirect contact; training of staff will include how and when to don and doff Personal Protective Equipment/PPE facemask (surgical, procedure, cloth for initial phases or when no cases); Phase II: staff will wear appropriate PPE when and where indicated, staff will wear cloth face coverings if not involved or near residents; Phase III: all staff will wear appropriate PPE when and where indicated, staff will wear cloth face coverings if not involved or near residents; when an outbreak occurs traditional PPE will be required rather than improvised versions (cloth masks), provided traditional supplies can be obtained. Facility Novel Coronavirus/COVID-19 Policy, undated, documents: COVID-19 is transmitted primarily through droplet particles and through indirect contact; every attempt will be made to assign designated staff to work with the residents in isolation and likewise, those in quarantine will have staff members dedicated to work with them; isolation can be very difficult for residents cognitively, socially, and physical. This also poses a challenge for the staff who must monitor and maintain the isolation while still meeting the needs of the residents, and isolation. Therefore, undertaken when necessary to protect other residents and staff from acquiring a contagious disease, such a COVID-19, and potentially spreading it further; upon receiving information confirming a resident has contracted COVID-19, isolation measures will be promptly initiated. The resident will be placed in an isolation room with a sign affixed to the door indicating the type of isolation to be maintained and PPE requirements; and if three or more positive COVID results occur within a 72 hour period, all residents of the facility will be placed in quarantine for a minimum of 14 days; if a cluster of positive COVID cases occurs, a facility-wide quarantine will be instituted and continue until there are no new cases for 14 days and the resident will be instructed on isolation precautions and transmission prevention. On 12/6/20, during the hours of 7:30 am and 9:30 am, ambulatory residents were at the South Nurses Station/Dining Room, and North Nursing Station/Dining Room. Approximately, over ten residents were eating in the North Hall Dining Room and multiple residents were ambulating and in the North F Hall, North G Hall, and North H Hall. Some residents were observed without masks and no residents were wearing protective eyewear. Dietary staff, housekeeping staff, and nursing staff were in the North Hall without proper PPE (facial coverings, gowns, gloves and protective eyewear). COVID positive resident rooms were scattered throughout North F Hall, North G Hall, and North H Hall. On 12/6/20, at 7:32 am, V6 (Licensed Practical Nurse/LPN) stated, All COVID residents reside on the North Hall, but we have quarantine residents assigned on the Sough Hall as well. All residents on both North, and South Hall that require supervision/assistance or have behaviors eat in the dining rooms, so we have quite a few in the dining rooms. On 12/6/20, during the hours of 7:40 am and 9:00 am, R1 and R10 F Hall, R4 and R5 G Hall, R7 and R8 G Hall, R9 G Hall, R3 H Hall, and R6 Hall did not have an isolation sign affixed to their doors. On 12/6/20, at 7:59 am, V10 (Dietary Aide), wearing a decorative cloth face covering, exited the Kitchenette off of the North Hall Dining Room, carrying kitchen supplies and walked passed the North Hall (nine COVID positive residents) nursing station, through the entrance door to the South Hall. North Hall residents (approximately 10), dietary staff, and nursing staff were in the North Hall dining room, and at the North Hall nursing station. On 12/6/20, at 8:40 am, V11 (Certified Nursing Assistant/CNA), wearing a decorative cloth face covering, walked through the South Hall Nursing Station to the South Hall Dining Room. South Hall Residents (approximately 15 residents), dietary staff and nursing staff were in the South Hall dining room and at the South Hall Nursing station. V11 then assisted residents with serving breakfast in the South Hall dining room, touching V11's cloth facial covering and then not performing hand hygiene. On 12/6/20, at 8:20 am, V2 (Assistant Administrator), wearing a decorative cloth face covering, walked through the South Hall Main Dining Room down the hallway to the North Hall (COVID positive), and returned through the South Hall Main Dining Room, and the South Hall Nursing Station. South Hall residents were eating breakfast in the South Hall dining room. Dietary staff, and nursing staff were in the South Hall dining room, and at the South Hall Nursing station. No hand hygiene was observed. On 12/6/20, at 8:22 am, V2 (Assistant Administrator) stated, I was in a hurry because you (State agency) were here, I was going to change my mask. With COVID in the building, we should not be wearing cloth face masks, we should all be wearing surgical or N95 masks, especially in the COVID positive areas. On 12/7/20 at 9:49 am, V3 (Director of Nursing/DON) stated, Our Census on 12/6/20 was 149. I am not sure if we are in Phase Two, or Phase Three. We have to cohort our COVID residents with non-COVID because we like for them to all have their own bathroom and we only have so many private bathrooms on each hall. We do not dedicate staff to take care of just the COVID residents, all our staff works the whole building and works with COVID and non-COVID residents on the same shift. We have two nurses on first, second shift, and one on third shift, and all the certified nursing assistants on all shifts, assigned to all three hallways work with COVID and non-COVID residents. One nurse split F Hall and half of G Hall and the other nurse splits half of G Hall, and all of H Hall. All my staff can work both sides of the building. It is impossible to move all the COVID residents to one hall, because I would have to move too many residents. We do not supply the non-COVID residents any eye protection or N95 masks, if they are co-horting on a hallway with COVID positive residents. We do the best we can do in educating them, cleaning and trying to keep them in their rooms. We have boxes and boxes of personal protective equipment available we should be using. I did not know that there were not any isolation signs on their doors, I think the residents take them down. On 12/8/20, V1 (Administrator/ADM) confirmed that R1 and R10 reside on the F Hall; R4, R5, R7, R8 and R9, reside on the G Hall and R3 and R6 reside on the H Hall, and that the Nursing Staff (Nurses and Certified Nursing Assistants) are assigned to COVID and non-COVID residents on the same shift. The Immediate Jeopardy was identified on 12/7/20, at 11:00 am. The Immediate Jeopardy began on 11/24//20 when the facility failed to ensure COVID positive residents were co-horted in a specific area/unit separate from non-COVID residents and ensure there were dedicated staff to care for COVID positive residents. V1 (Administrator) was notified of the Immediate Jeopardy on 12/11/20 at 9:38 am. On 12/15/20 at 8:40 am, the surveyor confirmed through observation, interview, and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/11/20, at 9:38 am, V1 (ADM) confirmed that room moves had occurred on 12/10/20 for all of the COVID residents and that the COVID positive residents residing on G Hall were moved to the end of G Hall on the north side which was then barricaded off from the rest of the hallway. V1 also stated that there is a dedicated nurse caring for the COVID positive residents now. V1 also stated that on 12/10/20, the facility barricaded the end of E Hall on the south side and isolation signs were placed on the doors at that time. 2. All staff were in-serviced by V1 (Administrator) on proper facial coverings. Additional staff would be in-serviced by V1 (Administrator) prior to the start of their next shift. 3. On 12/15/20, at 8:45 am, the North side, G Hall was barricaded off with COVID positive residents and on the South side, the E Hall was barricaded off, with no residents residing on it. 4. The Facility Census Roster, dated 12/15/20, isolation rooms were reviewed. 5. Facility Inservice Sheet, dated 12/10/20, was reviewed. 6. On 12/15/20, all employees observed with proper facial coverings and PPE. 7. On 12/15/20, isolation signs were on designated isolation rooms.

Based on observation, interview and record review, the facility failed to implement skin breakdown prevention interventions for three residents (R1, R2, and R3) and prevent worsening of a pressure ulcer for one (R1) of three residents reviewed for pressure ulcers in a sample of three. This failure resulted in the progression of R1's right posterior upper thigh pressure ulcer to an unstageable wound that required surgical excisional debridement due to necrosis. Findings include: Undated facility wound policy documents Upon admission and at least weekly, residents identified to have pressure ulcers will have the following: 1) turn and position as needed of individual needs. 5) Supportive device i.e. waffle boots. 1. R1's medical record dated 9/9/20 documents, No skin issues. R1's Braden Skin Risk Assessment (8/12/2020, 9/9/2020 and 9/23/2020) documents R1 was at moderate risk for skin breakdown. R1's medical record dated 9/23/20 documents, Right gluteal fold pressure ulcer measuring 4.0 centimeters (cm) x 2.0 cm and Right gluteal fold pressure ulcer measuring 2 cm x 2 cm. R1's medical record dated 10/15/20 documents, Right gluteal fold pressure ulcer measuring 5.0 cm x 7.0 cm and left heel pressure ulcer. R1's medical record dated 10/29/20 documents Unstageable pressure ulcer (due to necrosis) measuring 2.5 cm x 1.3 cm of the right posterior upper thigh requiring surgical excisional debridement. R1's care plan does not address R1's pressure ulcer to right posterior upper thigh, pressure relieving device or need for turning and repositioning. On 11/12/20 at 10:20 am, V5, certified nursing assistant (CNA) stated There's a task called safety check in our point of care (POC) charting that tells us when a resident is to be turned and repositioned every two hours. On 11/12/20 at 11:50 am, V6, CNA, stated We know which residents to turn and reposition every two hours because they'll have a safety check task in POC. R1's medical record does not document a task in POC for turning and repositioning to prevent or reduce pressure ulcers. 2. On 11/12/20 at 11:14 am, R2 observed with dark circular spot on right heel with no pressure relieving boots in place. R2 stated he uses his right heel to propel himself around the facility due to his left leg amputation. R2 stated that it usually doesn't hurt, but can when he gets in a hurry. R2's medical record dated 10/24/20, documents Resident noted with 4.0 cm x 3.5 cm circular dark spot on his right heel, non fluid filled. Medical doctor notified. New order for [MEDICATION(S)] and bordered dressing daily. R2's care plan does not document R2's right heel pressure ulcer, pressure relieving device or need for turning and repositioning. 3. R3's medical record dated 10/7/20 documents new onset suspected 4 cm x 4 cm deep tissue injury to left heel. On 11/12/20 at 11:27 am, R3 observed to have pressure ulcer on left heel and coccyx. R3's current care plan does not document left heel or coccyx pressure ulcer. R3's POC does not include a turning and repositioning task for CNAs. On 11/12/20 at 1:32 PM, V2, Director of Nursing (DON), stated It is the expectation that those things (pressure ulcers, turning and repositioning and skin integrity interventions) are documented in the care plan. On 11/12/20 at 2:33 PM, V2, Director of Nursing (DON), stated Unfortunately the turning and repositioning task was not added in POC for (R1, R2 and R3). On 11/13/20 at 7:50 am, V3, Wound Doctor (WD), stated The facility should be offloading pressure points for residents at risk for skin breakdown and turning and repositioning at least every two hours. They should also have a pressure boot on (R2)'s heel. I've told them this before. It's in my notes that residents with pressure ulcers on the heels should have pressure boots on to offload the pressure. This helps prevent the heels from getting pressure sores. I have issues with a lot of the pressure ulcers in that facility. I tried doing my wound rounds last time and they didn't have the staff to assist me so I was unable to do my wound rounds. On 11/13/20 at 8:50 am, V2, DON, stated I don't think the facility policy states how often the resident should be turned and repositioned. It should be documented in the care plan and a task added to the CNAs POC documentation. The POC charting is set up to have the residents turned and repositioned every two hours. On 11/13/20 at 11:04 am, V2, DON, stated turning and repositioning is every two hours regardless of whether they are moderate or high risk and regardless of what type of wound they have.

Based on record review, and interview, the facility failed to ensure all residents were free from physical and verbal abuse, for one of three residents (R3) reviewed for abuse, in a sample of four. This failure resulted in R3 appearing traumatized and scared after being yelled, cursed at and being physically forced to sit in (R3)'s wheelchair by V12 (Certified Nursing Assistant); additionally causing red marks on (R3)'s neck and scratches to (R3)'s shoulder. Findings include: The facility policy, titled Abuse Prevention Program (no date), documents, Federal and state laws and regulations mandate that 'a nursing home resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.' The following definitions for these actions are based on federal and state laws, regulations and interpretive guidelines: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. The policy further documents, Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. A Minimum Data Set assessment, dated 8/10/20, documents R3 requires the assistance of 1-2 staff members for all Activities of Daily Living, utilizes a high-back reclining wheelchair, and has severe cognitive impairment. R3's current physician's orders [REDACTED]. An Abuse Investigation Report, dated 10/05/20, documents staff alleged V12 cursed at and was inappropriate in her redirection of R3, causing injury of superficial red marks/scratches to upper chest. A witness statement provided by V11 (Certified Nursing Assistant) within the investigation, dated 10/08/20, documents, I had heard some loud bangs, and moans that sounded like a man coming from down the hall. I stopped and focused and could hear a man yelling 'no' and 'stop' over, and over again as I heard the bangs. I could hear (V12) yelling 'stop' and 'sit your a*s down' and other things I couldn't make out. I went to (R4's) room to hand him his drink, and went on to my next room which was the last room B6 to make the coffee, and tea for the other 2 residents that stay in that room. As I moved my cart to the next doorway I heard (R3's) door open, and (saw V12) pulling backwards a wheel chair. In the wheel chair, I saw R3 was sitting in that chair. Due to the dim lighting, and distance I could not see his face. (V12) backed him out of the room and then began to push the chair to wheel him down the hall but as she started to do so, his feet caught the floor which caused them to brake. (V12) then got mad and grabbed (R3's) shoulders, pulling him back and said 'sit the f*ck back!' (R3) of course pulling himself up was not listening and she grabbed him by the back of the neck and from what I seen was using her force to push down on him and squeezing him and said 'lift your fu*king legs up now!' and 'come on now.' (R3) finally lifted his feet up and she began to push him down the hall into the dining room for dinner. In V11's written statement, she later describes, R3's face immediately after the incident, as appearing traumatized and scared and observing (R3's) face was red and his neck was red, so she immediately informed V3 (Assistant Director of Nursing) ADON what had happened. A Skin Observation Tool, dated 10/05/20, immediately after the incident, documents R3 had four red scratches on his right shoulder, redness to his left shoulder and around his neck, and Notes: All areas noted above with bright redness. Scratches to right shoulder with spotty open areas and spotty purple/blue bruising. A Employee Report, dated 10/05/20, documents V12 was Suspended pending allegations of verbal/physical abuse. Investigation complete on 10/08/20. (V12) was found to violate facility basic standard of care in that you did not maintain the well-being and dignity of a resident in your care. On 10/14/20 at 1:49 pm, V11 stated on 10/05/20 at approximately 6:00 pm, she overheard yelling and banging coming from the closed door of R3's room. V11 stated she had observed V12 enter R3's room and closed the door, so she knew it was V12 who was yelling sit your a*s down! which was followed by a man's voice yelling No! and Stop! over and over. V12 then exited R3's room, pulling R3's wheelchair backwards out of the doorway with the handles, and R3 dropped his feet causing his body to get pulled forward. V11 stated she observed V12 get up on her tiptoes and place her hands on R3's shoulders, pushing with all her weight to force R3 down into his wheelchair, yelling sit the fu*k down! and pick up your fu*cking feet! V11 stated she observed V12 grab R3 by the neck from behind and R3 picked up his feet for her to propel him to the dining room. V11 stated when she saw R3 in the dining room he looked terrified. V11 stated she observed the collar of R3's t-shirt to be balled up as if it had been in a fist and pulled, along with red marks on R3's neck, that had not been there prior. On 10/14/20 at 12:38 pm, V3 (Assistant Director of Nursing), stated she was approached by V11 at approximately 6:15 pm on 10/05/20, who informed her what she had observed and overheard just then between R3 and V12. V3 stated she immediately informed V2 (Director of Nursing) DON, who happened to be in the building, and escorted V12 out of the facility. V3 stated she found R3 in the dining room and observed four fresh scratch marks from fingernails on his right shoulder, and multiple bright red marks on his shoulders, upper chest and below the neck. V3 took R3 into his room to further assess him and inquire as to what happened. V3 stated R3 seemed scared and intimidated, which was not his normal demeanor. V3 stated R3 could only convey to her the words, she hurt me, while patting his shoulders where the red marks were. On 10/14/20 at 3:00 pm, V1 (Administrator/Abuse Coordinator) stated it was his conclusion upon completion of his investigation that V12 did cause the scratches and red marks to R3's shoulders and neck. V1 stated V12 refused to provided him with a statement of what occurred, and V12 was terminated for her actions.

Based on record review, and interview, the facility failed to provide thorough skin inspections, develop and implement pressure reducing interventions, provide a skin assessment (Braden Scale) every week for four weeks after admission, and obtain a treatment for [REDACTED]. These failures resulted in R1 developing an infected stage four pressure ulcer that required hospitalization , surgery to debride (remove damaged tissue from a wound) the ulcer, and intravenous antibiotics. Findings include: The National Pressure Ulcer Advisory Panel Pressure Injury Prevention Points dated 04/2016 documents, Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury on admission and weekly for four weeks after admission for long term care residents. Skin Care: Inspect the skin at least daily for signs of pressure injury, especially nonblanchable [DIAGNOSES REDACTED]. Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices. The facility's Pressure Sores policy (undated) documents, The comprehensive assessment and plan of care determines the amount of care needed by each individual resident to ensure that a resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Resident assessment identifies residents at risk of developing pressure sores and routine preventative care provided. For all residents who have pressure sores identify if measures to assist healing are necessary (relieving pressure, moving resident without shearing, applying medicated dressing, and [MEDICATION NAME] eschar (dead skin tissue). R1's Face Sheet documents that R1 was admitted to the facility on [DATE]. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 needed extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. This same MDS Assessment documents is at risk for developing pressure ulcers however is not on a turning/repositioning program or nutrition/hydration intervention to manage skin problems. R1's Braden Scale for Predicting Pressure Sore Risk dated 11-13-19 and signed by V6 (Licensed Practical Nurse/LPN) documents R1 was at moderate risk of developing a pressure ulcer. This same assessment documents a Braden Scale should be completed on admission for four weeks and then quarterly thereafter. R1's Medical Record does not include documentation of R1 having a Braden Score done, as instructed, for the four weeks after R1's admission (11-13-19). R1's Braden Scale for Predicting Pressure Sore Risk dated 2-11-20 and signed by V5 (Treatment Nurse) documents R1 had declined to being a high risk of developing a pressure ulcer. R1's Care Plan from admission (11-13-19) to discharge (2-18-20) does not include any pressure relieving interventions to prevent pressure and does not indicate that R1 was at high risk for developing a pressure ulcer. R1's Documentation Survey Report dated 2-1-20 to 2-18-20 (date of R1's discharge) documents the following interventions/tasks: Skin Observation every shift. This same report indicates that R1's skin observations every shift was not completed for 13 shifts during this time frame. This report also documents that an open skin area was identified on 2-2-20 at 6:59 AM. R1's Medical Record does not include an assessment or treatment to the open area identified and documented on 2-2-20. R1's Skin Observation Tool dated 1-28-20 and 2-11-20 documents R1 had no skin alterations except for excoriation to R1's groin. R1's Progress Notes dated 2-18-20 at 1:57 PM and signed by V5 documents, (R1) assessed by writer and noted with rash like areas over left and right buttock. Upon further assessment (R1) also to have severe breakdown between the buttocks. (R1) is incontinent of bowel and bladder, has poor skin turgor, and is unable to voice his needs including pain or discomfort. Contacted Medical Doctor and received orders to send to hospital for further evaluation. R1's Progress Notes dated 2-18-20 at 2:48 PM and signed by V4 (Registered Nurse/RN) document, (R1) sent to hospital for evaluation of wound on sacrum/ischium. R1's Progress Notes dated 2-19-20 at 12:03 AM document, (R1) admitted to hospital with [DIAGNOSES REDACTED]. R1's Hospital Discharge Summary dated 2-23-20 and signed by V8 (R1's Hospital Medical Doctor) documents, (R1) was admitted to the hospital on 2-18-20 with a pressure injury of skin involving the back and buttock. (R1) presented to the emergency department with complaints of a coccyx wound. Surgery was consulted for wound debridement and (R1) was initiated on [MEDICATION NAME] and [MEDICATION NAME] (intravenous antibiotics) therapy. (R1) underwent debridement of the Decubitus ulcer on 2-20-20. Nursing home reports states ulcer has been present for at least two weeks but is getting worse. R1's Operative Notes dated 2-20-20 document, Procedure: Debridement of Sacral Decubitus Ulcer. Brief Findings: Two [MEDICAL CONDITION], bone exposed in anterior wound. Debridement taken to muscle. Wound Class: Four. The inferior wound measure 7.0 cm (centimeters) x 3.0 cm x 0.5 cm deep and the superior wound measures 6.0 cm x 5.0 cm x 2 cm deep. Upon inspection of the sacrum there is obvious dead devitalized tissue overlying the sacrum in two regions. On 2-26-20 at 9:15 AM V4 (RN) stated, The treatment nurse (V5) came and got me to look at (R1's) skin area on 2-18-20. (V5), (V1/Administrator), and I all decided that the wound was bad and (R1) needed to be sent to the emergency room for treatment. The wound was in the center of (R1's) butt crease, red in color in the center, and had two purple areas on each side. I did not document anywhere what the wound looked like and did not measure the wound. I do not do skin checks on the residents. The treatment nurse does the skin checks. On 2-26-20 at 9:30 AM V5 (Treatment Nurse) stated, On 2-18-20 V9 (Certified Nursing Assistant/CNA) and I laid (R1) down after lunch. We cleaned (R1) up after (R1) had a bowel movement. That is when I noticed (R1) had two necrotic areas. The area was bad, and I knew it was beyond what treatment I could provide within the facility. (R1's) wound needed treated at the hospital. (V9) said to me that the wound had been there for a while but was unsure how long. The staff should have reported the wound to a nurse when it was first found. We could have prevented the wound from becoming that bad. I am the only staff that does (R1's) skin checks weekly. Whenever I checked (R1's) skin I just looked at his skin. I never separated his butt cheeks to look for wounds when I did his skin checks. (R1) was in a low bed so it was hard to re-position him. (R1) was totally dependent on staff for re-positioning. After I did the Braden Scale for Predicting Pressure Sore Risk Assessment on 2-11-20 and determined (R1) was at a high risk for developing a pressure ulcer, I should have developed and implemented pressure relieving interventions to prevent (R1) from developing pressure ulcers. (R1) did not have any pressure relieving interventions implemented. I am new to this position and thought that the care plan coordinator would implement pressure relieving interventions. (R1) did not have a Braden scale assessment done every week for four weeks after (R1) was admitted to the facility. I am just learning and did not realize the Braden scale was supposed to be done on admission and every week for four weeks after admission. (R1's) skin checks were supposed to be done every shift by the CNA's and were not completed as documented. The first documentation of (R1) having an open area was on 2-2-20. I was not made aware of (R1) having an open area on 2-2-20. (R1) did not have an order to treat the open area. On 2-26-20 at 11:30 AM V7 (Care Plan Coordinator) stated, I got (R1's) Braden Scale Scores indicating (R1) was at a moderate and high risk for developing pressure ulcers. I guess I am not sure what to do with those scores once I get them. (R1) did not have a pressure relieving care plan with interventions to prevent pressure ulcers. (R1) probably should have had individualized pressure relieving interventions put into place. On 2-26-20 at 1:15 PM V10 (R1's Physician) stated, The facility should have identified (R1's) pressure ulcer when it was a stage one and notified me to get (R1) a treatment, some laboratories done, and pressure relieving interventions. It should not have been found at a stage three or four. On 2-26-20 at 1:20 PM V9 (CNA) stated, (R1) had an open area to his bottom for a while. I am not sure exactly how long. The CNA's would just put cream on the area. On 2-26-20 at 1:45 PM V2 (Director of Nursing) stated, When the treatment nurse does a weekly skin check, all areas of the skin should be observed to the best of the nurse's ability. I am not sure what we (the facility) does when a resident's Braden Scale indicates the resident is at high risk of developing a pressure ulcer. Pressure relieving interventions should be implemented and a pressure relieving care plan should be developed at the least. The physician should have been notified when (R1's) open area was first found to at least get a treatment order or get referral to the wound specialist. On 2-26-20 at 2:15 PM V8 (R1's Hospital Physician) stated, (R1) was brought to the emergency room with a necrotic coccyx pressure wound that was infected into (R1's) bone. (R1's) pressure ulcer was so bad that it would have had to developed and worsened for weeks prior. That pressure ulcer did not develop overnight. The facility should have recognized that pressure ulcer at a stage one and treated it as soon as it developed to prevent the pressure ulcer from getting as bad as it was when (R1) arrived at the hospital. (R1's) pressure ulcer had to be treated with intravenous antibiotics and surgery to debride the ulcer.

Based on interview, and record review, the facility failed to prevent staff to resident verbal/mental abuse of one resident (R1) and failed to prevent staff to resident mistreatment of [REDACTED]. These failures resulted in emotional distress for R1 and R2. Findings include: Physician order [REDACTED]. Comprehensive assessment dated [DATE] indicates R1 uses a wheelchair for mobility and that R1 is fully oriented with no cognitive or memory impairments. Final Abuse Investigation Report (undated) indicates a determination was made through video surveillance, staff and resident interviews that V3, CNA (Certified Nurse Assistant) refused to give R1 a cigarette (during a scheduled smoking time) without just cause, berated R1 over insignificant issues by unduly raising her voice to R1, pointing her finger toward R1 and pushing R1's wheelchair away from her. Report indicates these actions by V3 caused unwarranted emotional distress and anxiety for R1. Report indicates a determination was made that V3 violated R1's rights and while scolding R1 - harshly and unjustly - caused significant emotional harm, resulting in the allegation of verbal/mental abuse to be founded. Report indicates V3 was terminated from employment. Signed Investigation Interview of V4, LPN dated 7/17/19 indicates V4, LPN (Licensed Practical Nurse) was in the medication room when she heard a female voice screaming She shoved me. (V4) walked out of the medication room and saw (V3, CNA) walk behind the nurse's desk where (V5, RN (Registered Nurse) was sitting at the computer. (V4) asked who had been screaming and at that time (R1) wheeled up to the desk and started yelling that (V3) had shoved her. (V3) then stood up and began yelling at (R1), pointing in (R1)'s face and stating, I didn't shove you - I pushed you away. At that time (V3) was told to stop and (R1) stated that (V3) wouldn't give her a cigarette at smoke pass. (V3) was asked if she had given (R1) a cigarette and (V3) responded I'm not giving her anything. (V3) was then sent to the staff break room and (V5) gave (R1) a cigarette. Investigation Interview dated 7/18/19 indicates R1 stated that she was in line for a cigarette during smoking pass and that V3 told her and R4 to be quiet. R1 stated that she reached out for the cigarette and V3 said she wouldn't give her one and pushed the wheelchair away. R1 indicated that she followed V3 to the nurse's station to get a cigarette. On 7/31/19 at 3:20pm R1 stated that the way V3 treated her Made me feel like I'm being scolded - like a child. (V3) is a bully. R1 stated that she was upset afterward and that I shouldn't have to beg to get my cigarette and she (V3) did push me. I was shocked that she did that. On 7/31/19 at 10:15am V2, Resident Services Coordinator stated that R1 was still visibly anxious and upset when he interviewed her on 7/18/19 almost 16 hours after the incident. 2) physician's orders [REDACTED]. Comprehensive assessment dated [DATE] indicates R2 has mild cognitive impairments, can make needs known; understands and is understood. Signed Investigation Interview of V6, CNA dated 7/17/19 indicates (on that date) (V3, CNA) removed (R2) from the dining area and brought (R2) into the nurse's station area. (V3) obtained nail clippers and told (R2) she was going to clip her fingernails. (R2) repeatedly told (V3) she did not want her nails clipped. (V3) continued to grab (R2) by the hand and (R2) repeatedly tried to push (V3) away from her stating I don't want you to cut my nails. Get away from me. Signed interview indicates (V3) was forcing R2's hand into hers and continued to clip (R2's) nails with(R2) still saying No. Signed interview indicates V6 left the area at that point. On 7/31/19 at 11:15am V4, LPN stated that after V3, CNA was sent home due to allegation of abuse by R1 - V6, CNA reported that earlier in the evening V3 forced R2 to get her fingernails clipped. At that time R2 was asked if she had wanted her nails cut and R2 stated No and appeared upset that they had been cut. V4 stated that V6 should have intervened and reported V3 right away and that residents should not be forced to do anything. On 7/31/19 at 11:35am R2 stated that it made her mad and afraid when V3 cut her nails and pulling on her hands. R2 stated I told her no, but she did it anyway. Final Abuse Investigation Report (undated) indicates a determination was made that V3, CNA did cut R2's fingernails and V3, CNA admitted that R2 was resistive and verbally expressed that she did not want her fingernails cut.

Based on interview and record review the facility failed to prevent abuse for one of three (R1) residents reviewed for abuse in the sample of three. This failure resulted in R1 crying and feeling that he may be put out with nowhere to go. Findings include: The facility Abuse Investigation documents, in part, The video recording of (R1) and the entrance to the room was replayed from 11:44PM on 1/25/2017 to 7:39AM on 1/26/2017. (E8) Certified Nurse Aide (CNA) can be seen standing in front of (R1) as he is sitting in his wheelchair in his doorway. (E8) is speaking to (R1) and reached down, grabs his wheelchair and forcibly pulls him out of the doorway, letting go and allowing (R1) to run into the opposing wall and laundry barrel. (E8) enters the room immediately without looking where (R1) is going with total disregard for his safety. On 3/1/2017 at 12:00PM, E7 CNA stated, On 1/29/2017, (R1) was tearful when he said that a CNA took (feces) and smeared it in his hair, stomach and in his mouth. (R1) did not know the name of the person but said he would know her if he saw her. E7 stated she reported it to the nurse, (E9) Licensed Practical Nurse (LPN). E7 stated she actually took report on 1/26/2017 from (E8). E7 said it was clear that (E8) was upset and frustrated that morning but E7 didn't think much about it. E7 stated R1 was clean and neat without an unclean body odor that morning. E7 explained she does not think E8 actually threw feces at R1 or smeared it in his hair because E8 would have probably had to have given R1 a shower. The facility investigation documents a statement dated 1/30/2017 from (E9) LPN, This nurse spoke with (R1) and asked what happened. Resident became tearful and stated, 'the CNA was mad at him because he had pooped on himself and said she should throw it in his mouth'. (R1) stated this occurred (R1) stated 'Thursday or Friday' .(R1) stated he did not tell anyone else because he was scared no one would believe him and he would be put out and have nowhere to go. Resident again became tearful. The 2/3/2017 facility Final Abuse Investigation Report for R1 documents the following conclusions have been determined, Account of incident led investigators to believe (E8) was highly frustrated and had lost patience with (R1). Therefore its believed that (E8) did infact verbally and mentally abuse (R1). for the incident with R1 dated 2/3/2017, documents E8 was immediately terminated for verbal/mental abuse.

Based on interview and record review, facility staff failed to implement safety precautions in accordance with the resident care plan for one resident (R1) of three residents reviewed for a history of falls. This failure resulted in a forward fall in which R1 sustained a forehead laceration requiring sutures. Findings include: A facility Incident Report dated 8/15/13 at 9:05 AM indicated that R1 fell straight out of R1's wheelchair onto the floor at that time. The report indicated that R1 sustained a large open wound to the forehead with much bleeding. The report also indicated that R1 was sent to the hospital via ambulance for evaluation. An Incident Report Investigation dated 8/15/13 pertaining to R1's fall indicated that staff members were instructed and disciplined regarding use of the seatbelt for R1. Facility Employee Report forms attached to the fall investigation indicated that Certified Nurse Aides (E5 to E8) and Licensed Practical Nurse (E4) were all disciplined and given a final warning for "poor nursing care" by the "failure to provide and apply bilateral foot pedals and safety self release belt to prevent injury and falls as careplanned." R1's hospital Emergency Department report dated 8/15/13 indicated that R1 had a "U shaped" 2.5 cm (centimeter) laceration on the frontal area of the head. R1's 2013 Fall Risk Assessment sheet indicated on 1/1/13, 3/27/13, and 6/25/13 that R1 had a risk score of "17," where a score of an eight or higher was defined as a high fall risk. According to R1's care plan updated on 6/21/13, R1 fell from the wheelchair on that date and lacerated R1's forehead. The care plan then implemented a self-release seatbelt safety intervention for R1's wheelchair. E1 (Administrator) stated on 8/21/13 at 3:25 PM that the five staff members (E4 to E8) were disciplined in regards to R1's 8/15/13 accident for not following R1's care plan and failing to have foot pedals on R1's wheelchair. E1 said that the facility has an unwritten policy that foot pedals are to be on all resident wheelchairs unless the resident can self-propel themselves in the wheelchair with their feet. .

Based on interview and record review the facility failed to operationalize their Safety policy by assessing fall risk upon admission and failed to implement new interventions with each fall for one of three residents (R1) in a sample of three. R1 sustained a fractured cervical spine and nose after three consecutive falls. Findings include: Facility Admission Data Base documents that R1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The Facility's undated Resident Accident/Incident Safety Policy documents "all residents will have an assessment done at the time of admission." "Those individuals identified as high risk for falls will be identified for staff to monitor closely." "On a daily basis incidents/accidents will be reviewed by the facility administrative staff. Necessary changes in the resident's plan of care will be implemented." The Facility's undated Incident/Accident Reporting and Investigation Policy documents: "For residents with persistent problems, list on their care plan, with measures taken to correct." R1's Fall Risk assessment dated [DATE], six days after admission documented R1 had a total score of 11 which indicated a high fall risk. E6 (Restorative Nurse) confirmed R1's Fall Risk Assessment was not completed until 4/24/13, 6 days after admission. R1's Interim Care Plan (Care Card) dated 4/18/13 documents under the section High Risk Program, "fall." Interventions were not listed to specifically address R1's fall potential. The Facility's Incident log documents R1 had falls on 4/21/13 at 12:05 p.m., 4/25/13 at 10:00 p.m. and 4/27/13 at 4:00 a.m., 10:33 a.m. and 10:50 a.m. R1's Incident Report dated 4/21/13 at 12:05 p.m. documents R1 was found on the floor. R1 was "lying on his right side and noted with blood on the Left side of his face and hands." The report documents R1 had a "2 cm (Centimeter) laceration to medial bridge of nose. Nose noted with swelling." On R1's Incident Form under the section titled "Actions Taken" it documents the doctor was notified and sent to the hospital for evaluation and treatment. R1's History and Physical from the Hospital dated 4/21/13 documents under Admission Diagnosis: [REDACTED]. The Hospital's Diagnostic Imaging Report documents "Comminuted, Depressed Nasal bone Fracture. R1's Incident Report Dated 4/25/13 documents R1 was found Lying face down in his room with no injuries noted. The section titled Actions taken documented: assisted back to bed. R1's Incident Report Investigation documents recommendation for action: Hospice referral and Side rails for bed mobility. R1's Care Plan dated 4/26/13 documents as a problem for R1: risk for falls. The Care plan also documents under problem: resident noted with 2 falls in his room, siderails ordered for bed. Individual interventions were not indicated or dated for the fall that occurred 4/21/13. R1's Incident Report dated 4/27/13 documents at 4:00 a.m. R1 was found lying on his left side with no injuries noted. Under the section titled description of incident it documents "nose laceration open." The Section on the Incident Form titled action taken is blank. On the same day at 10:33 a.m. R1's Incident Form documents R1 fell on the floor. The section titled Description of Incident documents R1 sustained a small laceration to the left elbow with active bleeding and altered skin with bruises to face "from previous incident." R1's Incident Report dated the same day, 4/27/13 at 10:50 a.m. documents R1 "was on the floor again." On R1's Incident Report under Action Taken it is documented to send to hospital. R1's History and Physical dated 4/27/13 at 11:45 a.m. documents facial contusion (bruising), neck pain and possible acute fracture of C5 and C6 Vertebrae in the neck. The section titled Chief Complaint on the Hospital History and Physical documents weakness, frequent falls and altered mental status. The Assessment and Plan section of R1's History and Physical documents a cervical spine fracture. R1's Hospital Diagnostic Imaging report dated 4/27/13 documents under the section titled Impression: "Hematoma (Collectin of blood outside of a blood vessel) over right side of forehead and nose with mildly depressed fracture of anterior Nasal bones Bilaterally. Cannot exclude Fracture of an anterior Osteophyte (bony projection) at C5 C6." R1's care plan dated 4/26/13 documents a problem for R1 as a risk for falls. The Fall care plan contains undated interventions with the only intervention dated being on 4/29/13. The Care Plan does not include interventions for R1's falls on 4/21/13 or 4/27/13 at 4:00 a.m. and 10:33 a.m.. On 5/7/13 at 12:20 p.m. E5 (Assistant Administrator) stated an Interim Care Plan (Care Card) is used for residents for the 1st 14 days after admission. E5 stated after R1 fell on [DATE] a full Care Plan should have been initiated to direct the staff with cares. E5 stated R1's Interim Care Plan did not direct staff with interventions for R1's falls. E5 confirmed that R1's care plan nor Incident Report documented an intervention for R1's falls on 4/21/13 and 4/27/13 at 4:00 a.m. and 10:33. E5 stated "we should have done better." On 5/6/13 at 3:10 p.m. E2 DON (Director of Nursing) stated new interventions were not put in place for R1's fall on 4/27/13 at 4:00 a.m. E2 confirmed no new interventions were put in place for any of R1's falls that occurred on 4/27/13 until 4/29/13. On 5/6/13 at 2:20 p.m. E3 (Care Plan Coordinator) stated a new intervention should be put in place after each fall. E3 provided an example, if a fall occurs at 10:00 p.m. at night an intervention for that fall is not decided until the next day at the daily fall meeting that takes place. E3 stated R1's falls that occurred on 4/27/13 were not addressed with new interventions by the fall committee until 4/29/13. On 5/7/13 at 12:10 p.m.

Based on record review and interview, the facility failed to transfer one of three residents (R1) with recent falls in the sample of three residents in a safe manner with the appropriate number of staff specified by R1's assessment. This failure resulted in a staff-assisted fall to the floor and a broken ankle injury to R1. Findings include: A facility list prepared on 5/16/11 of resident hospitalization s and emergency room visits for April and May 2011 indicated that R1 went to the local emergency roiagnom on [DATE] for ankle and leg pain. An X-ray report dated 5/15/11 from the facility's mobile radiology service indicated that R1 had sustained "an oblique fracture" of the distal right fibula with soft tissue swelling. A hospital Imaging Result Report dated 5/16/11 indicated that R1's right ankle showed a "minimally displaced oblique fracture of the distal fibula" and an "avulsion fracture off the medial malleolus." A hospital Patient Care Facilitator Nurse (Z1) for the Orthopedic Unit stated on 5/17/11 at 9:45 AM that R1 was scheduled for surgical repair of the right ankle fracture on 5/18/11. R1 stated on 5/17/11 at 9:50 AM at the hospital that her leg was hurt when "an African person pushed me (R1) to the floor." R1 was not able to give details of the incident. E1 (Administrator) stated on 5/16/11 at 2 PM that R1 learned from Nurse E5 on 5/15/11, after R1` had been sent to the hospital, that R1 had to be lowered to the floor by Nurse Aide E6 during a transfer on Friday evening 5/13/11. E1 said that E5 told E1 that E5 had not charted the matter in R1's record because it was not really a fall, and E1 showed no signs of harm at the time. E1 stated that E1 instructed E5 at that time to chart the incident in R1's record as a late entry. Nurse E5 stated at 2:10 PM on 5/16/11 that when E6 reported to E5 that R1 had to be assisted to the floor on 5/13/11 at about 5:30 PM, E5 went to R1's room to assess R1's condition. E5 said that R1 denied actually falling, hitting her head, or having any pain at the time. E5 stated that R1 never did complain of any pain until the morning of 5/15/11, when R1 was screaming and yelling "hurting" while at breakfast in the dining room with regards to R1's right ankle. E5 said that x-rays were obtained for R1's leg by a mobile radiology company, and then R1's right leg exhibited signs of a possible blood clot. E5 said that an order was obtained to send R1 to the hospital. E5 said that while the ambulance was there to transport R1 on the afternoon of 5/15/11, the mobile radiology company called to report that R1 had a fractured ankle. Nurse E5 stated that R1 usually transfers from one surface to another with the assist of one to two persons, depending on the resident's "willingness to assist." E5 said that the number of Aides involved in a transfer of R1 is left to the aides' discretion at the time. Nurse Aide E6 stated on 5/16/11 at 2:40 PM that E6 herself assisted R1 out of bed for the evening meal on 5/13/11 at about 5:30 PM. E6 said that she was transferring R1 from the bed to the wheelchair with a stand and pivot process when R1 started to lose her balance. E6 said that E6 leaned R1 against E6's leg, and physically sat R1 on the floor without any assistive device. E6 said that she gave R1 a pillow so R1 could lay down on the floor, and E6 went to summon aides and E5 for help. E6 said that they transferred R1 from the floor to the wheelchair, and R1 showed no signs of pain. E6 said that for the rest of that shift, R1 had no problems or pain during transfers. E6 further stated on 5/17/11 at 3:10 PM that after E6 thought back about the incident with R1, that E6 did have to turn R1 slightly as R1 slid down E6's leg to the floor. E6 said that R1's right foot was turned inward at the time, as is normal for R1, and that perhaps turning R1 as R1 went down caused twisting of R1's right leg. E6 stated that she never heard any crack or "pop" from R1's leg during the incident. E6 also said that R1 had a habit of sliding her feet and not lifting them during a stand and pivot transfer. E6 said that E6 has not worked at the facility very long, and that when she was oriented some weeks ago, her training Aide instructed E6 that R1 required a one person assist for transfers. Nurse Aide E8 stated on 5/17/11 at 1:10 PM that E8 also takes care of R1, and that E8 is able to transfer R1 by herself, since E8 has worked with R1 for a long time. E8 said that some Aides use two staff to transfer R1. R1's Care Plan last updated on 4/5/11 indicated that R1 had [DIAGNOSES REDACTED]. The Care Plan indicated that R1 was at "High risk for falls/safety per fall risk assessment" and had "Decreased mobility ability related to [DIAGNOSES REDACTED]/Schizophrenia secondary to decreased motivation." R1's MDS (Minimum Data Set) assessment dated [DATE] coded R1, with regards to transfer, as needing extensive assistance ( staff provide weight bearing support) and two + persons physical assist. Rehabilitation Coordinator E13 stated on 5/17/11 at 3:40 PM that with regards to transfer, R1 required a two person assist for safety reasons, before the accident last week. Restorative Nurse E11 stated on 5/17/11 at 3:45 PM that R1 was on the facility's restorative program, and requires a one to two person assist with transfers, depending on R1's endurance on a given day. E11 said that R1 was on E Hall, which is for residents who require more assistance, and that two aides work that hall together. E11 said that E11 "would expect (R1) to be transferred with an assist of two." E11 further added on 5/18/11 at 12:20 PM that R1 had been recently relocated from B Hall to E Hall for the reason that R1 required more assistance, due to the fact that R1 had "varying strength day to day."