Every finding on record at Signature Healthcare of South Pittsburg Rehab & We

Based on facility policy review, medical record review, facility investigation review, observation and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 residents (Resident #65 and Resident #6) of 13 residents reviewed for abuse. On 8/6/2024, Resident #6 grabbed Resident #65 by the shirt causing Resident #65 to turn over in his wheelchair causing scratches to the left shoulder, 3 skin tears to the left forearm, and a skin tear on the right hand to reopen. Resident #65 retaliated and struck Resident #6 in the face causing a laceration to the resident's right upper lip. The facility's failure to protect the residents' right to be free from physical abuse resulted in actual Harm for Resident #65 and Resident #6. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 9/15/2023, revealed .It is the organization's intention to prevent the occurrence of abuse .abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .It includes .physical abuse . Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety Disorder, Osteoarthritis Right Shoulder, and Alcohol Dependence. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #65 had behaviors of rejection of care for 4 to 6 days during the assessment period with no other behaviors noted. Review of a Nurse's Note for Resident #65 dated 8/6/2024 at 7:30 AM, revealed .called to room by CNA [Certified Nursing Assistant]. Elder [Resident #65] observed laying supine in the floor by roommate's [Resident #6's] bed. Elder [Resident #65] states roommate [Resident #6] grabbed him by the shirt, would not let go, and eventually pulled him down into the floor. WC [wheelchair] was flipped over as well. T-Shirt noted to be ripped. Denies hitting his head. Scratches noted to left shoulder. Skin tears noted to right hand and left forearm. Elder also states he hit his roommate in the mouth several times with his fist when he would not let go of him. Head to toe assessment complete without further injury noted or C/O [complaint of]. Elder assisted back to WC x [times] 3 staff. Skin tears cleansed with NS [normal saline] and covered with a dry dressing per orders. Shirt changed. Denies further needs . Review of a Nurse Practitioner's (NP) Note for Resident #65 dated 8/6/2024, revealed .Chief Complaint/History of Present Illness .Patient scheduled for visit following altercation with another resident [Resident #6] this morning. The patient [Resident #65] is [AGE] year-old male who was in an altercation with another resident [Resident #6] this morning. Patient sustained skin tears to upper extremities. Skin tears are currently bandaged, and dressing is clean dry and intact. Patient denies any other injuries or complaints other than skin tears at this time. Patient denies any acute concerns or needs at this time .No acute distress noted, cooperative, alert, and oriented x 3 [to person, place, and time] .New skin tears noted to upper extremities [right hand and left forearm] with dressing in place that are clean, dry, and intact .Skin tear of upper extremity .Nursing to complete wound care. Instructed patient that if he developed any additional or worsening symptoms following altercation to notify nursing for further evaluation .Patient verbalized understanding. Plan of care ongoing . Review of a facility investigation dated 8/6/2024, revealed the staff heard a commotion in the residents' (Resident #65 and Resident #6) room. When the nurse arrived to the room, Resident #65 was in the floor beside the roommate's (Resident #6's) bed and Resident #6 was lying sideways in the bed. The residents agreed that Resident #6 had pulled Resident #65 from his wheelchair by his shirt and would not let go. Resident #65 received skin tears and Resident #6 received a laceration to his upper lip. The residents were separated immediately, and Resident #6 was placed on one on one (supervision of 1 staff to 1 resident), was sent to the hospital for a medical clearance, for possible transfer to a Geriatric (Geri) Psychiatric (Psych) facility. However, there was not facility (Geri-Psych) availability at the time. Resident #6 was moved to another room (after return from the hospital's emergency room ) and the staff stayed 1 on 1 for 48 hours, he was then placed on every 15-minute rounds after the 48 hours concluded. Review of a facility document titled, Event Report Skin Integrity, for Resident #65 dated 8/6/2024, revealed .Skin Tear/Laceration left lower arm X 3 skin tears, some scratches to left shoulder. 1 inch [skin tear #1], 0.5 inch [skin tear #2], 0.5 inch [skin tear #3] .controlled bleeding .wound edges smooth .no pain .resident to resident .monitor for signs/symptoms of infection to skin tears .to left arm Q [every] shift until healed .cleaned with normal saline and cover with dry dressing . Review of a comprehensive care plan for Resident #65 dated 8/6/2024, revealed the resident was involved in a resident-to-resident altercation and the roommate (Resident #6) was moved to a different room. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia with Behavioral Disturbance, Hemiplegia affecting Left Non-Dominant Side, Mood Disorder, Schizoaffective Disorder Bipolar Type, Intracranial Injury, and Compression of the Brain. Review of an annual MDS assessment dated [DATE], revealed Resident #6 scored 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed no behaviors were noted during the assessment period. The resident was dependent for transfers. Review of a Nurse's Notes for Resident #6 dated 8/6/2024, revealed .Called to room by CNA. Elder's roommate [Resident #65] observed laying in the floor beside elder's bed. Elder states he [elicit word] [beat] [NAME] [Resident #65] up because he was wearing his shirt and wanted it back . Elder's roommate was not named [NAME] and the roommate [Resident #65] was not wearing elder's [Resident #6's] shirt. Head to toe assessment completed. Laceration noted to right upper lip with scant amount of bleeding. Laceration cleansed . bleeding stopped. Elder assisted into his WC x 2 staff and placed 1:1 [1 on 1] with nurse. Elder states 'bye [elicit name]!' as he is assisted out of room with nurse [speaking to Resident #65]. Elder continues to exclaim, 'I [elicit word] [NAME] up like a soup sandwich and I want to do it again! I am proud of myself, and my family would be too.' Elder believes '[NAME]' [roommate, Resident #65] is 'messing around with Aunt [NAME] [Certified Nursing Assistant A, not related to Resident #6].' Elder cannot be re-directed at present. Neuro [neurological] checks completed. [baseline following traumatic brain injury (TBI)] .Elder transferred to [hospital] ER [emergency room ] for medical eval [evaluation] at approximately 9:30 AM . Review of a facility document titled, Event Report Skin Tear/Laceration, for Resident #6 dated 8/6/2024, revealed .laceration .right upper lip .0.2 cm [centimeter] .controlled bleeding .no pain .behavioral outburst .first aide .monitor for signs/symptoms of infection Q shift .until healed . Review of a Physician's order for Resident #6 dated 8/6/2024, revealed .one on one . Review of a Physician's order for Resident #6 dated 8/6/2024, revealed .send to ER [emergency room ] for medical clearance . (medical clearance by ER for possible transfer to a Geri-Psych unit for evaluation). Review of a Nurse's Note for Resident #6 dated 8/6/2024 at 12:19 PM, revealed .Elder [Resident #6] returned to facility at 11:35 AM, following being medically cleared at [hospital] .ER reports elder had negative CT [computerized tomography], baseline UDS [urine drug screen], and un-concerning labs. Also states elder calmed down initially but eventually became agitated when he 'wanted to come home.' Shortly after arrival, elder began yelling for '[NAME] to come down here so I can whoop your [elicit word]!' Other elder [Resident #65] (who has been moved temporarily) heard elder yelling down the hallway and became irritated and began cussing elder from doorway. Staff intervened again. Elder continues stating he wants to '[elicit word] [NAME] up again' and attempting to tear down his privacy curtain and bed rail .NP [Nurse Practitioner], notified with new orders for Haldol [antipsychotic medication] 5 mg (milligram) IM [intramuscular] now . Review of a comprehensive care plan for Resident #6 dated 8/6/2024, revealed the resident was involved in a resident-to-resident altercation, was placed on 1 on 1 monitoring and had a psychosocial follow-up for 72 hours. The residents (Resident #6 and Resident #65) were separated immediately. Review of a Nurse's Note for Resident #6 dated 8/8/2024 at 12:01 PM, revealed .NP seen pt [patient], no further behaviors noted, not combative at this time. new order to dc [discontinue] 1 on 1 and begin q 15 min [minute] checks at this time . Review of a Physician's order for Resident #6 dated 8/8/2024, revealed .every 15-minute checks . Review of a NP's Note for Resident #6 dated 8/21/2024, revealed .Patient is scheduled for routine follow-up and maintenance of chronic conditions .Patient [Resident #6] recently had exacerbation of schizoaffective disorder requiring additional doses of Haldol. Patient was sent to ER for medical clearance and referred to Geri psych. Patient was cleared medically. However, Geri psych referrals were declined due to patient's history of TBI. Following additional doses of Haldol patient returned to his baseline mental state. Patient is currently receiving Haldol 3 mg twice daily. Nursing denies any continued or worsening agitation since patient was placed on 15-minute checks .Positive for agitation and irritability but improved since altercation occurred . schizoaffective disorder, bipolar type .Continue haloperidol (Haldol) 3 mg twice daily. Will discontinue every 15-minute checks since patient's return to baseline mental state. Nursing to notify provider with any increased agitation . During an observation on 10/14/2024 at 10:20 AM, in the day room, Resident #6 was seated in a high back wheelchair, awake and alert, with no behaviors or concerns identified. During an interview on 10/14/2024 at 10:20 AM, Resident #6 initially stated he did not recall the incident (with Resident #65) and later stated .he [Resident #65] made me mad he was a talker he called me a [elicit name]. I tried to choke him to death, but he didn't hit me back . When asked if he recalled having a small cut to his lip he stated .I was so mad he might have hit me I just don't know . When asked if he had any further problems with Resident #65 or any other resident he stated No .he [Resident #65] isn't in my room any more . During an interview on 10/14/2024 at 10:40 AM, CNA A stated .I was both [provided care for Resident #6 and Resident #65] of their CNA that day [8/6/2024] .they were in their room, [Resident #6] was still in bed and [Resident #65] was in his wheelchair. I walked by and saw something had happened. [Resident #65] was on the floor, and his wheelchair was laying on its side .they were still exchanging words .[Resident #65] said he rolled by [Resident #6], and he grabbed him .[Resident #65] was out of the reach of [Resident #6] he can't get out of bed by himself, so I walked to the door and yelled at [Registered Nurse] (RN) B and the other nurse [Licensed Practical Nurse] (LPN) C came in too. They assessed [Resident #65] and got him out of the floor. [RN B] went to get bandages and I got [Resident #6] up and got him dressed and took him to the day room .[Resident #6] calls [Resident #65] [NAME] but that isn't his name . During an interview on 10/14/2024 at 10:55 AM, RN B stated .they were roommates [Resident #6 and Resident #65] they had been known to exchange words but nothing ever aggressive before .it was mainly because [Resident #6] would call [Resident #65] [NAME] and get mad when [Resident #65] didn't answer .that day [8/6/2024] he thought [Resident #65] had on his T-shirt, but he didn't he had on his own shirt .it was just a plain white T-shirt .he also stated he thought [Resident #65] was fooling around with his Aunt [NAME] which is [CNA A] but he calls her Aunt [NAME]. [CNA A] hollered for me and said that [Resident #65] was in the floor. [Resident #6] was still in his bed he had his hand on the side rail, and he was just looking at [Resident #65]. I asked what happened and [Resident #65] stated that [Resident #6] had just grabbed him as he rolled by his [Resident #6's] bed he had grabbed him by the shirt and would not let him go .after we got them separated he [Resident #65] told me that he had hit [Resident #6] a couple of times in the mouth to get him [Resident #6] to let him [Resident #65] go .[Resident #65] said when he was pulling away from [Resident #6] that his wheelchair tipped over .[Resident #65] had a skin tear on his right hand .he had 3 or 4 superficial scratches a couple of inches long to his left shoulder and 3 new skin tears to his left forearm. I [RN B] cleaned them with normal saline and put on a dry dressing .[Resident #65] wasn't afraid or withdrawn he did tell me that he felt bad for retaliating because of [Resident #6's] disability .[Resident #6] did have a small cut to the top right lip. I cleaned it up, it wasn't bleeding .neither one of them complained of any pain .[Resident #65] didn't want to leave the room, he prefers to stay in his room and look at his phone or watch TV. So we got [Resident #6] up and dressed and took him to the day room .he likes to be in the day room, and spends most of his time in there .we were able to move [Resident #6] .both are monitored daily for behaviors .[Resident #6] had a couple of days that he was yelling out, but nothing after that .neither one of them has shown any aggressive behaviors after the incident, and I am not aware of any aggressive behaviors before the incident . During an observation and interview on 10/14/2024 at 11:30 AM, Resident #65 was awake, alert, and lying in bed watching TV. Resident #65 stated .[Resident #6] grabbed me by the shirt, he said it was his shirt but I got it out of my closet, it was my shirt .he [Resident #6] stretched my shirt and scratched me .he grabbed my wheelchair and when I was trying to get away from him my chair turned over .he is crippled but he's got a strong grip .I [Resident #65] wanted to hit him back but something told me not to since he is crippled and his mind isn't right .he is not all upstairs .no that is the only problem I have had with anybody .[no] he didn't hurt me I was able to brace myself when I fell .no I am not afraid of him . During an interview on 10/14/2024 at 9:25 AM, the Director of Nursing (DON) stated, .both residents [Resident #6 and Resident #65] admitted the incident occurred [on 8/6/2024] .the physical altercation was not witnessed by staff .we did send [Resident #6] out for medical clearance for in-patient psychiatric treatment, but after he was cleared we were not able to place him .we kept him on one on one care for 48 hours then on 15 minute checks until 8/24/2024, when the Nurse Practitioner saw him and discontinued the 15-minute checks due to no further behaviors. [Resident #65] did receive 3 small new skin tears to his left forearm and some small superficial scratches to his left shoulder. [Resident #6] did receive a small cut to his right upper lip .yes, both residents did receive minor injuries . During the interview the DON confirmed the facility failed to prevent abuse of Resident #65 and Resident #6, resulting in physical harm to both residents. 49568

Based on facility policy review, medical record review, facility documentation review, resident financial statements review, and interviews, the facility failed to protect the residents' right to be free from misappropriation and/or exploitation when a staff member deliberately used multiple residents' personal monetary funds without consent for personal gain for 7 residents (Resident #16, Resident #55, Resident #69, Resident #25, Resident #54, Resident #52, and Resident #61) of 53 sampled residents reviewed for misappropriation of personal funds. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, dated 9/15/2023, revealed .Misappropriation of Resident Property .defined as the deliberate .use of a resident's .money without the resident's consent . Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Heart Failure, Epilepsy, and Diabetes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #16, undated revealed .Resident #16's daughter brought concerns to the facility when she received a bill for patient liability in an amount over $17,000 .[Resident #16's daughter] .cancelled the debit card [for Resident #16] and requested 6 months of statements .[Resident #16's family] was able to get .bank statement which revealed a charge to a local carwash .[Resident #16's daughter] visited the carwash and found [former Business Office Manager] (BOM) used [Resident #16's] debit card to pay [at the local carwash] .[former BOM] was interviewed by the Administrator and Director of Nursing (DON) .[former BOM] admitted to using [Resident #16's debit card] [without consent] .[Resident #16] was interviewed by the Administrator and DON .[Resident #16] reported that she had given .[former BOM] her debit card so that she [former BOM] could make her payments [facility balances] and pick up items as needed .[Resident #16] believed that her patient liability was being paid [by the former BOM] .[facility] received [Resident #16's] bank statements back to May 2022 .Outstanding patient liability [bill] dates back to June 2022 .[Resident #16] reviewed all bank statements back to May 2022 and was able to verify the following expenditures one charge on 6/7/2024 at an ATM [Automated Teller Machine] for a cash withdrawal of $30. An online store purchase on 7/16/2024 for $164.61 .approved by [Resident #16] . Review of Resident #16's bank statements dated January 2024 through July 2024, revealed monthly transactions for cash purchases in the amount of $32.99 at a local carwash each month which totaled $230.93. Further review revealed on 7/8/2024 an ATM cash withdrawal for $300 was removed from Resident #16's bank account. Review of a witness statement for Resident #16 dated 7/30/2024, revealed .I [Resident #16] gave [former BOM] my [debit] card and she was supposed to pay my bill here [facility name] .I never gave [former BOM] permission to buy things for herself or to use my [debit] card without my knowledge . Review of a letter from [Facility] to Resident #16 dated 8/26/2024, revealed .currently investigating the matter related to [Resident #16] receiving an outstanding bill for [from] the Facility .we [the facility] have notified the police, the Ombudsman, Adult Protective Services, and the [State Entity] . Facility did waive patient liability as of end of 7/2024 in the amount of $18,760.00 and $2,900.30 total reimbursement to Resident #16. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Heart Disease, Heart Failure, and Hypertension. Review of a quarterly MDS assessment dated [DATE], revealed Resident #55 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #5, undated revealed .Resident #55 reports that she gave [former BOM] her debit card and [former BOM] would purchase a money order to pay Resident #55's liability to facility .debit card and copy of money order would be given back to .Resident #55 .Resident #55 believed patient liability was paid in full .provided copies of money orders as proof .facility was able to request information .money orders from post office .copies of money orders show that [former BOM] .making money orders out to herself [former BOM] .rather than paying Resident #55's patient liability .total of 13 money orders were made out to [former BOM] .total amount was $7,520 .money orders associated with Resident #55 were made payable to [former BOM] .money order .10/20/2023 .$1,000 .money order .10/20/2023 .$80 .money order .12/11/2023 .$860 .money order ./19/2024 .$116 .money order .1/19/2024 .$1,000 .money order .4/19/2024 .$1,000 .money order .4/19/2024 .$116 .money order .5/20/2024 .$1,000 .money order .5/20/2024 .$116 .money order .6/13/2024 .$1,000 .money order .6/13/2024 .$116 .money order .7/16/2024 .$1,000 .money order .7/16/2024 .$116 .after reviewing outstanding accounts receivable and money orders provided as proof of payment . Review of a letter from [facility] to Resident #55 dated 8/27/2024, revealed .currently investigating the matter related to payments made, or potentially not made, on your monthly bill for the facility .notified the police, the Ombudsman, Adult Protective Services, and the [State Entity] . Facility did waive outstanding balance patient liability for Resident #55 as of 7/2024 in the amount of $9,366.45. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Hypertension and Irritable Bowel Syndrome. Review of a quarterly MDS assessment dated [DATE], revealed Resident #69 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #69, undated revealed, .Resident #69 communicated that [former BOM] informed Resident #69 that her purse and wallet were placed in storage .Resident #69 reports having questioned [former BOM] about the purse and debit card and was told that it was no longer in storage .bank statements were reviewed for 4/2024 through 7/2024 .ATM cash withdrawals equaled $3,332.54 .Three money orders were located that had [Resident #69's] name on them and were made out to [former BOM] for a total amount of $2,768.00 .Resident #69 received her bank statement which shows ATM withdrawals as late as 8/5/2024 for $352 and 8/12/2024 in the amount of $92 .The following money orders associated with Resident #69 were made payable to [former BOM] .Money order .7/21/2023 .$960 .Money order .8/8/2023 .$1,000 .Money order .10/18/2023 .$808 . Review of a letter from [facility] to Resident #69 dated 8/27/2024, revealed .currently investigating the matter related to charges made, and potentially not made, on your debit card .we have notified the police, the Ombudsman, Adult Protective Services, and the [State Entity] . Facility did waive outstanding patient liability as of end 7/2024 in the amount of $21,207.03 and reimbursed the resident for ATM withdrawals in the amount of $444. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Heart Failure, Hypertension, and Anemia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #25 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #25, undated revealed, .Resident #25's family manages her finances .Resident #25 was interviewed and explained that her sister receives her [Resident #25] check and then brings cash to the facility to pay her rent .Resident #25's sister would give the money to [former BOM]. Resident #25 believed that her account was up to date .facility records indicate that some months were paid by credit cards and some months with money orders .Resident #25 has outstanding balance of $6,074.91 . Review of a letter from [facility] to Resident #25 dated 8/27/2024, revealed .currently investigating the matter related to payments that were supposed to have been made on your monthly bill for the Facility .we have notified the police, the Ombudsman, Adult Protective Services, and the [State Entity] . Facility did waive outstanding patient liability as of end of 7/2024 in the amount of $6,074.91. Review of the facility's investigation documentation for Resident #16, Resident #55, and Resident #68, undated revealed, .[Former BOM] admits to having Resident #16's debit card and using it to purchase the car wash subscription .copies of money orders show that [former BOM] was making the money orders out to herself rather than crediting it to [Resident #55's] account .total of money orders found equals $7,520 .copies of money orders show that [former BOM] was making money orders out to herself rather than crediting it to [Resident #69's] account .total of money orders found equals $2,768 . Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute Pulmonary Edema, Hypotension, Dependence on Renal Dialysis, and Diabetes Mellitus. Review of a quarterly MDS assessment dated [DATE], revealed Resident #54 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #54 dated 9/18/2024, revealed .social security checks that had been mailed to the facility [for Resident #54] and not received .issue [facility not receiving the social security checks] was reported to all legal entities .including law enforcement, APS, Ombudsman, and [State Entity] .[Resident #54] [social security check in the amount of] $1,429.00 deposited and cleared 9/10/2024 [not credited to the resident's liability] .called social security and indicated trace would be placed on cashed check .stated they cannot fax copy of the cashed check but can mail them . Review of the facility's investigation documentation for Resident #54 dated 10/8/2024, revealed .after not receiving copy of the cashed check [social security check] follow-up call was made to social security .stated they [social security] would look into it and call back . Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's Disease, Hypertension, and Seizures. Review of a quarterly MDS assessment dated [DATE], revealed Resident #52 scored a 2 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the facility's investigation documentation for Resident #52 dated 9/18/2024, revealed .social security checks that had been mailed to the facility and not received .issue [facility not receiving the social security checks] was reported to all legal entities .including law enforcement, APS, Ombudsman, and [State Entity] .[Resident #52] [social security check in the amount of] $1,510.00 deposited and cleared 9/9/2024 [not credited to the resident's liability] .called social security and indicated trace would be placed on cashed check .stated they cannot fax copy of the cashed check but can mail them . Review of the facility's investigation documentation for Resident #52 dated 10/8/2024, revealed .after not receiving copy of the cashed check [social security check] follow-up call was made to social security .stated they [social security] would look into it and call back . Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Complete Traumatic Amputation of Left Lower Leg, Diabetes Mellitus, Acquired Absence of Right Leg Above Knee, and Hypertension. Review of a quarterly MDS assessment dated [DATE], revealed Resident #61 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #61 dated 9/18/2024, revealed .social security checks that had been mailed to the facility and not received .issue [facility not receiving the social security checks] was reported to all legal entities .including law enforcement, APS, Ombudsman, and [State Entity] .[Resident #61] [social security check in the amount of] $1,014.00 deposited and cleared 9/13/2024 [not credited to the resident's liability] .called social security and indicated trace would be placed on cashed check .stated they cannot fax copy of the cashed check but can mail them . Review of the facility's investigation documentation for Resident #61 dated 10/8/2024, revealed .after not receiving copy of the cashed check [social security check] follow-up call was made to social security .stated they [social security] would look into it and call back . During an interview on 10/16/2024 at 7:35 AM, the Director of Nursing (DON) revealed the former BOM was in possession of Resident #16's debit card and did admit to monthly car wash subscription charges and taking $300 out of the ATM without Resident #16's consent. The DON confirmed Resident #16, Resident #55, Resident #69, and Resident #25 had their debit cards misused, had unauthorized money orders made out to the former BOM, and the residents' funds were unaccounted. The DON stated the facility's investigation outcome was that the former BOM had mishandled residents' funds and the incident had been reported to the police, Ombudsman, Adult Protective Services, and the [State Entity]. During an interview on 10/16/2024 at 8:45 AM, the Regional BOM revealed Resident #54, Resident #52, and Resident #61's social security checks were mailed to the facility, checks were cashed, and were not credited to the facility.

Based on facility policy review, medical record review, observation, and interviews the facility failed to follow infection control practices during medication administration for 1 resident (Resident #59) of 3 residents observed for medication administration. The findings include: Review of the facility's policy titled, Policies and Practices-Infection Control, undated, revealed .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary .environment .to help prevent and manage transmission of diseases and infections .for .residents . Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Osteomyelitis of Lower Left Extremity, Need for Personal Assistance with Personal Care, and Diabetes. During an observation of medication administration on 10/15/2024 at 7:31 AM, Licensed Practical Nurse (LPN) D donned gloves and prepared medications for Resident #59. Further observation revealed LPN D dropped 1 tablet of Gabapentin [medication used to treat chronic pain] 100 milligram (mg) on the surface of the medication cart. LPN D picked up the tablet and placed the tablet in a medication cup. LPN D continued to prepare the remaining scheduled medications for Resident #59, placed the medications in the same medication cup, and administered the medications to Resident #59. During an interview on 10/15/2024 at 1:51 PM, LPN D confirmed she dropped the Gabapentin 100 mg tablet on top of the medication cart and confirmed the medication should have been discarded and not administered to Resident #59. During an interview on 10/16/2024 at 9:10 AM, the Director of Nursing (DON) confirmed LPN D did not follow standard precautions with facility infection control practices during medication administration.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide a homelike environment for 3 residents (Resident #73, Resident #40, and Resident #33) of 81 residents reviewed for a homelike environment. The findings include: Review of the facility's policy titled, A Safe, Clean, Comfortable, and Homelike Environment, undated, revealed .the resident has a right to a .homelike environment .the facility provides .maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Seizures, and Hemiplegia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #73 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation in room [ROOM NUMBER], on 10/16/2024 at 7:43 AM, revealed multiple areas of chipped paint, of various sizes, with the bottom trim baseboard peeling away from the wall below the air conditioning unit. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Chronic Pain, and Dementia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #40 had a memory problem and was severely impaired of cognitive skills for daily decision making. During an observation in room [ROOM NUMBER], on 10/16/2024 at 7:45 AM, revealed multiple areas of chipped paint, of various sizes, on the wall behind Resident #40's bed. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, and Anxiety. Review of a quarterly MDS assessment dated [DATE], revealed Resident #33 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. During an observation in room [ROOM NUMBER], on 10/16/2024 at 7:48 AM, revealed multiple areas of chipped paint, of various sizes, on the wall behind Resident #33's bed. Further observation revealed multiple areas of chipped paint, of various sizes to the upper perimeter of the air conditioning unit. During an interview on 10/16/2024 at 8:05 AM, the Plant Director confirmed room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] did not reflect a homelike environment for Resident #40, Resident #73, and Resident #33 and the rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) needed repairs.

Based on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interviews the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #55) of 20 residents reviewed for accuracy of MDS assessments. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 2/9/2024, revealed .The facility will develop and implement a comprehensive person-centered care plan for each resident that .meet a resident's medical .nursing .psychosocial needs that are identified in the comprehensive assessment . Review of the RAI Manual 3.0 dated 10/2023, revealed .Hospice care .Code residents identified as being in a hospice program .for management of terminal illness . Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Convulsions, Prescence of Cardiac Pacemaker, and Heart Failure. Review of a Physician's Order for Resident #55 dated 8/23/2023, revealed .Hospice care . Review of a comprehensive care plan for Resident #55 revised 8/23/2023, revealed .hospice services . Review of an annual MDS assessment for Resident #55 dated 9/4/2024, revealed the MDS assessment was not coded for hospice services. During an interview on 10/15/2024 at 2:28 PM, Licensed Practical Nurse (LPN) C stated Resident #55 received hospice care services. During an interview on 10/16/2024 at 8:57 AM, the MDS Coordinator confirmed Resident #55 received Hospice services and the annual MDS assessment dated [DATE] was inaccurate.

Based on review of a facility policy, medical record review, review of a facility investigation, and interview the facility failed to protect the resident's right to be free from physical abuse of 1 resident (#3) of 7 residents review for abuse of 13 resident sampled residents. The Facility's failure to prevent resident to resident altercation resulted in actual harm for Resident #3 when Resident #4 threw a plastic coke bottle and hit Resident #3 in the face causing a contusion under her left eye and yelled at Resident #3 causing her to cry and be afraid. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, last revised on 10/17/2022, showed .It is the organization's intention to prevent the occurrence of abuse .Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's Disease, Abnormal Posture, Dementia with Behavioral Disturbance, Hypertension, Parkinson's Disease, Bipolar Disorder, Restlessness/Agitation, Congestive Heart Failure and Generalized Anxiety Disorder. Review of Resident #3's annual Minimum Data Set (MDS) assessment, dated 5/9/2023, showed a Brief Interview for Mental Status (BIMS) assessment score of 3 indicating severe cognitive impairment. The resident had potential indicators of psychosis of delusions, behavioral symptoms of verbal behavior directed toward others 1 to 3 days during the assessment period. Review of Resident #3's Other Events-Change in Condition Report, dated 6/7/2023 at 4:58 AM, showed .Description Resident to resident .Pt [patient] was lying in bed when another pt. wandered into room, tore her TV off of wall, threw coke on her, and allegedly hit her in the face .Provider Notified: Yes .NP [Nurse Practitioner] .resident sent to ER [emergency room ] for eval [evaluation] and treat . Review of Resident #3's Nursing Progress Note, dated 6/7/2023 at 5:06 AM, showed .Pt. heard from room yelling, other pt. had wandered into room, Pt. reports that the pt. that wandered into her room had hit her, contusion noted underneath left eye. DON [Director of Nursing] contacted as well as NP and order was given to send to ER for evaluation . Review of Resident #3's Hospital ER Progress Note dated 6/7/2023, showed .presents from nursing home for assault by another patient .The assault was not witnessed. The patient complains of pain under her left eye as well as neck pain. She denies headache. No other complaints .Follow up with PCP [primary care physician] . Review of Resident #3's Nursing Progress Note, dated 6/7/2023 at 7:12 AM, showed .Ambulance .here to return elder to facility . Review of Resident #3's Behavioral Medicine Progress Note dated 6/7/2023, showed .nsg [nursing] reports resident altercation where pt. was the non-aggressor .Today patient is calm with no acute anxiety or agitation. Currently, pt. has no recollection of recent altercation .No noted clinical evidence of any psychological harm noted per exam . Review of Resident #3's comprehensive care plan, revised 6/7/2023, showed .at risk for an alteration in my mood, behavior, cognition, and level of functioning .at risk to experience adverse psychosocial changes such as an increase in depressive and anxious signs/symptoms that have the potential to negatively affect my well-being r/t [related to] negative encounter with another resident .observe and report to physician any changes in mood, behavior, cognition and level of functioning caused by situational stressor(s) .Observe for psychosocial changes .Psych PA [Physician Assistant]/NP to follow up with resident on next scheduled visit reinforce appropriate expressions of feelings .Sent to ER for evaluation of contusion under eye .SSD [Social Service Director] to visit with resident as needed . Review of a facility investigation, dated 6/7/2023, showed all residents were in bed. Resident #4 was sitting on his bed. CNA #2 had gone to the restroom and at 2:15 AM heard screaming she rushed out and went in Resident #3's room where the TV was on the floor broke, and Resident #4 was standing over Resident #3's bed and yelling .you crackhead [explicit name] I know you took my pills . CNA #2 was rushing to bed and Resident #4 picked up a plastic bottle of diet coke and began to throw it. She (CNA #2) got in between the residents and Resident #4 grabbed CNA #2 around the throat and started choking her. CNA #2 got away and called a CNA from up front to come and help. Resident #4 backed up and set down in floor. LPN #1 came back to room and coaxed Resident #3 to his room where he was placed on one on one with CNA #2. LPN #1 immediately went to Resident #3's room and did a head-to-toe skin assessment where he found a contusion below her left eye . Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Metabolic Encephalopathy, Delirium, Parkinson's Disease, Dementia with Behavioral Disturbance, Depression, Restlessness/Agitation, Legal Blindness and Traumatic Brain Injury. Review of Resident #4's comprehensive care plan dated 8/5/2022, showed .behavioral .at risk and/or active behavior problems including physical/verbal aggression and making threatening actions towards others as evidenced by resistant to asking for assistance for transfers/ambulation resulting in multiple falls, blocks others from entering his bedroom by sitting in his wheelchair against the door .throws food on the floor, pulls built-in furniture off the walls such as the sink and toilet, dresser, bed frame (has a mattress on the floor) and televisions, yells and curses others .At risk for causes harm to himself and or others .intervene as needed to protect the rights and safety of others; approach in calm manner, divert attention, remove from situation and take to another location as needed .investigation/monitor need for psychological/psychiatric services .no blinds or curtains due to elder pulling them down with the potential for causing harm to himself .Resident is legally blind in both eyes and is at risk for harm related to visual impairment .adapt environment to resident's needs . Review of Resident #4's quarterly MDS assessment dated [DATE], showed a BIMS assessment score of 5 indicating severe cognitive impairment. The resident had signs and symptoms of Delirium including inattention, disorganized thinking, potential indicators of Psychosis of delusions, behaviors of other behavioral symptoms not directed toward others 4 to 6 days during the assessment period. Review of Resident #4's Nursing Progress Note, dated 5/26/2023, showed .pt. yelled and cursed the entire shift .pt. attempted to assault this nurse. Pt. was only able to grab this nurse's arm once and only swung fist and kick not open air, pt. calmed with aggression . Review of Resident #4's Event-Change in Condition Report, dated 6/7/2023, showed .resident to resident altercation .resident wandered into another residents room, tore TV off of wall, threw coke on her, allegedly hit her in the eye .Provider notified: Yes .[NP] .remains 1:1 at present . Review of Resident #4's Nursing Progress Note dated 6/7/2023 at 5:10 AM, showed .Pt. was found in another pt. room, pt. threw coke on that pt. [Resident #3] and had tore TV from wall, pt. stood and transferred to wheelchair and was taken to room, placed on 1:1 monitoring d/t [due to] other resident [Resident #3] accusing him of striking her on the face since being placed back in his room he has been hitting the walls in his room and screaming. Pt. has had to be redirected multiple times . Review of Resident #4's Physician Order dated 6/7/2023 at 1:31 PM, showed .emergency discharge due to danger to self and others . Review of Resident #4's Behavioral Medicine Progress Note, dated 6/7/2023, showed .nsg [nursing] reports resident altercation where pt. was the aggressor .some increased agitation, hitting walls, verbal aggression, delusions .patient with noted increased labile mood, paranoia, agitation, aggression. Currently on 1:1 . Review of Resident #4's Nursing Progress Note dated 6/7/2023 at 3:13 PM, showed .ambulance here to transfer to ER . During an interview on 9/11/2023 at 12:45 PM, CNA #3 stated .[Resident #3] did have a bruise under her left eye . During an interview on 9/11/2023 at 4:00 PM, CNA #2 stated .heard [Resident #3] holler I ran down to the room, it looked like he [Resident #4] had hit the TV when he enter the room .he [Resident #4] had thrown the coke bottle at her [Resident #3] and she did have coke all over her .she said he threw the bottle at her .he was leaned over her yelling at her about his pills he said she had taken all of his hydrocodone and called her a dumb [explicit name] .I immediately separated them and he grabbed my throat I said [Resident #4] it's me [CNA #2] we didn't take you your medicine .he is blind, he is very loud and always fixated on pills .I think he was throwing the bottle because he was mad thinking someone taking his pills .she was upset her diet coke had been thrown at her and was spilled .she did say she was scared, and she was crying .she did have a red mark under her left eye I think it was her left .she was very concerned about her diet coke, but it was late in the night and a man had came in her room so naturally she was upset . During an interview on 9/11/2023 at 6:40 PM, LPN #1 stated .she [CNA #4] had left the unit to take a break [CNA #2] came to the unit to watch the residents and I had gone to lunch .[CNA #2] did a round and went to the bathroom .she came out and heard [Resident #4] yelling at [Resident #3] that she had taken his pills .[CNA #2] reported that [Resident #4] was standing over [Resident #3] and it appeared he had thrown coke all over her .it was like he had knocked her TV off the wall it was twisted and cracked it looked like he had head butted it but he didn't have any marks on him .Everything was thrown all over her room, with him being blind it would be hard to say if he threw the coke at her or just threw it .but he was intentionally yelling at her cursing saying you took my [explicative] pills but yes he said the word .[CNA #2] said she [Resident #3] was just lying there not defending herself or nothing .her left eye was just a little red under it and it did later bruise .it wasn't a black eye it was just a small bruise under her eye where the plastic bottle hit her .we did sent her to the ER .after she came back she seemed a little sad . During an interview on 9/20/2023 at 1:45 PM, the Administrator stated .this was a resident to resident altercation .he is blind and cannot see at all .he does scream and curse and he is accusatory of staff taking his medications . because of the situation he is in with the traumatic brain injury, he has no sense of his surroundings, he is delusional .it was just a freak accident that the resident was in the path of the bottle .the point is he screamed all the time . During an interview on 9/21/2023 at 8:40 AM, the DON stated .when I got here before 2:30 AM, and the incident occurred at approximately 2:15 AM .she was in her bed her TV was laying in the floor .I saw the place below her left eye at that time it did not look like a bruise it was just a little reddened area .he was accusatory and verbally abusive to staff but he had never been to any residents .

Based on facility policy review, medical record review, observation and interview, the facility failed to obtain an admission Physician's Order for wound care for 1 Resident (#2) of 3 residents reviewed for wound care. The findings included: Review of the facility policy Admissions to the Facility, revised 7/30/2018, showed .Prior to or at the time of admission, the resident's Physician must provide the facility with information for the immediate care of the resident . Resident #2 was admitted to the facility on [DATE] at 12:30 PM, and left Against Medical Advice 3 days later on 5/30/2023 at 10:41 AM, with diagnoses including Sepsis, Cellulitis of Abdominal Wall, Unsteadiness on Feet, Muscle Weakness Generalized, Morbid Severe Obesity, Hyperlipidemia, Bipolar Disorder and General Anxiety Disorder. Review of Resident #2's Hospital Discharge Instructions, dated 5/27/2023, showed .Discharge to: Skilled Nursing Facility .Follow-up Appointments PCP [Primary Care Physician] 1-2 weeks .Call for Follow up appointment with Primary care DR . Review of Resident #2's Facility Admission Orders, dated 5/27/2023, showed medication orders were signed by the physician on 5/28/2023. Treatment orders included .Pressure/Relieving/Redistribution Mattress . signed by the physician on 5/29/2023. Review showed no order was present for wound care. Review of Resident #2's baseline care plan, dated 5/28/2023 at 2:50 AM, showed .Skin Integrity Goal: Resident will have intact skin or improving skin integrity .Resident at risk for compromised skin or has current skin condition .Yes .soft tissue infection lower pannus .Notify MD [Medical Doctor] if .any adverse findings in skin integrity .Inspect skin when repositioning, toileting, and assisting with ADLs [activities of daily living]. Notify nurse of adverse findings .dressing per MD order .Treatments per MD order .skin infection .Administer meds per MD order . Review of Resident #2's Admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 8, indicating moderate cognitive impairment. Review showed 1 surgical wound present with treatments of pressure reducing device for chair, and bed, and surgical wound care. During an interview on 9/12/2023 at 3:05 PM, Licensed Practical Nurse (LPN) #6 stated .I don't recall her having any wound care orders on admission .[Resident #2] was complaining the wound was draining I don't recall there being a bandage .I just covered the wound with [gauze bandage] pad and [tape] .she had a follow up order with the wound care office .and there was a phone number .I left that information for the scheduler .to make the appointment .I do not recall notifying the MD of the admission . During an interview on 9/13/2023 at 5:15 PM, LPN #8 stated .I did not undress the wound .the dressing that was on it .was dry and intact .I don't recall her [Resident #2] having any wound care orders, or contacting the physician . During an interview on 9/14/2023 at 10:50 AM, LPN #3 stated .her [Resident #2's] discharge orders [from the hospital] were to follow up with wound care .to perform any wound care we have to have a physician's order and she did not have any treatment orders . During an interview on 9/14/2023 at 1:30 PM, Resident #2's Physician stated .we would not have known about the wound unless we were informed .my expectation would be for the facility to notify the MD or the NP [Nurse Practitioner] for orders or direction on how to care for the wound until the resident was seen by the wound care clinic .we should have been notified of no wound care orders .my expectations would be the facility should call the NP [Nurse Practitioner] or MD [Medical Doctor] to start care .assess the wound .to the best of my memory I was not notified of the wound or the need for wound care orders .it was a surgical wound . During an interview on 9/18/2023 at 10:30 AM, LPN #7/Unit Manager stated .I did not notify the physician she [Resident #2] was here, but someone notified him because he signed her medication orders on Sunday the 28th. From what I can see that he signed there were no wound care orders sent to him .we did not have any wound care orders from the hospital only to follow up with wound care .[LPN #6] told me that the patient asked her to change the dressing she did not change the packing because she did not have an order, but she did change the outer dressing and she did reinforce the outer dressing .that is the only wound care I am aware she received while she was admitted .best practice would have been to call the physician or the NP and obtain wound care orders prior to her being referred to the wound care clinic . During an interview on 9/18/2023 at 1:05 PM, the Director of Nurses (DON) stated .there were no wound care orders or information about a wound in the information that Dr. [Resident #2's Physician] signed .to my knowledge no wound care orders came with the patient only to follow up with wound care .when the resident came in the nurse should have called the doctor to go over the orders, and if the resident had a wound he should have been made aware the resident had a wound .the nurse should have asked him about a dressing change .dressing changes do need a physician order and we had no orders . During the interview, the DON confirmed .we should have been monitoring to ensure the dressing was clean, dry and intact .there should have been either a physician or a nursing order to monitor for signs/symptoms of infection each shift and there was not .the physician should have been notified of the wound . During an interview on 9/19/2023 at 9:45 AM, the Administrator stated .personally if I had been the nurse, I would have asked the facility physician if there was anything that should be done for the wound prior to her follow up with wound care but that would have been the nurses doing the admission call .

Based on review of a facility policy, facility investigations, medical record review, observation and interview, the facility failed to report allegations of abuse for 1 resident (#4) and failed to report an allegation of abuse within the federal required timeframe for 1 resident (#12) of 8 residents reviewed for abuse. The findings include: Review of the facility policy Abuse, Neglect and Misappropriation of Property, revised 10/17/2022, showed .It is the organization's intention to prevent the occurrence of abuse .Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .every Stakeholder shall immediately report any 'allegation of abuse,' 'injury of unknown origin' .to the facility Administrator or designee as assigned by the facility Administrator in his/her absence . any abuse allegation must be reported to State within 2 hours from the time the allegation was received .any allegation of neglect .must be reported to the State Regulatory Agency within 24 hours. In the case or neglect .resulting in serious bodily injury it must be reported to the State Regulatory Agency and Police within 2 hours . Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Metabolic Encephalopathy, Delirium, Parkinson's Disease, Dementia with Behavioral Disturbance, Depression, Restlessness/Agitation, Legal Blindness and Traumatic Brain Injury. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 5, indicating severe cognitive impairment. Resident #4 had signs and symptoms of Delirium including inattention, disorganized thinking, potential indicators of Psychosis of delusions, and other behavioral symptoms not directed toward others 4 to 6 days during the assessment period. Review of Resident #4's Hospital History and Physical dated 6/7/2023, showed .Initially it was .the impression that the patient had been in some type of altercation and sustained some kind of injury from that, and there was concern for altered mental status, the patient of course is a poor historian due to brain injury. I am unsure of change in mental status as he is chronically confused and demented .No obvious sign of trauma .Computerized Tomography [CT] spine w/o [without] contrast .No CT evidence of acute cervical spine injury .CT Head w/o contrast .No acute intracranial findings . Review of a facility investigation, not dated, showed .on 9/11/2023, the [state survey agency] came in on a complaint survey about an outstanding resident to resident altercation. I [Director of Nursing/DON] did not have ER [emergency room ] records on Resident #4 who was sent to ER the day of the altercation [6/7/2023]. Upon obtaining the ER records it was noted that he had told the Dr [doctor] at the ER that staff at Nursing facility would kick him. I began an investigation into the allegation and could not find anyone that has witnessed any abuse toward [Resident #4] . During an interview on 9/14/2023 at 2:50 PM, the DON stated .I was not aware of the allegation until Monday [9/11/2023] when [the state surveyor] requested [Resident #4] hospital information .then I saw the allegation he made at the hospital that he had been kicked at the facility .it also said there was no trauma noted .[the allegation of abuse was made on 6/7/2023 when Resident #4 was in the ER]. The DON confirmed the allegation of abuse had not been reported to the state designated authority within 2 hours. During an interview on 9/18/2023 at 12:10 PM, the DON stated .Per his [Resident #4's] hospital History and Physical [dated 6/7/2023] he reported the nursing home staff had been jumping on him and kicking him, but there was no obvious sign of trauma .at the end of my investigation I was unable to substantiate abuse had occurred . During the interview, the DON confirmed the facility did not report this as an allegation of abuse to the state. She stated .I did see the allegation on Monday [9/11/2023] when I got the hospital information, but I don't think I actually really looked at the hospital information in detail until .Thursday [9/14/2023] . During an interview on 9/19/2023 at 9:45 AM, the Administrator stated .we had no knowledge of the allegation until 9/11/2023 . Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Neurocognitive Disorder with Lewy Bodies, Parkinson's Disease, Repeated Falls, Vascular Dementia, Psychotic Disorder, Anxiety, Major Depressive Disorder, Cerebral Infarction and Chronic Obstructive Pulmonary Disease. Review of Resident #12's comprehensive care plan, dated 7/17/2021, showed .at risk for skin breakdown related incontinence, fragile skin and impaired mobility and my [may] bruise easy d/t [due to] long term use of ASA [aspirin] . The care plan was revised on 9/17/2023 and showed .add padding to bed rail .Monitor area and observe resident for any psychosocial distress r/t [related to] area . Review of Resident #12's quarterly MDS assessment, dated 6/26/2023, showed the BIMS assessment was not completed due to short and long-term memory problems. The resident had Signs and Symptoms of Delirium including inattention and disorganized thinking. Review of a facility investigation dated 9/17/2023 showed at 12:37 PM, (on 9/17/2023) the DON received a call from Licensed Practical Nurse (LPN) #2 stating that Resident 12's son had came to desk and asked about a bruise to Resident #12's left forehead eye area. The son states that his father told him that a man hit him .LPN #2 reported this to DON, she came over to start an investigation. She attempted to interview Resident #12 but was unable to understand anything Resident #12 said to her. She did notice a yellow area to left eye area. Review of Resident #12's Skin Integrity Event-Bruise dated 9/17/2023, showed .location of bruise and size .left side of forehead around eye approx. 10 cm in diameter .yellowish green .activity during bruise occurrence .unknown . During an observation of Resident #12 on 9/18/2023 at 8:45 AM, in the day room, showed the resident to be seated in a wheelchair. The resident was observed with a light yellowish bruise on the left side of his temple approximately 1 inch wide and 1 1/2 to 2 inches in length. There was a very small scratch at the top front side of the bruise and a small brown spot below the scratch to the eye or front side of the bruised area. The resident was unable to be interviewed due to cognitive impairment. During an interview on 9/18/2023 at 2:50 PM, LPN #3 stated .Friday [9/15/2023] he [Resident #12] was in the day room. I saw the bruise, but it didn't look new, so I assumed his nurse knew about it. I asked him what happened to your eye, he felt of his eye, and I asked if he had fallen, and he said yes but with him it is hard to tell. Usually, it is a one-word answer and only to simple questions . When asked specifically if she reported the bruise to anyone, because at the time she saw the bruise it was an injury of unknown origin to her, and because she had no knowledge of how it occurred, she stated, .No I know I should never assume . During an interview on 9/19/2023 at 11:00 AM, the Administrator stated .the nurse [LPN #3] should have reported the bruise new or old if that was the first time, she saw it. She should not have assumed since it was old that his nurse knew about the bruise .no she did not report it and she should have, delaying our reporting and investigation .at this point we do not have evidence that abuse occurred .

Based on observations and interviews, the facility failed to maintain a safe, comfortable, and homelike environment for 1 resident (Resident #15) of 15 residents reviewed on the secure unit. The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Sepsis, Paranoid Schizophrenia, Bipolar Disorder, History of Self-Inflicted Gunshot Wound to the Head, Traumatic Brain Injury, and Dysphagia. Medical record review of the annual Minimum Data Set (MDS) dated [DATE] showed Resident #1 was cognitively impaired with a Brief Interview of Mental Status Score (BIMS) of 7, had behaviors directed at self and others and required assistance of 2 staff for activities of daily living (ADLs). Observations of Resident #1, in his room on the secure unit, on 1/6/2023 at 2:45 PM, showed the room in a state of disrepair. The wall mounted heat and air conditioning unit had no covering on it, the internal components were exposed, and the unit was unplugged and inoperable. The sink was absent. The location where a sink was supposed to be, showed plumbing capped off at the wall. Outlet covers on the same wall were cracked, partially dislodged, or otherwise damaged. Resident #1's room was equipped with a bed, but was otherwise devoid of personal items, other furniture or wall coverings. Resident #1 was observed in his wheelchair in the center of the room adjacent to the bed near the window and heat and air unit. The bed was unkempt. No beside table, other furniture or personal items were noted in the room. Interview with Licensed Practical Nurse (LPN) #1 on the secure unit on 1/6/2023 at 3:05 PM, in the nursing station, revealed Resident #1 had a history of behaviors which included multiple instances of breaking fixtures in the room when agitated. LPN #1 reported Resident #1 had destroyed the covering on the wall mounted air conditioning and heat unit several times over the years and had torn his sink from the wall and thrown it on the floor shattering it, several months beforehand. LPN #1 stated the facility had not repaired the damaged wall fixtures, the air conditioning and heat unit covering, and the sink as maintenance felt any new fixtures replaced would be broken shortly afterwards anyway. LPN #1 confirmed the room was devoid of fixtures or personal items and in its current state, was not homelike for Resident #1. LPN #1 also agreed no other rooms on the secure unit lacked fixtures, a sink, or functional wall mounted temperature control systems as Resident #1's room did. Interview with the Administrator on 1/6/2023 at 3:45 PM confirmed LPN #1's reports related to Resident #1's behavioral history. The Administrator confirmed the facility had not replaced the air conditioning cover or sink after they were last broken, fixtures in the room were minimal and the facility failed to maintain a safe, comfortable, and homelike environment for Resident #1's room.

Based on facility policy review, review of the Centers for Disease Control and Prevention (CDC) guidance, review of facility documentation, observation, and interview, the facility failed to provide employee screening at the beginning of the shift for 38 of 241 shifts between 2/2/2022 - 2/7/2022 which had the potential to result in the transmission of COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) to 71 of 75 residents. The findings include: Review of the facility's policy titled, Novel Coronavirus (COVID-19), dated 11/15/2021, showed .Signature will regularly monitor the Centers for Disease Control and Prevention (CDC) website, along with other selected official resources, for the latest COVID-19 updates and guidance .RESPIRATORY ILLNESS SURVEILLANCE MEASURES .A facility should actively screen all residents and stakeholders, and any other person entering the facility, for fever and respiratory symptoms, to include temperature checks before entrance to the facility is permitted . Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 2/2/2022, showed .Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed .a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 infection .symptoms of COVID-19 or .close contact with someone with [CONDITION(S)]-CoV-2 infection . Review of the employee time punches, employee COVID-19 screening logs, and facility video footage for 2/2/2022 - 2/7/2022, showed 38 of 241 screening opportunities were not completed. Review of the facility documentation showed the facility currently had 4 positive residents with COVID-19. During an observation on 2/7/2022 at 6:48 PM, the Treatment Nurse assisted Certified Nursing Assistant (CNA) #2 at the computer screening station and stated remember you have to screen every time you come in. Review of the employee time punches and employee COVID-19 screening log dated 2/7/2022, showed CNA #2 punched in at 6:10 PM and screened at 6:57 PM (47 minutes after the shift started). During an interview on 2/8/2022 at 8:21 AM, the Director of Nursing (DON) stated it was the expectation of the facility that all staff members screen for temperature and symptoms of COVID-19 at the computer screening station prior to their shift. The DON confirmed not all staff had been screening prior to the start of their shift. She identified the issue on 2/7/2022 when she pulled employee screening documentation requested by the surveyor. Further interview with the DON confirmed there had been no process to ensure employees were screened prior to the start of their shift for temperature and symptoms of COVID-19. During an interview on 2/8/2022 at 11:19 AM, Restorative Aide #1 stated employees are screened daily when they enter the facility with a temperature check and a computer questionnaire that asked about symptoms of COVID-19. Restorative Aide #1 confirmed There was a day last week that I didn't screen. There was a line at the screening station, and I needed to get to work. During an interview on 2/8/2022 at 11:37 AM, Licensed Practical Nurse (LPN) #1 stated she was informed on 2/7/2022 by the DON that she had to screen every shift prior to starting work for temperature and symptoms of COVID-19. LPN #1 confirmed she had not been screening at the facility because, I thought it was only for visitors. During an interview on 2/8/2022 at 1:28 PM, the Administrator stated it was the expectation of the facility that all staff are screened for temperature and symptoms of COVID-19 prior to their shift. The Administrator confirmed all staff had not been screened prior to their shift and I thought someone was in charge of checking that but obviously they weren't.

Based on facility policy review, observation, and interview, the facility failed to separate resident and staff food items in 3 of 3 resident pantry rooms, failed to discard expired food in 3 of 3 resident pantry rooms, and failed to maintain a sanitary environment in 3 of 3 resident pantry rooms. The findings include: Review of the facility policy Food Storage: Dry Goods dated ,d+[DATE], revealed .all dry goods will be appropriately stored .regularly inspects .not subject to sewage or wastewater back flow or contamination by condensation, leakage, rodents or vermin .toxic materials will not be stored with food . Review of the facility policy Food Storage: Cold Foods, dated ,d+[DATE], revealed .all foods will be stored wrapped or in covered containers, labeled and dated . Review of the facility policy Foods Brought by Family/Visitors dated [DATE], revealed .containers will be labeled with the resident's name .discard perishable foods on or before the use by'' date . Review of the facility policy Food: Safe Handling for Foods from Visitor dated ,d+[DATE], revealed .ensure that the food is stored separate .from the facility food .label foods with the resident name and the current date .daily monitoring for refrigerated storage duration and discard of any food items that have been stored for > [more than] 7 days . Observation and interview on [DATE] at 8:40 AM, with the Dietary Manager in Training, Corporate Dietary Manager, and the Director of Nursing (DON) in Station 1 Resident Pantry Room, revealed inside a lower cabinet: 1 plastic bag, labeled with only the first name of an individual, with an unlabeled, undated, opened bag of 3 cinnamon raisin bagels; 1 plastic bag, labeled with only the first name of an individual, with 1 unlabeled, undated 8 ounce (oz) container of strawberry cream cheese; 1 unlabeled, undated, opened, 1.5 oz ice coffee drink, and 1 unlabeled, undated orange pie slice in a plastic baggie; 1 small cooler, and a coffee maker. Continued observation revealed the following under a working dual sink: 1 opened box of 1000 plastic sandwich bags; 1 toilet plunger in a plastic bag; 1 water filtration filter; 1 spoon in a plastic bag; and one 4 oz lemon water drink dated [DATE]. Further observation revealed in the working sink: 3 water glasses, 2 spoons, 1 maraschino cherry, and 1 used, wet washcloth with orange stains. During an interview the Dietary Manager in Training and the DON confirmed the 2 labeled plastic bags with the food items were identified as names of 2 Certified Nursing Assistants (CNA's), the facility failed to ensure resident and staff items were stored in separate locations, and the facility failed to maintain Station 1 Resident Pantry in a sanitary manner. Observation and interview on [DATE] at 8:50 AM, with the Dietary Manager in Training, Corporate Dietary Manager, and the DON in Station 2 Resident Pantry Room, revealed the following under a working double sink: 1 unlabeled, undated 16 ounce (oz) fast food cup with liquid; 2 unlabeled, undated, opened 2-liter lemon-lime soda containers; and 1 unlabeled, undated, opened 30.6 oz coffee can. Continued review showed 2 undated, unlabeled pepperoni pizzas on top of the paper shredder. During an interview the Dietary Manager in Training and the DON confirmed the food items were not dated or labeled and the facility failed to maintain Station 2 Resident Pantry Room in a sanitary manner. Observation and interview on [DATE] at 8:55 AM, with the Dietary Manager in Training, Corporate Dietary Manager, and the DON in Station 3 Resident Pantry Room, located in the Secure Unit, revealed the resident panty refrigerator contained: 1 opened to air 4 oz unlabeled, undated applesauce and 1 unlabeled, undated 16 oz orange soda. Continued observation revealed under a working dual sink the following items: 1 unlabeled, undated, opened 42.5 oz coffee container; 3 opened boxes with 1000 plastic sandwich baggies; 2 boxes containing 8 individual organic juice drinks with 1 box opened labeled for a current resident; 1 humidifier with dust debris; 1 roll of paper towels; 1 unlabeled, undated 8.75 oz grape juice pouch; 1 coffee maker; 2 empty lunch totes; three 4 oz applesauce cups, expired [DATE]; and two 4 oz applesauce cups, expired [DATE]. Further observation inside a lower cabinet revealed 2 opened containers of congealed 3.79-liter vegetable oil. One vegetable oil container was labeled on the cap ',d+[DATE]'. During an interview the Dietary Manager in Training and the DON confirmed the refrigerated foods were unlabeled and undated and the facility failed to maintain the Station 3 Resident Pantry in a sanitary manner.

Based on medical record review, observation, and interview, the facility failed to provide an appropriate set-up for intravenous (IV) fluid administration for 1 resident (#18) of 4 residents observed. The findings include: Review of the medical record showed Resident #18 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 0.9% [percent] .75mL [milliliters]/hr [hour]: intravenous . Review of an electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the resident's room on 11/29/2021 (4 days after the initiation of IV therapy) at 10:15 AM, showed Resident #18's IV fluid was infusing via a dial flow device (a medical device that is used when regulating the flow of fluid through an IV). The IV fluid bag was hanging from the light fixture located above the resident's bed. During an interview conducted on 11/29/2021 at 3:20 PM, Licensed Practical Nurse #1 stated she was unable to find a pole to hang the IV fluids and confirmed the IV bag was hanging from the light fixture. During an interview conducted on 12/1/2021 at 7:30 AM, the Director of Nursing (DON) stated that in accordance with professional standards she would expect that the needed equipment to begin IV administration would be gathered prior to initiation of the therapy. The DON further stated she was not aware of IV bags being hung from the light fixture and confirmed this was not a standard of practice for the facility.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain a falls intervention for 1 resident (#29) of 6 residents reviewed for accidents. The findings include: Review of the facility policy titled, Comprehensive Care Plan, dated 7/19/2018, showed .Care plan interventions are implemented after consideration of the resident's problem areas and their causes . Review of the medical record showed Resident #29 was admitted on [DATE] with diagnoses including Muscle Weakness, Other Abnormalities of Gait and Mobility, History of Falling, and Unspecified Dementia without Behavioral Disturbance. Review of a Comprehensive Care Plan dated 9/28/2021, showed Resident #29 was .at risk for falls due to poor balance, poor safety awareness, polypharmacy and having a hx [history] of falls . Further review showed interventions in place included .fall mat at beside [bedside] . Review of the Minimum Data Set, dated dated dated [DATE], showed Resident #29 had a Brief Interview for Mental Status score of 8 indicating moderate cognitive impairment. Continued review showed Resident #29 required extensive assistance with bed mobility, dressing, and personal hygiene; total dependence was required for toilet use. Observation of resident's room on 11/29/2021 at 7:26 AM, showed that Resident #29 was in her bed and a fall mat was not at bedside. During an interview and observation conducted on 11/30/2021 at 1:20 PM, Registered Nurse (RN) #1 confirmed that Resident #29 was care planned for a fall mat to be placed at bedside. RN #1 further confirmed that Resident #29's bedside did not have a fall mat in place.

Based on medical record review and interviews, the facility failed to provide a lunch tray to 1 resident (Resident #1) of 5 residents reviewed for nutrition. The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE] for Rehabilitation, Diabetes, Elevated White Blood Cell Count, Functional [CONDITION(S)] (paralysis), Stage 2 Pressure Ulcers to the Sacrum and Left Heel, Generalized Anxiety Disorder, and [CONDITION(S)]. Review of the Admission Minimum Data Set (MDS) dated [DATE] showed Resident #1 was cognitively intact with a brief interview of mental status (BIMS) score of 15. The resident was bedfast, required set up assistance with meals, and was dependent on moderate to maximum assistance of one person for all other activities of daily living (ADLs). During an interview on 6/17/2021 at 12:03 PM, the Director of Nursing (DON) confirmed the facility failed to provide Resident #1 his lunch time meal on 6/12/2021 in accordance with the resident's care plan. During an interview on 6/17/2021 at 3:03 PM, the unit Charge Nurse stated during the lunch time tray pass she was summoned to the front lobby of the facility by staff members and she was unaware the unit staff failed to distribute a lunch meal to Resident #1. During an interview on 6/17/2021 at 3:50 PM, the Assistant Director of Nursing (ADON) stated she was working the floor on 6/12/2021 as a Certified Nurse Aide (CNA) and was assigned to Resident #1. The ADON confirmed the facility failed to distribute Resident #1 his meal tray.

Based on review of a facility policy, review of a facility investigation, medical record review, observations, and interviews, the facility failed to prevent abuse for 1 resident (Resident #1) of 4 residents reviewed for abuse, resulting in Resident #1 being hit on the nose by another resident. The findings included: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, last revised 5/8/2019 showed .It is this organization's intention to prevent the occurrence of abuse.This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at issue.Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm.willful means non-accidental.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. Review of a facility investigation dated 2/18/2020 showed .Certified Nursing Assistant (CNA) #2 was cleaning the dining room and heard yelling.found (Resident #2) in (Resident #1's) room yelling at him to get out of his room. (Resident #1) was yelling that it wasn't his (Resident #2's) room. (CNA #2) was able to get (Resident #2) out of the room. Resident #1 told (CNA #2) that (Resident #2) hit him in the nose hard.reported the same thing to the nurse. When the nurse asked (Resident #2) if he had hit (Resident #1) he said 'Yes I hit him'. Actions taken to protect the resident: aggressor (Resident #2) placed 1:1 (one on one). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #1 scored a 14 (cognitively intact) on the Brief Interview of Mental Status (BI[CONDITION]). The resident had not exhibited any behaviors during the assessment look back period. Observation and interview in Resident #1's room on 2/20/2020 at 11:55 AM showed the resident lying in bed awake and alert. No fearful or anxious behaviors were observed. The resident stated .that person (Resident #2) hit me in the nose that happened 2 or 3 days ago.my nose is okay now. Resident #2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan dated 12/16/2019 showed .Elder has a history of behavior problems such as wandering, exit seeking, disrobing, being verbally abusive and sexually inappropriate with staff. At risk for causing harm to himself and/or others.Administer medications as ordered by the physician and monitor effectiveness/response to meds, Approach elder at a later time if he is agitated, Attempt to explain to elder why behavior is unacceptable, Discuss what types of music elder prefers to listen to when exhibiting behaviors, Talk to elder about baseball when exhibiting behaviors. Revision to the Care Plan on [DATE]20 showed .Behavioral elder placed on 1:1 awaiting transfer to Geri-psych.Stay 1:1 until transfer to Geri-psych. Review of the quarterly MDS dated [DATE] showed Resident #2 scored an 8 (moderate cognitive impairment) on the BI[CONDITION]. The resident had no signs or symptoms of [MEDICAL CONDITION] and no behaviors had been observed during the look back period. Medical record review of a Nurse's Progress Note for Resident #2 dated 1/20/20 showed .Elder continues to be inappropriate with staff. Told another resident he was going to kick her butt. Refused to take medication. Gave writer the finger and ask me to give him one, he said if I did he would break it. Medical record review of a Nurse's Progress Note for Resident #2 dated 1/31/2020 showed .Elder started on new med without adverse reactions noted. Elder continues to be verbally aggressive with staff, making derogatory remarks to staff. Medical record review of a Nurse's Progress Note for Resident #2 dated [DATE]20 at 3:27 AM showed .Elder has been up at nurses station several times this shift, cursing staff and trying to hit staff with fist. Elder went to back door and was kicking at back door. Medical record review of a Nurse's Progress Note for Resident #2 dated 2/8/2020 at 10:53 PM showed .Elder cussing at staff banging on the door and kicking the door going outside. Charging at staff with fist balled up, threatening to hit us. Called.(Psychiatric Nurse Practitioner) gave order for.[MEDICATION NAME] (antipsychotic). Medical record review of a Nurse's Progress Note for Resident #2 dated [DATE]20 showed .No adverse reaction noted from med (medication) changes. Elder continues to yell/scream/curse/ threaten staff. Medical record review of a Nurse's Progress Note for Resident #2 dated [DATE]20 showed .Elder at nurses station several times throughout day, yelling threatening to knock nurses head off for keeping him here. Medical record review of a Nurse's Progress Note for Resident #2 dated 2/18/2020 11:13 PM showed .Elder has been pacing in and out of his room since evening shift began. Elder has admitted to this nurse that he entered another resident's (Resident #1's) room and struck him in the nose. During an interview on 2/20/2020 at 1:00 PM Licensed Practical Nurse (LPN) #1 stated .(CNA #2) reported she heard some yelling and went to (Resident #1's) room.(Resident #1) had told her (CNA #2) that man (Resident #2) had hit him in the nose. I asked.(Resident #2) if he hit (Resident #1) he said 'yes'.(Resident #1) said it happened.(Resident #2) had actually been really good that night he had been pacing the floor but that was his normal. He has never been bad about going into other resident's room that is why it was so bazar he did that. During an interview on 2/20/2020 at 1:30 PM CNA #1 stated .(Resident #2) wasn't too bad that night he was just pacing the hall.(LPN #1) and I were in another resident's room and when we came out.(CNA #1) told us he (Resident #2) had gone in (Resident #1's)'s room and hit him in the nose.(LPN #1) asked (Resident #2) if he hit (Resident #1) and he said 'yes'. During an interview on 2/20/2020 at 2:20 PM the Director of Nursing stated Resident #2 did have ongoing behaviors of cursing and threatening the staff, but he had never hit any other resident. The DON confirmed the facility failed to prevent abuse to Resident #1.

Based on review of facility policy, review of a facility investigation, medical record review, observations, and interviews, the facility failed to prevent abuse for 2 residents (#2 and #4) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation of Property, not dated, revealed .It is this organization's intention to prevent the occurrence of abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment .willful means non-accidental .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 . Review of a facility investigation dated 7/20/19 revealed Resident #1 rolled out into the courtyard in a wheelchair and up to a table. Continued review revealed Resident #2 cussed Resident #1 and then Resident #1 spit in the face of Resident #2. Further review revealed the two residents reached for each other and Resident #1 proceeded to hit and scratched Resident #2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) for Resident #2 dated 6/27/19 revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident # 1 dated 7/18/19 revealed a BIMS score of 15 indicating the resident was cognitively intact. Observation and interview with Resident #2 on 8/21/19 at 8:05 AM, in her room, revealed the resident seated on the side of her bed eating breakfast. Continued observation revealed the resident was pleasant and no anxious or fearful behaviors were observed. Interview revealed the resident was able to recall the incident and replied .(Resident #1) scratched me up .my face looked like a road map. It healed up pretty fast. She spit in my face too she is just mean . She was spitting and I told her to stop. That's when she spit on me. Observation and interview with Resident #1 on 8/21/19 at 9:00 AM, in her room, revealed the resident lying in bed awake and alert. Interview revealed .I remember that she (Resident #2) started running her mouth and she made me mad. I remember that much, I didn't want to hit her so I spit on her, then she said some more stuff and I scratched her face. I know I shouldn't have done that, I know better, but she made me mad . Telephone interview with Licensed Practical Nurse (LPN) #2 on 8/21/19 at 10:45 AM revealed .It was right at time for smoke break, but they weren't smoking yet .I was going down the sidewalk and was about half way down the walk way when I saw they were intertwined .(Resident #1) had her claws in .(Resident #2's) face .(Resident #1) didn't have any marks on her .(Resident #2) had some scratches on her face .There were 3 other residents out there and they all told me that .(Resident #1) started it and that she had spit in (Resident #2)'s face . Interview with Resident #5 on 8/21/19 at 2:50 PM, in her room, revealed .(Resident #1) was spitting and .(Resident #2) told (Resident #1) to quit spitting then .(Resident #1) spit in (Resident #2's) face .(Resident #2) swung at (Resident #1) but I don't think she actually hit (Resident #1) .(Resident #1) was clawing (Resident #2's) face. I didn't see .(Resident #2) do anything to provoke (Resident #1) . Interview with Resident #7 on 8/22/19 at 9:00 AM, on the patio, revealed .they (Resident #1 and Resident #2) were arguing about something and (Resident #1) spit on (Resident #2) .(Resident #2) said hey you spit on me and (Resident #1) went for (Resident #2's) eyes . Interview with the Director of Nursing (DON) on 8/22/19 at 9:30 AM, in the conference room, revealed .(LPN #2) called me and told me what happened .I went to .(Resident #2's) room the first thing out of her mouth was she (Resident #1) is always antagonizing me .we had words and she (Resident #1) spit on me and I pulled her hair .I went to .(Resident #1)'s room .I said what happened between you and (Resident #2) and (Resident #1) said I'm tired of (Resident #2) every time she is around me she cusses me. I asked (Resident #1) if she had spit on (Resident #2) and she said no, I said are you sure several people said you did and she said 'I guess I did' .through the investigation it appeared that (Resident #1) was the aggressor and(Resident #2) was defending herself . Review of a facility investigation dated 7/19/19 revealed Resident #4 was sitting in front of the dining room entrance across from the nurses' station and Resident #3 walked out of the dining room, up behind Resident #4, and began hitting Resident #4 on the back several times. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] for Resident #4 revealed the resident had a BIMS score of 10, indicating the resident had moderate cognitive impairment. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE] for Resident #3 revealed the resident had short and long-term memory problems. Observation and interview with Resident #4 on 8/21/19 at 10:30 AM, in her room, revealed the resident was awake and alert and exhibited no anxious or fearful behaviors. Interview revealed .she (Resident #3) knocked the hell out of me . Interview with LPN #1 on 8/21/19 at 8:30 AM, at the 300 hall Nurses' Station, revealed .(Resident #3) was kind of agitated she gets that way sometimes, and she was in the dining room pacing around, but she wasn't bothering anybody. I was behind the nurses' desk and .(Resident #4) was sitting right outside the dining room door she had just came out of the dining room and had stopped .(Resident #3) came out of the dining room and walked up behind (Resident #4) and started punching (Resident #4) in the back. It wasn't an accident (Resident #3) meant to hit (Resident #4) . Interview with the DON on 8/22/19 at 9:30 AM, in the conference room, confirmed Resident #1 willfully spit on and scratched Resident #2. Further interview confirmed Resident #3 hit Resident #4 on the back. Continued interview confirmed the facility failed to protect Resident #2 and Resident #4 from abuse.

Based on facility policy review, medical record review, observation, and interview, the facility failed to revise a comprehensive care plan to address use of an anticoagulant medication (a blood thinner) for 1 resident #79 of 8 residents reviewed for anticoagulant medication use. The findings include: Review of the facility's policy Care Planning-Comprehensive, reviewed 9/21/16, revealed .The .Interdisciplinary Team develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment .The comprehensive care plan is prepared by an interdisciplinary team including .Care plans are ongoing and revised as information about the resident and the resident's condition changes .The nurse/Interdisciplinary Team is responsible for the review and updating of care plans . Medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed .Section N-Medications .N0410E: Medication received: Days: anticoagulant 7 . Medical record review of the Physician Recapitulation Orders for (MONTH) 2019 revealed .3/1/19 .ELIQUIS (a blood thinner used to prevent blood clotting) 2.5MG (milligram) GIVE 1 TABLET BY MOUTH 2 TIME(S) DAILY . Medical record review of Resident #79's care plan dated 3/27/19 revealed the use of an anticoagulant medication had not been addressed in the care plan. Interview with the Director of Nursing (DON) on 3/27/19 at 8:39 AM, on the secured unit, revealed the anticoagulant had not been addressed on Resident #79's care plan. Continued interview confirmed the facility failed to follow the care planning policy. Interview with MDS Coordinator #1 on 3/27/19 at 9:59 AM, in the MDS office, confirmed a care plan had not been revised to address the use of anticoagulant medication for Resident #79.

Based on medical record review, observation, and interview the facility failed to ensure resident (#19) had a right hand wrist orthosis (splint) device was in place for 1 resident (#19) of 4 residents reviewed for positioning and mobility of 31 sampled residents. The findings include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #19's Current Care Plan dated 12/18/18 revealed .Resident has Contracture(s) to her right hand/wrist As Evidence By inability to achieve full functional range of motion .Approach .Right hand/wrist orthosis for 2-3 hours daily . Medical record review of the Occupational Therapy Treatment Encounter Note dated 2/12/18 revealed .staff was able to don (to put on) . pt's (patients) splint this date after training in proper techniques used to don .educated on wearing schedule . Medical record review of the Occupational Therapy Note dated 2/16/18 revealed .This pt (patient) is being d/c (discharged to the care of nursing .Her right hand is very pliable (easily bent flexible) due to consistent use of othotics (orthotics splint device) .Staff demonstrated understanding of application and schedule . Medical record review of Resident #19's quarterly Minimum Data Set ((MDS) dated [DATE] revealed no Brief Interview for Mental Status should be conducted on the resident and indicated the resident was severely cognitively impaired. Continued review revealed the resident had a functional limitation in range of motion in her upper extremity with impairment on one side. Medical record review of the Physician order [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Observation of Resident #19 on 03/25/19 at 10:43 AM, in the resident lounge area near nursing station 2, revealed the resident seated in a wheelchair watching television with peers. Continued observation revealed the resident's right hand wrist splint device was not in place. Observation of Resident #19 on 03/26/19 at 9:14 AM, in the resident lounge area near nursing station 2, revealed the resident was seated in a wheelchair, watching the television with 4 other peers. Continued observation revealed no evidence Resident #19 was wearing the right hand/wrist splint device. Observation of Resident #19 on 03/26/19 at 2:31 PM, in the resident lounge area near nursing station 2, revealed the resident was in a wheelchair watching television with peers. Continued observation revealed the resident's right hand wrist splint device was not in place. Interview with the Rehabilitation Manager on 3/26/19 at 3:06 PM, in the therapy office confirmed Resident #19 was discharged from occupational therapy after being followed for her right hand contracture on 2/16/18. Continued interview confirmed Resident #19 tolerated her right hand wrist splint well. Further interview confirmed the resident currently had an order in place to continue to wear the right hand wrist splint. Interview with License Practical Nurse (LPN) #1 on 3/26/19 at 3:45 PM, in the hall, outside of the conference room, confirmed Resident #19 had an order to wear a right hand wrist splint. Continued interview confirmed the splint was scheduled to be applied daily to Resident #19 at 8:00 AM, and was to be removed at 11:00 AM. Further interview confirmed LPN #1 was unable to locate Resident #19's splint in the resident's room or personal belongings and had not applied the resident's splint. Interview with the Director of Nursing (DON) on 3/26/19 at 4:08 PM, in the conference room, confirmed the facility failed to ensure Resident #19 had a right hand wrist splint device applied 2-3 hrs a day 7 days a week to prevent worsening of Resident #19's right hand wrist contracture.

Based on facility policy review, observation, and interview the facility failed to provide timely dental services for 1 resident #86 of 31 sampled residents. The findings include: Review of the facility's policy, Dental Services, revised 8/24/17 revealed .dentists must be available to provide follow-up care . Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. Observation and interview with Resident #86 on 3/25/19 at 3:55 PM, in the resident's room, revealed the resident was edentulous (no teeth). Interview with the resident revealed he had his teeth pulled about 6 months ago and he was supposed to get dentures. Further interview revealed he would like to have his dentures. Medical record review of a Dental Treatment Note revealed .Facility .(name of facility) .Provider .(name of dental service) .Patient .(Resident #86) .Dentist .(name of dentist) .Date of Visit: 9/26/18 .Treatment Notes: Saw pt (patient) bedside due to being bed bound. Previous extraction sites healed well. Impressions taken for F/F (full set of dentures) .Treatment Plan Notes: Possible delivery F/F . Medical record review of the resident's weight record revealed the resident refused to be weighed 11/2018 and 12/2018. Further review revealed his weight 1/2019 was 280 pounds and he refused to be weighed 2/2019 and 3/2019. Interview with the Social Service Director on 3/26/19 at 2:42 PM, at the secure unit nurse's desk, revealed Resident #86 was evaluated on 9/26/18 by mobile dental services. Further interview revealed the Dentist made impressions for dentures and the facility decided to quit using that mobile dental service. Continued interview revealed the facility started using a different mobile dental service and the contract became effective 10/4/18, and the note from the previous mobile dental service had not been transferred to the current mobile dental service concerning the residents dental impressions from the visit on 9/26/18. Further interview revealed the resident had not received his dentures at this time. Interview with the Social Service Director on 3/27/19 at 8:15 AM, in the conference room confirmed the facility failed to ensure Resident #86 received dentures in a timely manner.

Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to protect 1 resident (#3) from abuse of 3 residents reviewed for abuse, of 5 residents sampled. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property revealed, not dated, revealed .It is .policy to prevent the occurrence of abuse .the policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at the time .abuse is the willful infliction of injury .intimidation .includes .verbal abuse .for purposes of this policy 'willful' means non-accidental .means the individual acted deliberately .not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 5 (severe cognitive impairment) on the Brief Interview for Mental Status. Continued review revealed the resident had a history of [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 14 day MDS dated [DATE] revealed the resident scored a 4 (severe cognitive impairment) on the BIMS. Continued review revealed the resident had no history of behaviors and was dependent upon moderate to maximum assistance of others for all ADLs. Review of a facility investigation dated 11/26/18 revealed Resident #2 wandered into Resident #3's room on the secured memory care unit and sat on Resident #2's bed. Continued review revealed Licensed Practical Nurse (LPN) #1, who was at the nurses' station, heard a commotion, entered the resident's room and observed Resident #3 pull on Resident #2's pants leg. Further review revealed LPN #2 observed Resident #2 tell Resident #3 to stop and then slap Resident #3 on the right cheek with an open hand. Interview with LPN #1 on 11/29/18 at 1:25 PM, in the dietary office, revealed she heard a commotion from Resident #3's room at the far end of the unit and when she responded she observed Resident #3 tug on Resident #2's leg and then she observed Resident #2 slap Resident #3. Interview with the Director of Nursing (DON) on 11/29/18 at 3:35 PM, in the dietary office, revealed the DON confirmed Resident #2 willfully slapped Resident #3 on the face and the facility failed to protect Resident #3 from abuse.

Based on medical record review, review of facility documentation and interview, the facility failed to notify the resident's physician/nurse practitioner of increased pain after a fall resulting in a [MEDICAL CONDITION] for one (#9) of twenty-six residents reviewed. The facility's failure resulted in harm for resident #9. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had difficulty with long and short term memory, and had impaired decision making skills. Review of facility documentation dated November 14, 2010, at 7:45 p.m., revealed the resident sustained [REDACTED]. Review of the nursing notes dated November 14, 2010, at 7:45 p.m., revealed the nurse, who assessed the resident after the fall, documented "...Pt. (Patient) does complain of (R) (right) inner thigh hurting..." Medical record review revealed there was no documentation the nurse offered the resident pain medication, or notified the Nurse Practitioner (NP)/Medical Doctor (MD) of the resident's pain from November 14 until November 16, 2010. Review of the nursing notes dated November 15, 2010, at 11:00 a.m., revealed, "...Pt. (patient) cont. (continues) to c/o (complain) pain mainly in (R) hip..." Medical record review revealed no documentation the nurse offered the resident pain medication or notified the NP/MD of the resident's complaint(s) of pain from November 14, until November 16, 2010. Continued review of the documentation revealed the NP was notified and ordered an x-ray, which was completed on November 15, 2010, with "...Findings strongly raise suspicion of a subcapital [MEDICAL CONDITION] proximal femur...No acute displaced fractures...CT scan (Computerized Tomography scan) would be helpful to confirm or deny a [MEDICAL CONDITION] subcapital region ..." Review of the hospital documentation revealed the resident was transferred to the hospital on November 16, 2010 for a CT scan of the right hip, due to "...increased pain described by the patient as 'sharp' ..." Continued review of the hospital documentation dated November 16, 2010, revealed the patient rated the pain as "...the worst pain ever..." Review of the results of the CT scan revealed "...Acute Impacted Right Femoral Neck Fracture with some 90 degrees of Varus Angulation and Posterior Rotation of the Femoral Diaphysis..." Interview with Licensed Practical Nurse #3 on March 2, 2011, at 11:45 a.m., in the Training Room, confirmed the resident had increased pain with activities of daily living, bathing, moving, transfers, etc. after the fall on November 14, 2010. Continued interview confirmed on November 15, 2010, the resident had "continued to complain of pain" and the Nurse (LPN #3) failed to notify the NP of the resident's initial pain which began on November 14, 2010 or continued pain, as documented in the nurse's notes on November 15, 2010. Interview with the Administrator In Training (AIT) on March 2, 2011, at 3:45 p.m., in the Training Room confirmed the NP or MD was not notified of the resident's pain and/or increased pain from November 14, 2010, after the fall, until November 16, 2010. Interview with the NP on March 2, 2011, at 4:00 p.m., in the Training Room confirmed the nurse(s) did not notify the NP of the resident's pain after the fall, and failed to notify the NP of the resident's increased pain prior to going to the hospital for the CT scan. Continued interview with the NP confirmed the NP was the person to be notified for medication orders related to new onset or increased pain because the NP was present in the facility five days a week, on call at night on alternate weekends.

Based on medical record review, observation and interview, the facility failed to assess/provide pain management interventions after a [MEDICAL CONDITION] for one (#9) of twenty-six residents reviewed resulting in unresolved pain and harm for resident #9. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired decision making skills. Review of the Nurse Practitioner's (NP)orders dated November 9, 2010, revealed, "[MEDICATION NAME] 2.5/500 mg. (Milligrams) p.o. (by mouth) (for abdominal discomfort)...D/C (discontinue) Tylenol BID (two times a day) when [MEDICATION NAME] available..." Review of the Medication Record for November 2010 revealed the resident received the Tylenol 650 mg. two times a day as ordered through November 15, 2010. Continued review of the November 2010 Medication Record revealed the resident did not receive the [MEDICATION NAME] 2.5 mg. as ordered from November 9, thru November 15, 2010, as indicated by an "X" or by the nurse signing and circling the times as "not administered" to the resident. Continued review of the back of the Medication Record revealed no documentation why the [MEDICATION NAME] was not administered on November 9, 10, or 11, 2010 (spaces were left blank). Continued review of the Medication Record, revealed on November 12, 13, 14, & 15th, the nurses documented "[MEDICATION NAME] not available-Pharmacy notified..." Continued review of the Medication Record for November 2010 revealed the resident received the first dose of [MEDICATION NAME] 2.5/500 mg. on November 16, 2010 at 8:00 a.m., a delay of six days. Review of facility documentation dated November 14, 2010, at 7:45 p.m., revealed the resident sustained [REDACTED]. Continued review of the documentation revealed the (NP) was notified and ordered an x-ray, which was completed on November 15, 2010, with a [DIAGNOSES REDACTED]. Review of the nursing notes dated November 14, 2010, at 7:45 p.m., revealed the nurse, who assessed the resident after the fall, documented " ...Pt. (Patient) does complain of (R) (right) inner thigh hurting ..." Medical record review revealed no documentation the nurse offered the resident pain medication, or notified the NP/Medical Doctor (MD) of the resident's pain for any of the shifts until November 16, 2010. Review of the nursing notes dated November 15, 2010, at 11:00 a.m., revealed, "...Pt. (patient) cont. (continues) to c/o (complain) pain mainly in (R) hip..." Medical record revealed no documentation the nurse offered the resident pain medication or notified the NP/MD of the resident's complaint(s) of pain from November 14, 2010, (at the time of the fall) until November 16, 2010, on all shifts. Review of the hospital documentation dated November 16, 2010, revealed the resident returned to the hospital on November 16, 2010 for a CT scan of the right hip, due to "...increased pain described by the patient as 'sharp'...". Continued review of the hospital documentation dated November 16, 2010, revealed the patient rated the pain as "...the worst pain ever..." Review of the results of the CT scan revealed "...Acute Impacted Right Femoral Neck Fracture with some 90 degrees of Varus Angulation and Posterior Rotation of the Femoral Diaphysis..." Review of the Medication Record dated November 2010, revealed on November 16, 2010, the NP increased the [MEDICATION NAME] from 2.5/500 mg. BID to 5/500 mg. BID, due to increased pain in the right hip, (two days after the resident's fall). Observation on February 28, 2011, at 3:45 p.m., revealed the resident lying on a low bed, one mat on the floor at bedside, one side of the bed pushed against the wall. Interview with Licensed Practical Nurse (LPN #3) on March 2, 2011, at 11:45 a.m., in the Training Room, confirmed the resident had increased pain with activities of daily living, bathing, moving, transfers, etc. after the fall. Continued interview confirmed on November 15, 2010, the resident had "continued to complain of pain" and LPN #3 did not offer the resident pain medication and failed to notify the NP of the resident's initial pain which began on November 14, 2010, or continued pain until November 16, 2010. Interview with the Administrator In Training (AIT) on March 2, 2011, at 3:45 p.m., in the Training Room confirmed the resident was not offered [MEDICATION NAME] 2.5/500 mg. for increased pain after a fall; the facility failed to provide any interventions to manage resident #9's pain; the Nurse Practitioner or Doctor was not notified of the resident's pain or of the resident's increased pain; and the nurse(s) did not notify the NP that the [MEDICATION NAME] 2.5/500 mg. was not available. Interview with the NP on March 2, 2011, at 4:00 p.m., in the conference room confirmed the nurses did not notify the NP of the resident's pain after the fall; and of the resident's increased pain prior to going to the hospital for the CT scan; or that the [MEDICATION NAME] 2.5/500 mg. was not available and had not been administered as ordered. Continued interview confirmed if the nurses had notified the NP of the resident's pain, or that the [MEDICATION NAME] 2.5 mg. was not available the NP would have ordered another pain medication. Further interview confirmed the NP was the person to be notified for medication orders related to new onset or increased pain, the NP was present in the facility five days a week, on call at night on alternate weekends.