Every finding on record at Spring City Care and Rehabilitation Center

Based on facility policy review, medical record review, observations, and interviews the facility failed to maintain dignity for 3 residents (Resident #25, #45, and #62) of 8 residents reviewed.The findings include: Review of the facility policy's titled, Assistance with Meals, dated 1/31/2025, revealed .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents who cannot feed themselves will be fed with .dignity . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Mood Disorder, and Unspecified Protein-Calorie Malnutrition. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and was independent with eating. During an observation on 5/5/2026 at 7:56 AM, Resident 25's room, revealed Certified Nursing Assistant (CNA) A stood while he fed the resident. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Dementia, Contracture of Left Hand, Contracture of Left Elbow, and Feeding Difficulties. Review of an annual MDS assessment dated [DATE], revealed Resident #45 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment and required substantial maximal assistance with eating. During an observation on 5/5/2026 at 8:10 AM, in Resident 45's room, revealed CNA A stood while he fed the resident. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Unspecified Protein-Calorie Malnutrition, Schizophrenia, and Feeding Difficulties. Review of an admission MDS assessment dated [DATE], revealed Resident #62 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and was dependent with eating. During an observation on 5/5/2026 at 8:12 AM, in Resident 62's room revealed CNA B stood while she fed the resident. During an interview on 5/5/2026 at 8:13 AM, CNA A stated he stood at times when he assisted residents with eating .I didn't think I could get a chair in here [Resident #45's bedside] . During an interview on 5/5/2026 at 8:14 AM, CNA B stated staff are supposed to sit to assist a resident with eating. She also stated .I was getting ready to pull a chair up [to Resident #62's bedside] . During an observation and interview on 5/5/2026 at 8:29 AM, with the Director of Nursing (DON) in Resident 45's room, revealed CNA A stood as he assisted the resident to eat. The DON stated the facility policy was for staff to sit while feeding a resident. The DON confirmed CNA A stood while feeding Resident #45. During an interview on 5/5/2026 at 1:39 PM, Resident #62 stated staff stood at times to assist her with eating. The resident also stated she preferred staff to sit while they assist her with eating .I like them to be at my eye level .

Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, interview, and observation, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 5 residents (Resident #32, # 62, #2, #59, and #27) of 20 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare and Medicaid Services Long Term Care Facility RAI 3.0 User's Manual Version 1.20.1, dated 11/2025, revealed .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . SECTION L .ORAL/DENTAL STATUS .This item is intended to record any dental problems present .check all that apply .obvious broken natural teeth . Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Anxiety Disorder, Depression, Unspecified Psychosis, and Adjustment Disorder with Depressed Mood. Review of a Notice of PASRR Level II Outcome dated 7/21/2025, revealed .Notice of PASRR Level II Outcome .Nursing Facility Approval .You are approved for nursing facility services .your PASRR Level II evaluation remains good during your stay . The individual meets criteria for having diagnosis of .Serious mental illness .Bipolar Disorder . Review of an annual MDS assessment dated [DATE], revealed Resident #32 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state level II PASRR process to have serious mental illness .related condition .no . Medical record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Schizophrenia, and Anxiety Disorder. Review of a Notice of PASRR Level II Outcome dated 3/23/2026, revealed .Notice of PASRR Level II Outcome .Nursing Facility Approval .You are approved for nursing facility services .your PASRR Level II evaluation remains good during your stay . The individual meets criteria for having diagnosis of .Serious mental illness .Bipolar Disorder . Review of an admission MDS assessment dated [DATE], revealed Resident #62 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state level II PASRR process to have serious mental illness .related condition .no . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Generalized Anxiety, and Psychophysiologic Insomnia. Review of a Notice of PASRR Level II Outcome dated 3/10/2026, revealed .Notice of PASRR Level II Outcome .Nursing Facility Approval .You are approved for nursing facility services .your PASRR Level II evaluation remains good during your stay .The individual meets criteria for having diagnosis of .Serious mental illness .Bipolar Disorder . Review of an admission MDS assessment dated [DATE], revealed Resident #2 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state level II PASRR process to have serious mental illness .related condition .no . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Post-Traumatic Stress Disorder, and Adjustment Disorder. Review of a Notice of PASRR Level II Outcome dated 3/10/2026, revealed .Notice of PASRR Level II Outcome .Nursing Facility Approval .You are approved for nursing facility services .your PASRR Level II evaluation remains good during your stay .Bipolar Disorder . Review of an annual MDS assessment dated [DATE], revealed Resident #59 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed .Is the resident currently considered by the state level II PASRR process to have serious mental illness .related condition .no . Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Down Syndrome, and Epilepsy. Review of a Dental Note dated 6/11/2024, revealed .chipped tooth #7 .Missing [teeth] 6, 4, 3, 2, 1, 30, 9, 14, 15, 16, 17, 18, and 19 . Review of an annual MDS assessment dated [DATE], revealed Resident #27 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment and had no dental concerns. Review of Dietary Notes from 6/2024-5/2026 revealed Resident #27 had no weight loss and received a pureed diet. Review of a quarterly MDS assessment dated [DATE], revealed Resident #27 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment and had no dental concerns. During an observation on 5/4/2026 at 3:10 PM, revealed Resident #27 lying in bed smiling with multiple missing upper and lower teeth. During an interview on 5/4/2026 at 3:40 PM, Licensed Practical Nurse (LPN) C stated Resident #27 had multiple missing teeth, eats a puree diet, eats 100% of his meals, and had not had weight loss. During an observation and interview on 5/5/2026 at 3:25 PM, Registered Nurse MDS Coordinator reviewed MDS assessments for Residents #32, #62, #2, #59, and #27. The MDS Coordinator confirmed the assessments were inaccurate and did not reflect Residents #32, #62, #2, and #59's serious mental illness. Further interview revealed Resident #27 had missing teeth, and the MDS was inaccurate for dental status.

Based on medical record review, observation's, and interview's, the facility failed to provide assistance for activities of daily living (ADL) for 1 dependent resident (Resident #42) of 26 residents sampled for ADL care.The findings include:Review of the facility's policy titled Activities of Daily Living (ADLs) dated 1/30/2026, revealed .For residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of cares .Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including Dementia, Stroke, and Schizophrenia.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #42 required substantial/maximal assistance with personal hygiene.Review of a comprehensive care plan for Resident #42 dated 3/3/2026, revealed .provide assistance for ADL's as needed .During an observation on 5/5/2026 at 8:30 AM in Resident #42's room, revealed resident sitting in her wheelchair with a large amount of facial hair.Review of the facility's bathing schedule on 5/5/2026 revealed Resident #42 was scheduled to receive showers on Monday and Thursday.Review of the Nurses progress notes for the past 30 days for Resident #42 revealed no documentation of refusal for shower or grooming care.During an interview on 5/5/2026 at 2:20 PM, Certified Nurse Assistant (CNA) C stated Resident #42 was to receive her shower on Monday and Thursday. The CNA C also stated residents are to have facial hair removed on shower days. CNA C confirmed Resident #42 had a large amount of facial hair and had not been removed.During an observation and interview on 5/5/2026 at 2:27 PM, in Resident #42's room, Registered Nurse A Confirmed Resident #42 had a large amount of facial hair.During an observation and interview on 5/5/2026 at 2:31 PM, the Director of Nursing confirmed Resident #42 had a large amount of facial hair and had not been removed.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure the safety of 1 resident (Resident #44) of 74 residents reviewed for accidents. The findings include:Review of the facility's policy titled, Medication Administration General Guidelines, dated 1/25, revealed .Medications are administered .in accordance with .good nursing principles and practices .Medications are to be administered at the time they are prepared .Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications .The resident is always observed after administration to ensure that the dose was completely ingested .Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Anxiety Disorder, Other Seizures, and Unspecified Cirrhosis of Liver.Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #44 scored a 4 on the Brief Interview for Mental Status assessment which indicated the resident had severe cognitive impairment. Review of a Physician Order Report for Resident #44 dated 4/6/2026-5/6/2026, revealed no order for Resident #44 to self-administer medications. Further review revealed .08/18/2023 .levetiracetam [a medication used to help control certain types of seizures] .500 mg [milligram] .Twice A Day .08/29/2023 .lactulose solution [a medication used to treat chronic constipation and reduce blood ammonia levels]; 10 gram/15 mL [milliliter] .30 ML .Twice A Day .04/01/2026 .Ativan [a medication used to treat anxiety] .0.5 mg .Twice A Day . During an observation on 5/4/2026 at 11:41 AM, revealed 2 medicine cups on Resident #44's overbed table. One cup contained two pills and one cup contained a clear pale-yellow liquid. During an observation and interview on 5/4/2026 at 11:44 AM in Resident #44's room, Licensed Practical Nurse (LPN) C stated the medicine cups on Resident #44's overbed table had been left there for approximately an hour. LPN C stated one medicine cup contained Resident #44's Ativan and Keppra (Levetiracetam), and the other contained his Lactulose. When asked if medications were routinely left at Resident #44's bedside, she stated .no, but he gets ornery sometimes . She further stated Resident #44 was not assessed to self-administer his own medications and confirmed the medications should not have been left at his bedside. During multiple observations from 5/4/2026-5/6/2026, revealed no wandering residents were observed attempting to enter Resident #44's room.During an interview on 5/6/2026 at 11:15 AM, the Director of Nursing stated leaving medications at the bedside with a resident who is not assessed to self-administer medications is .against our policy . She confirmed LPN C did not follow the facility's policy for medication administration when leaving medications at Resident #44's bed side.

Based on facility policy, facility investigations police reports, medical record review and interview, the facility failed to protect a resident's right to be free from abuse for 6 of 20 (Resident #23, #24, #7, #8, #10 and #11) residents reviewed for abuse. The facility failed to protect Resident #23, a cognitively impaired female resident, from sexual abuse when Resident #24, a cognitively impaired male resident, made sexual advances toward Resident #23 causing mental distress, which resulted in actual harm to Resident #23 and when the facility failed to protect Resident (#7, #8, #10, #11) from resident-to-resident physical abuse. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property revised 9/15/2023, showed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property .Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Resident #23 was admitted to the facility on [DATE], with diagnoses including Dementia Severe with other Behavioral Disturbances, Bipolar Disorder, Depressive Episodes, Cognitive Communication Deficit and Anxiety Disorder. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident required extensive assistance of 2-person with bed mobility, transfer, dressing and personal hygiene. Review of the facility investigation dated 7/29/2023 at 6:47 PM, showed Certified Nursing Assistant (CNA) #6, reported to the nurse that she heard someone screaming [Resident #23] and saw Resident #24 in Resident #23's room standing at the side of the bed. His pants and underpants were down on the floor. His left hand was between her legs. She was wearing a brief and a shirt and covered with a sheet. Review of a Police Report dated 7/30/2023, showed .On July 29th at 8:24 PM [police] .dispatched to [facility] in reference to a sexual assault. Police also spoke to [Resident #23] about the incident as well. Upon first questioning [Resident #23] denied memory of any event happening this date. When .was directly asked if she had any recollection of someone touching her without her permission .stated 'Oh yeah, you're talking about that man' .then stated that a man in a wheelchair came into her room and kept wheeling closer to her bedside .stated that the man kept asking her to move her leg and blanket which she refused to do .then stated that the man moved the blanket and was touching her in the groin area, that is when she began screaming for [staff member] .' When I asked [Resident #23] if the man had touched her privates, she stated 'He didn't get that far . Review of a facility obtained interview with Resident #23, dated 7/29/2023 at 9:00 PM, conducted by the DON and UM showed .How are you tonight? 'Nervous' Can you tell me why? 'Cause [because] every time someone comes in here, I don't know if it is that man [Resident #24].' The man that came in here earlier what did he do? 'Rolled his w/c [wheelchair] in beside my bed then he put his hands on my bed and reached for my leg then reached for my blanket like he was trying to pick it up. He tried to put his hand up my gown.' Then what happened? 'He unzipped his britches then tried to grab my hand I didn't let him' Did you see his privates? 'No' Did he touch your privates? 'No, just the outside of my diaper.' Did he hurt you? 'No, he didn't hurt me just made me nervous. I just hollered for [staff] 3 or 4 X [times] .they came and got him out.' Do you feel safe now? 'Yes, just nervous.' Do you want anything? 'Maybe a Tylenol later . Resident#23's record review showed the resident left the nursing facility at 9:10 PM, via ambulance to [hospital] to be evaluated accompanied by staff. Review of Resident #23's Emergency Department Physician Progress Note dated 7/29/2023, showed .Chief Complaint: Sexual Assault (alleged) .Patient states another resident [Resident #24] entered her room and put his hand on her thigh and attempted to slide his hand under her diaper. Patient states she called out mildly and staff removed male resident. Patient states his hand remained above her diaper and there was no sexual intercourse . Review of Resident #23's Nursing Progress Note dated 10:39 PM, showed .Late Entry: Telephone call to family .to advise of abuse and resident being sent out to ED [Emergency Department] for evaluation and treatment if needed. Resident family voiced understanding with no questions. MD notified with no new orders at this time . Review of Resident #23's comprehensive care plan, revised 7/29/2023, showed .Psychosocial Well-Being .at risk for 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 wellbeing related to negative encounter with male 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 .offer diversional activities if mood changes .Psych [Psychiatric] NP [Nurse Practitioner] to visit with resident on next visit .Sent to ER [emergency room ] for evaluation . Review of Resident #23's Psychiatric Periodic Evaluation NP (Nurse Practitioner) Progress Note dated 8/11/2023, showed .She has been successfully weaned of Seroquel. Staff reports no psych concerns. No problematic behaviors nor distressing delusions/hallucinations. Will attempt GDR [gradual dose reduction] of Depakote at this time. Her appetite is fair. Sleep is good with the use of Melatonin .On exam resident is oriented to person and situation. She only answered a few questions. She would often just stare at me and not answer. She is HOH [hard of hearing] .Decrease Depakote to 250 mg BID [twice daily] then 125 mg midday . Resident #24 was admitted to the facility on [DATE], and passed away at the facility on 8/14/2023, with diagnoses including Disorder of Brain, Hemiplegia and Hemiparesis following Cerebral Infarction and Convulsions. Review of Resident #24's comprehensive behavioral care plan, revised 7/6/2023, showed Resident #24 had socially inappropriate/disruptive behavioral symptoms toward the female staff. Assess whether the behavior endangers the resident and/or others intervene if necessary. Maintain a calm environment and approach to the resident. When available have male staff provide the care for the resident. Review of Resident #24's admission MDS assessment dated [DATE], showed a BIMS score of 9, indicating moderate cognitive impairment. Review of Resident #24's nursing progress note dated 7/29/2023 at 2:30 PM (approximately 4 hours and 15 minutes prior to the incident), showed, .Resident inappropriately touching staff. Staff provided redirection multiple times and resident would continue to grab at staff throughout the day. Redirection successful for a short time period. Resident placed in eye view of staff [for an undetermined and undocumented amount of time] . Review of a facility obtained interview with Resident #24 dated 7/29/2023 at 9:20 PM, by the DON and the the UM showed, .What happened tonight? 'I don't remember.' Did you go in a lady's room? 'I don't know.' Did you touch anyone tonight? 'I don't remember.' Interview stopped with Resident stating He does not remember. He states he has no memory to any portion of the incident when asked . Review of Resident #24's nursing progress note dated 7/29/2023 at 10:25 PM, showed, .Resident was placed on one-on-one monitoring at 6:47 PM [after incident with Resident #23] .spoke with [family member] she did give approval of room change [Resident #24's room had been next door to Resident #23] . Review of Resident #24's comprehensive care plan, revised 7/29/2023, showed, .Behavioral Resident exhibits inappropriate sexual behavior towards female resident administer medication per MD .order, notify appropriate agencies, Notify MD/Responsible party, one on one supervision until evaluated by MD/Psych NP and continue after as needed. Provide diversional activities as needed. Room change to room away from female resident. Review of Resident #24's Medication Administration Record dated 7/29/2023-8/26/2023, showed Resident #24 remained on one-on-one supervision from 7/29/2023 at 7:00 PM - 8/3/2023 at 11:55 PM. Review of a facility document Safety Check Log dated 8/4/2023-8/9/2023, showed Resident #24 remained on 15-minute safety checks. Review of Resident #24's Psychiatric Evaluation dated 8/4/2023, showed, .Initial visit made today. Resident has a history of brain cancer at 9yo [9 years old]. He had a CVA [cerebral vascular accident] in 2015. Now noted to have a cystic mass on brainstem. Resident has moderate cognitive impairment. He has right hemiplegia and requires assistance with ADLs [activities of daily living]. Today staff reports resident has had behaviors, sexual inappropriate in nature. He attempts to touch female staff and female resident. Resident was started on Medroxyprogesterone 10 mg tab PO [by mouth] QD [one time a day] on 7/30/2023, then switched to Medroxyprogesterone 150 mg IM [intramuscular] monthly. He is currently on 1:1 care to monitor his behaviors. On exam, resident is sitting in the hallway, drowsy, attempts to answer a few questions. He has minimal interaction with me . Recommendation . Problem/ condition: Vascular Dementia w [with]/Behaviors (sexual in nature)-Plan: Continue Medroxyprogesterone for now. If ineffective, try Depakote or Seroquel. Add diagnosis .Vascular dementia w/behaviors . Review of Resident #24's nursing progress note dated 8/7/2023 at 3:53 AM, showed, .Resident laying quietly in bed. No behaviors noted. Staff supervision with resident continues . During an interview on 1/29/2023 at 9:50 AM, the Medical Director stated, .[Resident #23] has severe dementia .In my professional opinion a reasonable person would act out being withdrawn and could have long-term emotional trauma. In her specific case with the severe dementia there were no physical or emotional harm .but a reasonable person could have emotional harm from an incident such as this . During an interview on 1/29/2023 at 10:30 AM, Resident #23 only answered questions asked of her. When asked how she was she stated, I'm alright I guess When asked if anyone here had ever hurt her or scared her she stated, I don't know .sometimes I am afraid. The surveyor asked what or who she was afraid of and she stated, bad people. The resident was unable to specify or elaborate on bad people or the incident which had occurred on 7/29/2023. During an interview on 1/29/2024 at 4:40 PM, Licensed Practical Nurse (LPN) #6 stated, .CNA #6 reported to me that she heard [Resident #23] scream, he [Resident #24] was there next to her bed he had his pants and underpants down .and he had his hand between her legs but she was covered with a brief and a sheet .she told me he was trying to get his hand inside her brief but that he had not .she was upset she was screaming, she was physically upset . During an interview on 1/30/2024 at 1:15 PM, the DON stated Resident #24 had been placed on one-on-one supervision for 72 hours, then on 15 minute checks until 8/9/2023. She stated at that point Resident #24 had a significant physical decline and was no longer a threat to other residents and passed away on 8/14/2023. During an interview on 2/1/2024 at 9:50, Resident #23's Family Member stated, .they [the facility staff] did call me and report what happened to me .I think .it would have upset her very much .I think she would have been afraid .and it would have .stuck in her mind . During an interview on 2/1/2024 at 2:00 PM, CNA #6 stated, .I heard a scream, I heard help, help .I was shocked to see that he [Resident #24] was standing at the side of her [Resident #23] bed, his hand was inside her brief at the side, I don't know how deep into the brief he got, the tape was still intact .the sheet was half way off but her brief was on .I yelled hey and I grabbed his hand off of her that is when I noticed his pants and brief were down his legs you could see his privates and his butt .I covered her [Resident #23] back up and pulled him [Resident #24] out of the room .I took him to the nurses' station and reported it to the nurse .the nurse went to [Resident #23] room we kept him at the nurses' station .her facial expression showed she was upset. I think she was .scared but she didn't say that she was .I had heard he could be inappropriate with staff . During an interview on 2/7/2024 at 11:15 AM, CNA #8 stated, .after the incident occurred I did one on one with Resident #24 at the nurses station .he was a little handsy he tried to grab my chest a couple of times .I was with him until the police came .another CNA provided one on one after the police arrived .I was sent to the hospital with [Resident #23] .At the .hospital she was .nervous .I asked her about the incident and she said .he had not raped her . During an interview on 2/13/2023 at 1:00 PM, the Administrator stated, .we did not substantiate this allegation as abuse because first [Resident #23] denied at the hospital [sexual assault] happened to her .the CNA saw what she saw .[Resident #24] had brain cancer and passed away on 8/14/2023, to me that says his cancer in his brain progressed so rapidly he did not know what he was doing .I can't quantify a reasonable person's reactions because that is not the situation . Review of the facility's investigation, police report, ER physician's progress note, medical records review for Resident #23 and #24 and interviews, showed the facility's failure to provide supervision and effective interventions for Resident #24's sexual behaviors resulted in actual harm for Resident #23 when Resident #24 was found in Resident #23's room with his hand inside her brief and she was screaming. Resident #7 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses including Cerebral Infarction, Schizoaffective Disorder Bipolar Type, Alzheimer's Disease and Dementia with other Behavioral Disturbance. Review of Resident #7's quarterly MDS assessment dated [DATE], showed a BIMS score of 14, indicating the resident was cognitively intact with no behaviors noted during the assessment period. Resident #8 was admitted to the facility on [DATE], with diagnoses including Disorder of Bone Density, Delusional Disorders, Dysphagia, Dementia with other Behavioral Disturbances, Major Depressive Disorder, Anxiety Disorder, and Alzheimer's Disease. Review of Resident #8's quarterly MDS assessment dated [DATE], showed a BIMS score of 3 indicating severe cognitive impairment. Potential Indicators of Psychosis of delusions were noted in the assessment period. Review of a facility investigation dated 8/2/2023, showed Resident #7 stated she and Resident #8 had a verbal altercation when Resident #8 came in her room. Resident #7 stated she told Resident #8 to get out. Resident #8 then slapped at her with no injuries and Resident #7 pulled Resident #8's thumb with no injuries. Resident #8 is delusional and thought Resident #7 was hitting a child. Resident #8's BIMS score is 3. The facility determined that both residents had contact with each other. Review of a Police Department Report dated 8/2/2023 at 4:52 PM, showed, .simple assault .no arrests associated with this incident .police dispatched to [facility] in reference to a delayed assault. When I arrived, I spoke with the Director [Administrator] .stated they had two patients get into a physical altercation today around 3:35 PM .[Administrator] stated [Resident #8] went into [Resident #7]'s room. When [Resident #7] told [Resident #8] to leave [Resident #8] then struck [Resident #7] in the neck/shoulder area with her hand and then [Resident #7] grabbed [Resident #8's] thumb and bent it backwards. [Administrator] stated she was told the incident occurred because [Resident #8] thought [Resident #7] was attacking a small child. [Administrator] then took me to the nurses' station and [Assistant Director of Nursing/ADON] took me to speak to both parties. I spoke to [Resident #8] first and [Resident #8] advised that she did not remember anything about the incident. [Resident #8] has a BIMS score of 3. I then went and spoke to [Resident #7] who has a BIMS score of 14 who stated [Resident #8] came into her room and [Resident #7] asked [Resident #8] to leave the room and then [Resident #8] put her finger in the face of [Resident #7] and they exchanged some words then [Resident #8] struck her in the neck/shoulder area and [Resident #7] stated she then grabbed [Resident #8's] thumb and bent it backward . Review of Resident #7's nursing progress note dated 8/2/2023 at 7:09 PM, showed, .ADON met with [Resident #7] to follow up regarding incident this afternoon, in which the resident was slapped . During an interview on 1/23/2024 at 12:15 PM, the ADON, stated, .[Resident #8] and [Resident #7] were roommates, [Resident #8] was moved .but they were roommates for a while .[Resident #8] has severe dementia and she would continuously go back to her old room with [Resident #7] .[Resident #8] entered [Resident #7]'s room and [Resident #7] reported she had asked her to leave several times .she reported that [Resident #8] had smacked her on the neck .When she smacked her, she [Resident #7] had grabbed [Resident #8's] thumb and bent it back .when I did [Resident #8]'s assessment her thumb was red but she had full range of motion .when I asked her what happened all she said was she was protecting the child, but she had no idea what happened to her thumb .she didn't recall hitting another resident . During an interview on 1/29/2024 at 3:10 PM, LPN #7 stated, .I was at the nursing station and [Resident #7] came up the hall and stated she just hit me .[Resident #7] was a little agitated at first over the fact that [Resident #8] had been in her room . During an interview on 1/30/2024 at 3:15 PM, the DON stated, .[Resident #7] reported that [Resident #8] slapped her on the neck .in turn [Resident #7] bent [Resident #8]'s thumb back trying to protect herself .I do not think her action of slapping [Resident #7] was a willful act related to her cognition score of 3 . During an interview on 2/12/2024 at 12:40 PM, the Administrator stated, .this was an unwitnessed allegation .I don't think [Resident #8] had the presence of mind to hurt somebody .she did not do it to abuse [Resident #7]. [Resident #7] reacted by bending [Resident #8's] thumb back, neither sustained injury . Resident #10 was admitted to the facility on [DATE], discharged to inpatient psych (psychiatric treatment) on 6/29/2023, readmitted on [DATE], discharged to inpatient psych on 9/29/2023, and returned on 10/9/2023, with diagnoses including Cerebral Infarction, Delusional Disorders, Major Depressive Disorder, Dementia Severe with other Behavioral Disturbance, Anxiety Disorder and Cerebrovascular Disease. Review of Resident #10's admission MDS assessment dated [DATE], showed a BIMS score of 3, indicating severe cognitive impairment. Resident #10 exhibited verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, rejection of care occurred 1 to 3 times a week and wandering behaviors occurred daily during the assessment period. Resident #11 was admitted to the facility on [DATE], with diagnoses including Dementia with other Behavioral Disturbance, Atrial Fibrillation, Dysphagia, Cognitive Communication Deficit, Depression, Anxiety Disorder, and Schizophrenia. Review of Resident #11's quarterly MDS assessment dated [DATE], showed a BIMS score of 3, indicating severe cognitive impairment, with no behaviors noted during the assessment period. Review of Resident #10's Skin Care Alert Sheet dated 7/27/2023, showed a bruise and skin tear to Resident #10's right arm and wrist. Review of a Police Report dated 7/27/2023, showed, .no arrests associated with this incident .on 7/27/2023, I [investigator] .was dispatched to [facility] in reference to a disorder between two residents. I made contact with [Director of Nursing] who stated that [Resident #10] had entered [Resident #11]'s room. [Resident #11] then started yelling and grabbed [Resident #10] by the wrist, which left bruising and a skin tear. [DON] stated this was on the [secure hall] and most of these residents suffer from memory loss and do wander the halls sometimes forgetting which room is theirs. I spoke with [LPN/Witness and Registered Nurse (RN)#1] who separated the two residents. [DON] stated medical personal on staff had taken care of [Resident #10] for her wrist . Review of Resident #10's social service note dated 7/27/2023 at 4:24 PM, showed, .SSD [social services director] met with [Resident #10] to follow up regarding incident, this morning, in which she received a skin tear when another resident grabbed at her arm to redirect her .was sitting in a chair in the dining room area of secure unit when SSD met with her. Pt. alert with noted temporal disorientation and short-term recall. Pt. did not recall the incident and did not acknowledge skin tear. Pt. calm and conversational with SSD .Psychosocial status stable at this time .IDT will continue to monitor psychosocial wellbeing . Review of Resident #10's medical record showed no further documentation related to the incident. Review of the facility investigation dated 7/27/2023, showed RN #1 heard screaming and went in Resident #11's room. Resident #11 was yelling for Resident #10 to get out and was holding her right arm. Review of Resident #11's social service progress note dated 7/27/2023 at 4:33 PM, showed .SSD met with [Resident #11] to follow-up with pt. [patient] after recent incident, involving another resident this morning. [Resident #11] grabbed another resident's arm, in attempt to redirect the resident from her room. Staff quickly intervened. SSD visited with resident in her room and found resident to be pleasantly confused. She had no recollection of the event. [Resident #11] has diagnosis of Dementia with Behavioral Disturbance and exhibits poor short-term recall. Pt.'s psychosocial wellbeing status is stable at this time and will continue to be monitored by IDT [interdisciplinary team] . Review of Resident #11's Nursing Progress Note dated 7/27/2023 at 5:55 PM, showed .N/O [new order] for UA [urinalysis] C&S [culture and sensitivity] and placed in the fridge for lab pick up. During an interview on 1/3/2024 at 3:30 PM, RN #1 stated, .I heard [Resident #10] .and saw [Resident #10] in [Resident #11's] room, and [Resident #11] yelled get out and was holding [Resident #10]'s right arm .and [Resident #10] was pulling away from her. I did not see the skin tear occur but I can only assume that is when the skin tear occurred .I took [Resident #10] to the nurses station, cleaned her arm and put steri-strips on her arm. It was a small skin tear .It was actively bleeding .within 10 minutes .got her watching TV she had forgotten all about it .[Resident #11] .calmed down when I took [Resident #10] out of her room .there were no changes in either of the residents emotional behaviors .[Resident #11] didn't like anyone in her room .[Resident #11] was yelling at [Resident #10] to get her out of her room .it was like she was pushing her arm to direct her out . During an interview on 1/30/2024 at 2:10 PM, the DON stated, .we did not substantiate abuse .it was unsubstantiated as abuse due to the cognition of the residents and the definition of willful must have acted deliberately .During the altercation [Resident #10] did receive a skin tear and bruising to her right hand . During an interview on 2/12/204 at 12:40 PM, the Administrator stated, .I don't think that was abuse it was a response to [Resident #10] being in her [Resident #11's] room .

Based on review of a facility policy, facility investigation, medical record review and interviews, the facility failed to report an allegation of sexual abuse within the required 2-hour timeframe for 1 resident (#21) of 8 allegations of abuse reviewed for reporting. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property revised 9/15/2023, showed, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property .Sexual abuse is defines as non-consensual sexual contact of any type with a resident .For the purpose of this guidance, Covered individuals include the owner, operator, employee, manager, agent, or contractor of the facility .Staff would also include caregivers who provide care and services on behalf of the facility .Reporting/Response .Every Stakeholder shall immediately report any allegation of abuse .or suspicion of a crime .to the Facility Administrator or designee .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Resident #21 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Abnormal Posture, Post-Traumatic Stress Disorder, Nightmare Disorder, Anxiety Disorder and Major Depressive Disorder. Review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of two plus person assist for bed mobility and toilet use. Review of a facility obtained interview with Resident #21 on 10/5/2023 showed, .What happened last Tuesday r/t [related to] [Alleged Perpetrator]? 'He came in my room before lunch.' Was your roommate in the room? 'Yes.' He came up to you [your] bed? 'He asked if he could check my brief to see if I need changed. I said yes if you think it needs to be changed.' Then what happened? 'He pulled my pants and brief down he started massaging my hip and behind I was laying on my right side. He pulled his pants down and put his penis in my vagina.' What did you say? 'Nothing.' How long was he in here? 'Probably 5-10 minutes.' Did he ejaculate? 'Not that I could tell.' What did he do when he was done? 'Pulled my brief and pants up then pulled his up. He kissed my hand and walked off.' Did you tell anyone that day? 'No When did you tell someone? 'That Friday [indicated the Behavioral Nurse Practitioner] and then today I told [name of Certified Nursing Assistant (CNA) #9.' Do you want anyone notified? 'No' . During an interview on 1/29/2024 at 3:55 PM, Social Service Director Float, stated, .I did speak with [Resident #21] I went in with the DON [Director of Nursing] and the Unit Manager/Licensed Practical Nurse (LPN) # 5 .she reported that a male CNA [Certified Nursing Assistant] approximately 2 weeks ago had sex with her .She reported that she had told one of the psychologists [Behavioral Health Nurse Practitioner] previously .and she had not said anything to staff. During an interview on 1/30/2024 at 12:45 PM, the FNP (Family Nurse Practitioner/Behavioral Health Nurse Practitioner/NP) stated, .I .provide behavioral health services .she did tell me on the 29th there was new black CNA, through an agency and he had worked her hallway came in to provide peri-care. She was already in the bed when he was changing her brief and that he inserted his penis in her .I asked her how did he manage to do that she said he climbed on the bed and got on top of her and that was how he had intercourse but said I don't think that he finished. She didn't tell me anything after that except she did say her roommate was in the room in bed sleeping and the curtain was closed. She said she was trying to be quite so her roommate didn't hear .I asked her why would you be quite you were getting violated you need to scream she never answered me she just started crying. She said she was afraid she was going to get kicked out of the facility if she told anyone. I reassured her that she would not get kicked out for something brought on her .I asked her if she had told anyone she said no she hadn't reported it. I asked her who did she want to report it to the DON, Social Service Director, or the Administrator. She said no she did not want to talk about it anymore today. I said I am supposed to report it what about the other residents here and their safety we need to protect others, and she kept saying no, no, I am not going to talking about it anymore. Then she said I promise I will go with you the next time you are here to report it .I said you promise when I am here next you will tell someone and she said she would .I did not report it to anyone, the Administrator called me a few days after because the resident had told her she had told me .I felt I should report it but I was trying to protect her privacy and her wishes and to make sure she did in the future .she was adamant she was not going to report it right then . During an interview on 2/5/2024 at 2:30 PM, CNA #9 stated, .it was the second time I had been in [Resident #21's room] that day .she [Resident #21] asked me if she could talk to me. I said yes, she asked me to shut the door. She just started crying she said a male CNA had intercourse with her .then she asked me not to say anything I told her I had to .I promised her everything would be okay and she would get the help she needed . During an interview on 2/12/204 at 12:40 PM, the Administrator stated, . we did not substantiate sexual abuse .the hall she is on the most traveled hall in the building, there were no witnesses, staff was interviewed, residents were interviewed, and her roommate and there was no witnesses to anything like that .[Resident #21] did report to the Behavioral Health NP on Friday September 29th an allegation, but the Behavioral Health NP did not notify the facility because the resident asked her not to .the Behavioral Health NP was one of our contractors she has not been allowed back into the facility since .based on our abuse policy she should have reported the incident to the facility . During the interview, the Administrator stated she did not follow our abuse policy for reporting and the facility did not report the allegation of sexual abuse within the federally required 2-hour time frame .

Based on review of facility policy, medical record review and interviews, the facility failed to follow physician orders for medication administration for 1 resident (#18) of 3 residents reviewed for medication administration. The findings include: Review of a facility policy titled, Medication Administration General Guidelines undated showed .Medications are administered as prescribed in accordance with manufacture's specifications, good nursing principles and practices .Medications are administered in accordance with written orders of the prescriber . Resident #18 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including Disruption of External Operation Surgical Wound, History of Falling, Parkinson's Disease, and Epilepsy. Review of Resident #18's Discharge Minimum Data Set (MDS) assessment dated [DATE], showed return not anticipated. Review of Resident #18's Physician Admission Orders dated 3/3/2023, showed May administer first dose of medications when received from pharmacy . The orders included: Amantadine HCL (hydrochloride) (a medication used to treat Parkinson's Disease) 100 milligram (mg) twice a day 6:00 AM-10:00 AM, 6:00 PM-10:00 PM; Aspirin 325 mg twice a day 7:00 AM-11:00 AM, 7:00 PM-11:00 PM; Carbidopa-levodopa (medication to treat Parkinson's Disease) tablet 25 mg-250 mg, 1.5 tablet four times a day 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM; Dicyclomine capsule (medication used to treat Irritable Bowel Syndrome) 10 mg three times a day as needed (PRN); Entacapone tablet (medication used to treat Parkinson's Disease in conjuction with other medications) 1.5 mg oral four times a day 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM; Gabapentin capsule (medication used to treat nerve ending pain such as Neuropathy) 400 mg, 2 capsules four times a day 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM; Levetiracetam (medication used to treat Seizure Disorder) 1000 mg three times a day 7:00 AM-11:00 AM, 11:15 AM-3:00 PM, 7:00 PM-11:00 PM; Metoprolol tartrate (medication used to treat Hypertension) 25 mg twice a day 7:00 AM-11:00 AM and 7:00 PM-11:00 PM; Oxcarbazepine (medication used to treat Seizure Disorder) 1200 mg once a day 7:00 PM-11:00 PM; Oxcarbazepine 900 mg once a day 7:15 AM-11:00 AM; Oxycodone (opioid pain medication) 10 mg-325 mg every 4 hours PRN; Trazodone (medication used to treat Depression and Insomnia) 50 mg once a day 7:00 PM-11:00 PM. During an interview on 1/18/2024 at 1:10 PM, Resident #18's spouse stated .I went first thing in the morning it was before 10:00 AM [3/5/2024] I'm sure, but he hadn't gotten his medication .and he was shaking . During an interview on 2/7/2024 at 1:50 PM, the Director of Nursing (DON) stated .he came in at 3:58 PM, which was too late to make the 2nd pharmacy run on 3/4/2023 [for delivery at approximately 11:00 PM] .he had orders for Amantadine .that is not something we have in our EDK [emergency drug kit] .his dosage [of Carbidopa-Levodopa] was not available and the Entacapone .was not in our EDK .his medications were put in the computer and ordered from pharmacy on 3/5/2023 at 10:01 AM [the morning after the admission] and would have been delivered on the first run at 4:00 PM on 3/5/2023 [24 hours after his admission] .Keppra 1000 mg three times a day, Metoprolol 25 mg twice a day .were available in our EDK and should have been administered as ordered .all .medications .not available in our EDK .would have been covered by our standing order to provide .dose when delivered from pharmacy . The DON confirmed Resident #18 had not been administered the following medications as ordered Levetiracetam [Keppra] 1000 mg on 3/4/2023 at 8:00 PM-11:00 PM dose, Metoprolol Tartrate 25 mg on 3/4/2023 at 9:00 PM-11:00 PM dose, Aspirin 325 mg on 3/4/2023 8:00 PM-11:00 PM dose, and Gabapentin 800 mg on 3/4/2023 at 8:00 PM dose which should have been available in the EDK. During an interview on 2/27/2024 at 10:50 AM, the Medical Director stated due to seizure type medications and Parkinson's medications .staying in the body, Resident #18 .could have been possible to have increased tremors, but missing a couple of doses of either type of medication would not cause harm . During an interview on 2/27/2024 at 11:15 AM, the Pharmacist stated medications ordered by 11:00 AM would be delivered during the first pharmacy delivery between 2:00 PM and 3:00 PM. Medications ordered by 7:00 PM would be delivered during the second pharmacy delivery between 12:00 AM-2:00 AM. Continued interview revealed if the facility needed a medication outside the ordering time parameters, the facility was to call the pharmacy and request the medication be added to the delivery. In the event the delivery was in route, the pharmacy could make a special delivery or the medication would be obtained from the back up pharmacy which would be delivered to the facility prior to the next scheduled delivery.

Based on facility policy review, manufacturer recommendations, observation, and interview, the facility failed to ensure the appropriate chemical sanitization ratio of a 3 compartment sink used for cleaning and sanitizing cooking equipment, failed to maintain a clean and sanitary work area in the dish room, and in 1 of 1 nourishment rooms which had the potential to affect 82 of 84 residents. The findings include: Review of the facility policy titled, Environment, revised 9/2017, showed .All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls .The Dining Services Director will ensure .proper procedures for cleaning and sanitizing of all food services equipment and surfaces .will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . Review of the facility policy titled, Manual Warewashing, revised 9/2017, showed .The Dining Service staff will be knowledgeable in proper technique including .Chemical sanitizer dispensing .Chemical sanitizer testing and concentrations .Appropriate test strips will be utilized to measure the concentration of the sanitizer solution . Review of the facility policy titled, Equipment, revised 9/2017 showed .All equipment will be routinely cleaned and maintained .All staff members will be properly trained in the cleaning and maintenance of all equipment .All food equipment will be cleaned and sanitized after every use .All non-food contact equipment will be clean and free of debris . Review of manufacturer guidelines titled EFFECTIVE SANITIZER AGAINST FOODBORNE BACTERIA, dated 2017, showed .146 Multi-Quat Sanitizer .The solution broad efficacy range of 150-400 ppm [parts per million] .EPA [Environmental Protection Agency]-registered for third sink sanitizing .Prevents cross-contamination on food contact surfaces .146 Multi-Quat Sanitizer is a concentrated, no rinse sanitizer that is effective across a dilution range of 0.26-0.68 ounces per gallon of water. Can be used as a third sink sanitizer .Expose all surfaces of equipment, ware or utensils to the sanitizing solution for not less than one minute . During an observation of the kitchen with Cook #1 and the Dietary Account Manager on 2/27/2023 at 10:30 AM, revealed the 3 compartment sink had been used for several pots and pans by the dietary staff, at the time of the observation. A test strip of the sanitizing compartment conducted by the Dietary Account Manager showed no result of the sanitizing chemical in the water. Observation showed the tubing which connected to the sanitizing solution and the chemical dispenser to the sink, was dripping the sanitizing chemical onto the floor, under the sink, and was not being dispensed into the sanitizing compartment of the sink. Continued observation of the kitchen showed a large portion of the wall, behind the sink, in the dish room, was covered with a black substance which appeared to be black mold. During an interview on 2/27/2023 at 10:47 AM, Cook #1 and the Dietary Account Manager confirmed the sanitizer in the 3 compartment sink did not register the appropriate amount of sanitizer and the chemical was leaking onto the floor. Cook # 1 further confirmed the sanitizing sink had been used at the time of the testing and the pots and pans had not been effectively sanitized. The pots and pans were later placed in the dishwasher for further cleaning and sanitizing. Cook # 1 confirmed there was black mold on the wall behind the sink in the dishwasher room. During an observation of the nourishment room, with the Dietary Account Manager, on 2/27/2023 at 10:55 AM, showed the freezer drawer had food debris and a brown discoloration in the bottom of the freezer drawer. Continued observation showed the microwave was dirty and contained copious amounts of dried food debris on the top, bottom, sides, and door of the microwave. During an interview on 2/27/2023 at 11:00 AM, the Dietary Account Manager confirmed the freezer and microwave were not maintained in a clean and sanitary manner and was available for resident use. During an interview on 2/27/2023 at 11:15 AM, the Director of Nursing (DON) confirmed the microwave and freezer in the nourishment room were not clean and had not been maintained in a clean and sanitary manner. The DON further confirmed it was her expectation the kitchen and the nourishment room be maintained in a clean and sanitary manner.

Based on facility policy review, medical record review, the facility documentation review, and interview, the facility failed to prevent and protect 3 residents (Resident #39, Resident #51, and Resident #52) from physical abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, 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 willful infliction of injury . Resident #67 was admitted to the facility on [DATE], with diagnoses including Dementia with Behavior Disturbance, Anxiety, Protein-calorie Malnutrition, and Hypertension. Review of Resident #67's admission MDS assessment dated [DATE], showed no BIMS score resident did not complete the interview, mood indicators by staff interview showed tired and trouble concentrating, no behaviors documented. Resident required extensive assistance of 1 staff for dressing, personal hygiene, and bathing, required supervision for bed mobility, transfers, ambulation, and eating. Resident #67 received antipsychotic and antidepressant medications. Review of Resident #67's care plan dated 12/22/2022, showed the resident had behavioral symptoms toward other residents 'rubbing the residents on the arms with interventions including resident 1on 1, 15-minute checks, psychiatric evaluation of behaviors addressed urinating in hallway and dining area, measures to distract resident from behaviors offer bathroom every 2 hours, TV shows, activity in group, offer snack, offer activity of interest country music. Medications as ordered monitor for side effects and behaviors daily. Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's Dementia with Behavioral Disturbance, and Depression. Review of Resident #52's quarterly MDS assessment dated [DATE], showed a BIMS score for the resident was not completed, no mood indicators, and no behaviors were documented. The resident required limited assistance of 1 staff for bed mobility, dressing, personal hygiene, bathing, supervision with transfers, ambulating, and eating. Review of Resident #52's care plan dated 1/6/2023, showed the resident refused care and was combative at times with staff/residents with an occurrence of resident-to-resident altercation. Resident #52 was care planned for behaviors with interventions for aggressive behaviors, use distraction measures, offer food, bathroom, offer activity, redirect when in same area of Resident #39 reintroduce resident to Resident #39 often during the day. Elopement risk addressed placed on secure unit. Review of a nurse progress note for Resident #52 dated 12/22/2022, showed resident following Resident #67 around asking him why you hit me, Resident #52 was noted to have bleeding from the lip, skin tear to right hand, and bruising to the neck area. Review of the facility documentation dated 12/22/2022, showed Resident #52 was following Resident #67 around asking him why he hit him. The nurse heard screaming from the hallway and went to check and saw Resident #52 coming out of his room with his lip bleeding, bruising to the neck area, and a skin tear to his right hand. Resident #52 said Resident #67 had hit him while he was in bed. Resident #67 was placed on 15-minute checks with 1 on 1 observation until he was transferred from the facility on 12/23/2022 to hospital for psychiatric evaluation. During a telephone interview on 3/1/2023 at 10:18 AM, Registered Nurse (RN#3) revealed she heard screaming in the hallway Resident #52 said Resident #67 hit him in his bed. Resident #52 was asking Resident #67 .why did you hit me . Resident #52's lip was bleeding, he had a skin tear to his right hand, and bruising on the neck. The 2 residents were separated immediately. Resident #67 was placed on 1 n 1 until he was transferred out to the hospital for behavior evaluation. No changes noted in the mood and behavior of Resident #52 after the altercation. Review of Resident #67's discharge MDS assessment dated [DATE], showed death in the facility. Resident #51 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Anxiety, and Depression. Review of Resident #51's quarterly MDS assessment dated [DATE], showed the BIMS assessment score was 3 which indicated the resident had severe cognitive impairment, no mood indicators, and no behaviors were documented. The resident was independent with bed mobility, transfers, dressing, eating, toilet use, required supervision of 1 staff for personal hygiene, dressing, and bathing. Resident #51 received antipsychotic, antianxiety, and antidepressant medications routinely. Review of Resident #51's care plan dated 1/7/2023 showed resident had experienced a resident-to-resident altercation with another resident. Resident #51 received psychotropic medications with interventions to monitor for side effects of medications, behaviors, and psychiatric services as indicated. Review of the facility documentation of an incident dated 1/7/2023 showed Licensed Practical Nurse (LPN) heard arguing and went into Resident #51' s room. LPN found Resident #67 had one hand on Resident #51 ' s arm and one hand at her throat. The LPN stepped between the residents and guided Resident #67 out of the room. During an interview with the Administrator on 2/28/2023 at 10:00 AM, showed the incident was witnessed by the LPN. Administrator stated Resident #67 was placed on 1:1 observation. During an interview with the Nurse Practitioner (NP) on 2/28/2023 at 3:00 PM, stated was aware of the abuse incident on 1/7/2023 ( related to Resident #51 and Resident #67). Resident #39 was admitted to the facility on [DATE], with diagnoses including Fracture of Unspecified part of Right Femur, Depression, Anxiety Disorder, Delusional Disorder, Emphysema, and Muscle Weakness. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Brief Interview of Mental Status (BIMS) assessment score was 0 which indicated the resident had severe cognitive impairment, had no mood indicators, and no behaviors were documented. The resident required supervision with bed mobility, transfers, ambulation, eating, and required limited assistance of 1 staff for dressing, toilet use, personal hygiene, and bathing. Review of Resident #39's care plan dated 3/8/2022, showed resident had behavior of refusal of care and elopement risk; resident was placed on the secure unit for safety. The care plan showed interventions which included to in place to distract resident, redirect, reminders often the male resident (Resident # 52) was not her spouse, administer medications as ordered, monitor behaviors and side effects of medications, and psychiatric services to follow resident as indicated. Review of a nurse progress note for Resident #39 dated 1/9/2023, showed residents were in the hallway talking, and Resident #52 slapped Resident #39 in the face, no injuries were assessed, no bruising or swelling to face to the face was noted. Review of the facility's documentation dated 1/9/2023, showed Resident #39 was slapped in the face by Resident #52 while the 2 residents were walking in the hallway together. No injury to Resident #39 was noted upon assessment. The residents were separated immediately. Resident #52 was placed on 15-minute checks with 1 on 1 observation until he was transferred from the facility on 1/9/2023 to the hospital for psychiatric evaluation. Review of a nurse progress note for Resident #52 dated 2/8/2023, showed resident ambulating in hallway with fell ow resident, residents were entering the dining room for meal, observed both residents communicating in a friendly manner. Staff members asked the residents to move from the front of the door for safety and introduced Resident #39 to Resident #52. Resident #39 then turned to Resident #52 and said .quit following me . which was like a joking manner, and she slightly nudged Resident #52 in the stomach while laughing. Resident #52 stated .I'm tired of this . then punched fell ow Resident #39 in the facial area, resident lost her balance and fell to the floor. The nurse immediately separated the 2 residents and assessed Resident#39 for injuries, a skin tear was noted to the left elbow with no other injuries noted. Review of the facility documentation dated 2/8/2023, showed while in the dining room, Resident #52 punched Resident #39 in the face. A skin tear to Resident #39's elbow was the only injury noted. The residents were separated immediately. Resident #52 was placed on 15-minute checks 1on1 observation until he was transferred from the facility on 2/9/2023 to the hospital for psychiatric evaluation and treatment for the behaviors. During an interview on 2/28/2023 at 2:36 PM, Certified Nursing Assistant (CNA#4) revealed the altercation between Resident #39 and Resident #52 occurred on 2/8/2023, the residents were entering the dining room, Resident #39 thinks Resident #52 was her husband, I had brought the residents into the Dining Room to keep them from blocking the doorway, she (Resident #39) said something to him (Resident #52) and she (Resident #39) elbowed him in the stomach while she was laughing, so then he punched her around the eye, she lost her balance, grabbed for her walker and fell to the floor on her bottom. She had a skin tear to her left elbow, no complaints of pain or discomfort. She was not sent out the hospital. Separated the 2 residents immediately, Resident #52 was placed on 1 on 1 checks until he was transferred to the behavioral hospital. No changes were noted in Resident #39's mood and behavior after the altercations. During a telephone interview on 2/28/2023 at 7:17 PM, CNA #5 revealed she was a witness to the resident-to-resident alteration between Resident #39, and Resident #52 on 1/8/2023. The 2 residents were standing in the hallway talking and suddenly Resident #52 slapped Resident #39 right side of the face. The residents were separated and assessed for injury and no injuries were noted. Resident #52 was placed on 1on 1 until he was transferred out to the hospital. No changes observed in Resident #39's mood and behavior. During an interview on 3/1/2023 at 7:34 AM, CNA #6 revealed Resident #39 thought Resident #52 was her husband and wanted to be around him all the time. The residents were introduced several times a day to each other, to show he was not her husband. He was placed on 1 on 1 whenever he became agitated to try to prevent him from being aggressive with other residents. The resident-to-resident alteration between Resident #67 and Resident #52 showed Resident #52 was bleeding from his lip .he hit me while I was in the bed . the altercation was unwitnessed. No changes were noted in Residents #39 or #52 after the altercations. During an interview on 3/1/2023 at 8:22 AM, Social Service Director, revealed follow up interviews for psychosocial harm were completed for each resident involved in a resident to resident altercation. The facility has psych services follow-up as well as social service follow-up. I do the psych referrals, and I do follow-up interviews to ensure no psychosocial harm to residents. During the interviews no psychosocial harm was observed or voiced by anyone of the residents involved in the resident altercations. During an interview on 3/1/2023 at 1:30 PM, the Administrator confirmed, the altercations between Resident #39 and Resident #52, and between Resident #52 and Resident #67 was resident to resident physical abuse.

Based on facility policy review, medical record review, and interview, the facility failed to ensure a decline in wound was reported to the physician for 1 resident (#7) of 3 residents reviewed for pressure ulcers. The findings include: Review of the facility's policy titled, Notification of Change of Condition Policy, dated 7/7/2022, showed .medical provider should be notified of change in condition . Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's Disease, Dementia, Stage 3 Pressure Ulcer of the Sacral Region, Contractures, and Type 2 Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had severely impaired cognitive skills for daily decision making. The resident required extensive assistance from staff members for bed mobility, dressing, toileting, eating, and personal hygiene and was totally dependent on staff for bathing. Resident #7 had impaired range of motion in bilateral upper and lower extremities and was always incontinent of bowel and bladder. Resident #7 was at risk for pressure ulcers and had 1 unhealed Stage 3 Pressure Ulcer. The assessment showed skin and ulcer treatment included pressure reducing device for bed and pressure ulcer care. Review of the Coccyx Wound Management Detail Report dated 1/15/2022, showed .New area noted . with measurements of 1.5 centimeters (cm) x (by) 2.6 cm with no depth noted. Review of the Care Plan dated 1/21/2022, showed .Stage 3 pressure ulcer to the coccyx .Treatment as ordered .Observe for signs and symptoms of infection and notify MD [Medical Doctor] as needed .Assess the pressure ulcer for location, stage, size .presence/absence of granulation tissue and epithelization weekly and as needed . Review of the Coccyx Wound Management Detail Reports dated 1/21/2022 - 2/3/2023, showed the wound was stable. Review of the Coccyx Wound Management Detail Report dated 2/9/2023, showed the Stage 3 wound measured 1.3 cm x 1 cm x 0.3 cm. Review of the Coccyx Wound Management Detail Report dated 2/17/2023, showed the Stage 3 wound measured 1.5 cm x 1.5 cm x 0.8 cm. Review of the Coccyx Wound Management Detail Report dated 2/24/2023, showed the Stage 3 wound measured 3.5 cm x 2 cm x 0.8 cm. It was noted .Wound healing status: Declining .wound assess unstable to decline with increase in cm. luq [left upper quadrant] assess with slough/necrotic tissue, mild maceration noted. wound base assess clean non granular tissue wit [with] some epibole [rolled or curled-under closed wound edges that can impede wound healing] edge . During an interview on 3/1/2023 at 9:17 AM, the Wound Care Nurse stated Resident #7 had a Stage 3 coccyx pressure ulcer that was identified on 1/15/2022. The wound was evaluated weekly, and treatments had been changed as needed. The Wound Care Nurse stated the wound had been stable until 2/24/2023. On the 2/24/2023 evaluation, the Wound Care Nurse noted the wound had declined and had a significant increase in measurements with worsening of the epibole in the left upper quadrant of the wound. The Wound Care Nurse confirmed the physician had not been notified of the wound decline because .I was leaving town the next day [2/25/2023] and forgot .he [Medical Director] will be notified today .The Wound Care Nurse stated she was aware that the physician was to be notified when there were changes in a residents wound or condition .the day you observe worsening of the wound . to discuss possible treatment changes. The Wound Care Nurse stated .the wound is still stable even with increased measurements .no signs and symptoms of infection .wound base is clean nongranular tissue with biofilm noted to wound base .Santyl is still appropriate treatment for that wound because there are no signs and symptoms of infection and no distress to the wound . During an interview on 3/1/2023 at 10:07 AM, the Director of Nursing (DON) confirmed changes in resident condition were to be communicated to the physician .immediately .the same day . the change was noted. During a telephone interview on 3/1/2023 at 11:03 AM, the Medical Director stated he was familiar with Resident #7's wound and stated the resident had the wound for a .good year or so . The Medical Director confirmed he was unaware of the decline in Resident #7's wound and stated .it is the expectation all around that changes are communicated . The Medical Director stated if he had been made aware he would not have changed the treatment and the resident had not been harmed by the delay of notification. The Medical Director stated Resident #7's wound was unavoidable due to her worsening dementia, poor nutritional status, immobility, and contractures.

Based on review of the facility's nurse staffing schedules and interview, the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 hours a day for 2 days of 92 days reviewed. The findings include: Review of the facility's nurse staffing schedules for the period of 10/1/2022-12/31/2022 (92 days) revealed no RN on duty for 10/1/2022 and 11/26/2022. During an interview on 3/1/2023 at 7:46 AM, the Director of Nursing (DON) confirmed she was aware there were days of no RN coverage 7 days a week for at least 8 hours a day. During an interview on 3/1/2023 at 10:15 AM, the [NAME] President of Operations confirmed there was no RN coverage on 10/1/2022 and 11/26/2022.

Based on review of a facility policy, facility investigation, medical record review, observation and interview, the facility failed to prevent abuse of one Resident [#1] of 5 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect and Misappropriation of Property revised 5/8/2019 showed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment .Abuse includes physical abuse, mental abuse verbal abuse and sexual abuse .For the purpose of this policy, '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 . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment and had inattention and disorganized thinking. Review of a facility investigation dated 2/27/2022 showed Resident #1 was sitting in the activity room when Resident #2 entered activity room and offered Resident #1 a sandwich. Resident #1 accepted the sandwich. Resident #2 then sat next to Resident #1 on her right side. Resident #2 then took his right hand, reached across, and touched Resident #1 on her right breast on the outside of her shirt. Review of Resident #1's Progress Note dated 2/27/2022 showed . This SSD [Social Service Director] called .[Power of Attorney] to inform her of an incident between this resident and a male resident where he inappropriately touched her. Observation of Resident #1 on 3/28/2022 at 11:50 AM, in the Dining Room, showed the resident to be seated at a table with other residents, she was well groomed, and no distressful behaviors were observed. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive care plan dated 3/9/2021 and revised on 2/5/2022 showed .I have been heard making inappropriate sexual comments to staff .engage in diversional activities .if reasonable, discuss behavior with resident; explain/reinforce why behavior is unacceptable .Psych services to follow resident both talk therapist and NP [Nurse Practitioner] . The care plan was revised on 2/6/2022 and showed .I have been observed to make sexually inappropriate gestures to another female resident . Review of Resident #2's Progress Notes dated 2/12/2022 showed .Resident observed at entrance of .hall at 8:05 PM, After complaint from other resident that someone was in her room, Resident was observed in his room lying in bed at 8:45 PM. CNA [Certified Nursing Assistant]#1 reported that resident made sexually inappropriate comments to her at approximately 8:20 PM, before going to his room . Review of Resident #2's Progress Notes dated 2/16/2022 showed .Resident reviewed. Behavior review as resident is exhibiting inappropriate sexual comments to staff. Staff have noticed an increase in confusion in the evening time, where he is wandering in his wheelchair and again increased confusion. The inappropriateness is being seen later in the evening . Review of Resident #2's Progress Notes dated 2/18/2022 showed .Resident reviewed. Behavior review as resident is exhibiting inappropriate sexual comments to staff. Staff have noticed an increase in confusion in the evening time, where he is wandering in his wheelchair .the inappropriateness is being seen later in the evening . Review of Resident #2's Progress Note dated 2/27/2022 at 2:16 PM, showed .Resident observed up in wheelchair propelling self toward main dining room where fell ow female resident was sitting. Staff re-directed resident .Resident then approached separate female resident on .unit at her doorway . Review of Resident #2's Event Report dated 2/27/2022 at 4:30 PM, showed .Allegation of sexual abuse .This resident touched a female resident on the outside of shirt on her right breast .When interviewed by nurse if someone had touched her [Resident #1] breast she replied 'yes' . During an interview with Licensed Practical Nurse (LPN) #1 on 3/28/2022 at 8:15 AM, she stated .We were leery after the first incident so we kept a close eye on them if they were in the same room .somewhere around right after lunch they were both in the activities room she was looking out the windows, and he was facing her, they were just talking when I walked in just to check he had his arm on her arm and I saw her reaching for what appeared to be his lap. But I intervened before she could touch him. She said she was reaching for ice. I asked him what he needed, and he said a coke. I separated them I kept her in the activity room with me and the CNA took him to his room .Later in the day around 4:30 PM, he was back in the activity room, and she was still in the activities room, she was looking out the windows, he rolled through the 400 hall he rolled over beside her and was looking out at the nurse's station. I got up and walked over to the windows, the CNA came up we were watching them I said where is his hand and we both immediately entered the room, and I saw his right hand and reached across and touched her right breast. It was a willful act he intended to touch her breast . During an interview with CNA #2 on 3/29/2022 at 9:15 AM, she stated .I was walking by the activity room, he was setting by her I could see them through the window I saw him take his right hand and he grabbed her right breast I immediately entered the room and he turned loose of her breast .I am not sure what his intention was all I know is that he did grab her breast. It was a willful act to touch her, and he turned loose when he saw me, I do think he knew what he was doing . During an interview with the Administrator on 3/29/2022 at 1:00 PM the Administrator stated .the incident occurring on 2/27/2022 between .[Resident #1] and .[Resident #2] was a witnessed willful event and the facility failed to prevent abuse of .[Resident #1] .

Based on review of a facility policy, facility investigation, medical record review, observation and interview, the facility failed to report and allegation of abuse of one Resident [#1] to the State within the required 2 hour required time frame. The findings included: Review of a facility policy Abuse, Neglect and Misappropriation of Property revised 5/8/2019 showed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Reporting Guidelines: Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Review of a facility investigation dated 2/27/2022 at 4:30 PM, showed Resident #1 was sitting in the activity room when Resident #2 entered activity room and offered Resident #1 a sandwich. Resident #1 accepted the sandwich. Resident #2 then sat next to Resident #1 on her right side. Resident #2 then took his right hand, reached across, and touched Resident #1 on her right breast on the outside of her shirt. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment and had inattention and disorganized thinking. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's annual MDS dated [DATE] showed a BIMS score of 7 indicating severe cognitive impairment the resident had behaviors of physical behavioral symptoms director toward others 1 to 3 days during the assessment behaviors. Review of Resident #2's Event Report dated 2/27/2022 at 4:30 PM, showed .Allegation of sexual abuse .This resident touched a female resident on the outside of shirt on her right breast . During an interview with the Administrator on 3/29/2022 at 1:00 PM the Administrator stated .the incident occurring on 2/27/2022 between .[Resident #1] and .[Resident #2] was a witnessed willful event .there was a delay in the nursing staff reporting the incident and the facility failed to notify the state of the alleged abuse on 2/27/2022 within the required time frame of 2 hours .

Based on facility policy review, facility incident report, medical record review, observation and interview, the facility failed to ensure 2 residents (#2 & #3) were free from abuse of 4 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Property, dated 5/8/2019, showed .This policy applies to all residents without respect to resident's cognitive .awareness, or ability to understand the event at issue .Abuse .includes .physical abuse, mental abuse, verbal abuse . even if he or she does not understand the incident . Review of the facility's self-reported incident showed 2 residents (Resident #2 & #3), residing in the secured unit, had a physical interaction with Resident #1 on the evening of 5/24/2021. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set), dated 5/24/2021, showed Resident #1 rarely understood others, could not participate in a brief interview for mental status, scored 15 out of 30 on the mood severity score, had wandering behaviors daily and physical behaviors directed toward others 4-6 days each week. Review of Resident #1's comprehensive care plan showed two behavior problems, wandering and placing herself on the floor, care planned on 4/16/2021. Review showed an additional behavior problem was entered on 5/26/2021 by the DON (Director of Nursing) with a start date of 5/24/2021, .physical behavioral symptoms toward others .Pinching . Medical record review showed Resident #2 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's progress note, dated 5/24/2021 at 9:00 PM, showed, .Other resident [Resident #1] hit [Resident #2] on the left arm with palm of hand. No physical injury noted on assessment . Medical record review showed Resident #3 was readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's progress note, dated 5/24/2021 at 9:00 PM, showed, .Other resident (Resident #1) hit this [Resident #3] on left cheek. No physical injury noted on assessment . Review of a Social Services (SS) progress note, dated 5/25/2021 at 5:37 PM, showed Resident #1 went out to an ortho appointment yesterday and experienced behaviors that were seen upon her initial admission . The social worker went on to document behaviors including sitting on the floor, crying spells, negative interactions with other residents and staff late afternoon and early evening. The social worker added the resident does not communicate well, and was placed on the Gated Community [secured unit] for safety and adjustment. Continued review of the SS note showed, .nsg [nursing] reported a negative physical interaction with staff and another resident .referral has been made to Sr. Care [gero-psych]. Resident does not have any recollection of what happened .due to her cognitive impairment. Review of the facility's Incident/Occurrence Investigation for the Resident to Resident interaction on 5/25/2021, included a written statement reported by the CNA who initially observed and separated the residents, .Walked into dining room .[Resident #1] yelling and holding and pinching [Resident #2] on her right forearm .separated residents immediately and reported to my nurse. Continued review of the incident report showed Resident #2 sustained a skin tear where Resident #1 was pinching her right forearm. Review of the Event Report, dated 5/25/2021, filed after the incident, showed .CNA walked into dining room door closest to 700 hall entrance way and saw [Resident #2] sitting in wheelchair with another [Resident #1] holding her arm and yelling .[Resident #2] was just trying to pull her arm away not saying anything, just staring at .[Resident #1] .[Resident #2] has small 1/2 [inch] skin tear to right forearm .asked her if she was okay, she said yes .said nothing else, just looked at us .[Resident #2] proceeded to eat her dinner . Observation of Residents #2 and #3 on 6/3/2021 at 3:50 PM, showed both residents were seated in the dining room. Resident #3 did not have any bruising or marks on the left cheek of her face. Observation included the right arm of Resident #2. Certified Nurse Aide [CNA] #1 assisted in the observation and stated she helped to redress the skin tear that morning and it was healing well. Resident #2 had a gauze dressing over the skin tear site and the surrounding skin appeared clear of any inflammation. Interview with the Director of Nursing (DON) on 6/1/2021 at 3:00 PM, showed there wasn't an incident report for the incidents between Resident #1 the 2 other residents (Resident #2 and Resident #3) that occurred the evening of 5/24/2021. Interview revealed Resident #1 was recently in a gero-psych facility for evaluation and treatment, prior to admission to this facility on 4/12/2021. Interview on 6/2/2021 at 3:00 PM, with Licensed Practical Nurse (LPN) #1, on duty 5/25/2021 when Resident #1 grabbed Resident #2's right forearm, pinched it and a skin tear occurred revealed the LPN had been out of the secured unit on another unit passing medications at the time of the incident. Continued interview showed there were 2 CNA's on duty in the secured unit at the same time LPN #1 was out of the secured unit. LPN #1 stated the evening of 5/24/2021, after her shift ended and she was charting, she heard about the incidents with Resident #1 and [Resident #2 and Resident #3] and .knew to keep her [Resident #1] closely watched and keep her separate from the other residents. The LPN confirmed Resident #1 was in the dining room at suppertime on 5/25/2021, with other residents, when the 2 CNA's were .both out of the dining room . Interview by phone with CNA #1 on 6/3/2021 at 10:50 AM, showed the 2 CNA's on duty in the secured unit on 5/25/2021 were, doing our rounds .taking people to the bathroom . CNA #1 stated the other CNA on the secured unit was in another resident's bathroom. CNA #1 said she walked back into the dining room after assisting another resident to the bathroom and saw (Resident #1) .had a grip on (Resident #2's) arm .I got them apart and took (Resident #1) to her room and came back and saw (Resident #2) had the skin tear . CNA #1 said she thought it was mentioned to watch (Resident #1) closely. CNA #1 confirmed while the 2 CNA's were making their rounds no one was in the dining room to observe Resident #1. Interview by phone with the Administrator on 6/4/2021, at 2:30 PM, confirmed LPN #1 was out of the secured unit at the supper hour on 5/25/2021, at the same time the 2 CNA's conducted their rounds. Interview confirmed Resident #1 was left unattended in the dining room with Resident #2 and other residents. Resident #1 became physical abusive with Resident #2 for the second consecutive evening and was observed yelling at Resident #2, while grabbing and pinching her arm.

Based on facility policy review, facility's self-reported incident, medical record review, observation and interview, the facility failed to report an allegation of Resident to Resident abuse for 2 residents (#2, #3) of 4 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Property, dated 5/8/2019, showed .All alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Review of a facility self-reported incident, dated 5/25/2021, showed 2 residents (Resident #2 & #3), residing in the secured unit, had physical contact with Resident #1 on the evening of 5/24/2021. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set), dated 5/24/2021, showed Resident #1 rarely understood others, could not participate in a brief interview for mental status (BIMS), scored 15 out of 30 on the mood severity score, had wandering behaviors daily and physical behaviors directed toward others 4-6 days each week. Review of Resident #1's comprehensive care plan showed two behavior problems, wandering and placing herself on the floor, care planned on 4/16/2021. Review showed an additional behavior problem was entered on 5/26/2021 by the DON (Director of Nursing) with a start date of 5/24/2021, .physical behavioral symptoms toward others .Pinching . Medical record review showed Resident #2 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's progress note, dated 5/24/2021 at 9:00 PM, showed, .Other resident [Resident #1] hit this resident [Resident #2] on the left arm with palm of hand . Medical record review showed Resident #3 was readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's progress note, dated 5/24/2021 at 9:00 PM, showed, .Other resident [Resident #1] hit this resident [Resident #3] on left cheek . Observation of Residents #2 and #3 on 6/3/2021 at 3:50 PM, showed both residents were seated in the dining room. Resident #3 did not have any bruising or marks on the left cheek of her face. Observation included the left arm of Resident #2, and no new bruising was apparent. Interview with the Director of Nursing (DON) on 6/1/2021 at 3:00 PM, showed there wasn't an incident report for the incidents between Resident #1 and the 2 other residents [Resident #2 and Resident #3] on the evening of 5/24/2021. During interview, the DON shared a Resident-to-Resident Altercation Flowchart she stated was used in the decision made not to file facility incident reports or report the allegation of abuse by Resident #1 to the State Survey Agency. The DON stated the resident had a BIMS of zero and did not have the mental capacity to abuse another resident.

Based on a facility incident report, medical record review, observation and interview, the facility failed to provide adequate supervision for 1 resident of 4 residents reviewed for accidents. The findings include: Review of a facility incident report showed 2 residents (Resident #2 and #3), residing in the secured unit, each had a physical interaction with Resident #1 on the evening of 5/24/2021. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's Dementia with Behavioral Disturbance, Type II Diabetes, Anxiety Disorder and Major Depressive Disorder (recurrent and moderate). Review of the MDS (Minimum Data Set), dated 5/24/2021, showed Resident #1 rarely understood others, could not participate in a brief interview for mental status, scored 15 out of 30 on the mood severity score, had wandering behaviors daily and physical behaviors directed toward others 4-6 days each week. Review of Resident #1's comprehensive care plan showed two behavior problems, wandering and placing herself on the floor, care planned on 4/16/2021. Review showed an additional behavior problem was entered on 5/26/2021 by the DON (Director of Nursing) with a start date of 5/24/2021, .physical behavioral symptoms toward others .Pinching . Medical record review showed Resident #2 was readmitted on [DATE] with diagnoses including Dementia without Behavioral Disturbances, [CONDITION(S)], and [CONDITION(S)]. Review of Resident #2's progress note, dated 5/24/2021 at 9:00 PM, showed, .Other resident (Resident #1) hit this resident (Resident #2) on the left arm with palm of hand . Medical record review showed Resident #3 was readmitted [DATE] with diagnoses including Dementia without Behavioral Disturbances, Weight Loss, and Kidney Disease. Review of Resident #3's progress note, dated 5/24/2021 at 9:00 PM, showed, .Other resident [Resident #1] hit this resident [Resident #3] on left cheek . Review of a Social Services (SS) progress note, dated 5/25/2021 at 5:37 PM, showed Resident #1 went out to .an ortho appointment yesterday and experienced behaviors that were seen upon her initial admission . The social worker went on to document behaviors including sitting on the floor, crying spells, negative interactions with other residents and staff late afternoon and early evening. The social worker added the resident does not communicate well, and was placed on the Gated Community [secured unit] for safety and adjustment. Continued review of the SS note showed, .nsg [nursing] reported a negative physical interaction with staff and another resident .referral has been made to Sr. Care [gero-psych] . Review of the facility's Incident/Occurrence Investigation for the Resident to Resident interaction on 5/25/2021, included a written statement reported by the CNA [Certified Nurse Aide] who initially observed and separated the residents, .Walked into dining room .Resident [#1] yelling and holding and pinching Resident [#2] on her right forearm .separated residents immediately and reported to my nurse. Continued review of the incident report showed Resident #2 sustained a skin tear where Resident #1 was pinching her right forearm. Review of the Event Report, dated 5/25/2021, filed after the incident on 5/25/2021, showed CNA walked into dining room door closest to 700 hall entrance way and saw resident [Resident #2] sitting in wheelchair with another resident [Resident #1] holding her arm and yelling .resident [Resident #2] was just trying to pull her arm away not saying anything, just staring at other resident [Resident #1] .Resident [Resident #2] has small 1/2 [inch] skin tear to right forearm . Observation of Residents #2 and #3 on 6/3/2021 at 3:50 PM, showed both residents were seated in the dining room. Resident #3 did not have any bruising or marks on the left cheek of her face. Observation included the right arm of Resident #2, and a CNA assisted in the observation and stated she helped to redress the skin tear that morning and it was healing well. A gauze dressing was noted and the surrounding skin appeared clear of any inflammation. Interview with the Administrator on 6/1/2021 at 2:30 PM, showed the Administrator was aware there had not been incident reports of the physical contact between Resident #1 and both Residents #2 and #3. She stated Resident #1 was placed on every 15 minute checks . During an interview with the Director of Nursing (DON) on 6/1/2021 at 3:00 PM, the DON stated Resident #1 was on every 5 minute checks after the physical contact with the other 2 residents on 5/24/2021. The DON stated after Resident #1 had the incident with Resident #2 on 5/25/2021, Resident #1 was placed on 1:1 observation, when not asleep. Interview with Licensed Practical Nurse (LPN) #1, on duty 5/25/2021 (when Resident #1 grabbed Resident #2's right forearm, pinched it and a skin tear occurred) on 6/2/2021 at 3:00 PM, showed the LPN had been out of the secured unit on another unit passing medications at the time of the incident. Continued interview showed there were 2 CNA's on duty in the secured unit at the same time LPN #1 was out of the secured unit. LPN #1 stated, .knew to keep her [Resident #1] closely watched and keep her separate from the other residents. The LPN confirmed Resident #1 was in the dining room at suppertime on 5/25/2021, with other residents, when the 2 CNA's were both out of the dining room. Interview by phone with CNA #1 on 6/3/2021 at 10:50 AM, showed the 2 CNA's on duty in the secured unit on 5/25/2021 were, doing our rounds .taking people to the bathroom . CNA #1 stated the other CNA on the secured unit was in a resident's bathroom. CNA #1 said she walked back into the dining room after assisting another resident to the bathroom and saw (Resident #1) .had a grip on (Resident #2's) arm .I got them apart and took (Resident #1) to her room and came back and saw (Resident #2) had the skin tear . CNA #1 said she thought it was mentioned to watch (Resident #1) closely. CNA #1 confirmed while the 2 CNA's were making their rounds no one was in the dining room to observe Resident #1 with other residents in the secured unit. Interview by phone with the Administrator on 6/4/2021, at 2:30 PM, confirmed LPN #1 was out of the secured unit at the supper hour on 5/25/2021, at the same time the 2 CNA's conducted their rounds. Interview confirmed Resident #1 was left unattended in the dining room with Resident #2 and other residents. Resident #1 physically abused Resident #2 for the second consecutive evening and was observed yelling at Resident #2, while grabbing and pinching her arm.

Based on facility policy review, medical record review, observation and interview the facility failed to ensure 2 residents (#10 and #53) were free from abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19 revealed .Abuse .includes physical abuse .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 .Physical abuse .includes, but not limited to, hitting, slapping, pinching, kicking . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 7/9/19 revealed .increased behaviors noted this shift toward staff when trying to redirect resident or provide care . Medical record review of Resident #10's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Medical record review revealed Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #231's Quarterly MDS dated [DATE], revealed the resident was rarely understood. Review of the facility Event Report dated 8/2/19, revealed Resident #231 approached Resident #10 in her wheelchair and struck him with an open hand. Continued review revealed no injury occurred. Interview with Certified Nursing Assistant (CNA) #1 on 10/22/19 at 2:45 PM, in the conference room, confirmed on 8/2/19 she observed Resident #231 in her wheelchair pushing herself by the shower room in the 300 hallway. Continued interview confirmed Resident #231 pushed her w/c up to Resident #10 and struck Resident #10 on the arm with her (Resident #231) hand. Interview with CNA #2 on 10/22/19 at 3:00 PM, in the conference room confirmed on 8/2/19 she observed Resident #231 push her w/c up to Resident #10 and slapped him on the arm. Further interview confirmed Resident #231 had become agitated with staff and residents prior to the incident on 8/2/19 . Interview with the Nurse Consultant on 10/23/19 at 3:25 PM, in the conference room, confirmed there was a resident to resident altercation between Resident #231 and Resident #10 on 8/2/19. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Medical record review of Resident #41's nurse's note dated 8/12/19 revealed .had a negative interaction with another resident back on the gate (gated) community .they were in each other's personal space . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #53 had a Brief Interview for Mental Status score of 1 indicating severe cognitive impairment. Medical record review of the facility Event Report dated 8/12/19 revealed .this resident (Resident #41) .yelled 'get the hell over there' .this resident (Resident #41) .reached up and smacked the other resident (Resident #53) .across the right cheek .certified nursing assistant (CNA) .immediately separated both residents .when .asked .why she (Resident #41) smacked the other resident (Resident #53) .resident (Resident #41) .stated 'she got in my face' . Continued review revealed no injuries were noted. Interview with the Facility Administrator on 10/23/19 at 11:17 AM, in the conference room, confirmed the facility failed assure Resident #53 was free from abuse.

Based on facility policy review, medical record review, and interview, the facility failed to report abuse for 1 resident (#53) of 24 residents reviewed. The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19, revealed .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #53 had a Brief Interview for Mental Status score of 1 indicating severe cognitive impairment. Medical record review of Resident #41's nurse's note dated 8/12/19 revealed .had a negative interaction with another resident back on the gate (gated) community . Medical record review of the facility Event Report dated 8/12/19 revealed .this resident (Resident #41) .yelled 'get the hell over there' .this resident (Resident #41) .reached up and smacked the other resident (Resident #53) .across the right cheek .certified nursing assistant (CNA) .immediately separated both residents .when .asked .why she (Resident #41) smacked the other resident (Resident #53) .resident (Resident #41) .stated 'she got in my face' . Continued review revealed no injuries were noted. Medical record review of Resident #53's Event Report dated 8/12/19, revealed .DESCRIPTION .RESIDENT TO RESIDENT ALTERCATION 8/12/2019 . Further review revealed .DON (Director of Nursing) notified .Yes . Interview with the Facility Administrator on 10/23/19 at 11:17 AM, in the conference room, confirmed the facility failed to report the incident of abuse that occured on 8/12/19. Refer to F-600

Based on facility policy review, medical record review and interview the facility failed to investigate abuse for 1 resident (#53) of 24 residents reviewed for abuse. The findings include: Review of facility policy,Abuse, Neglect, and Missappropriation of Property revised 5/8/19 revealed .The Facility Administrator will investigate all allegations, reports .incidents .may delegate .the investigation to the Director of Nursing .the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #53 had a Brief Interview for Mental Status score of 1 indicating severe cognitive impairment. Medical record review of the facility Event Report dated 8/12/19 revealed .this resident (Resident #41) .yelled 'get the hell over there' .this resident (Resident #41) .reached up and smacked the other resident (Resident #53) .across the right cheek .certified nursing assistant (CNA) .immediately separated both residents .when .asked .why she (Resident #41) smacked the other resident (Resident #53) .resident (Resident #41) .stated 'she got in my face' . Continued review revealed no injuries were noted. Medical record review of Resident #53's Event Report dated 8/12/19, revealed .DESCRIPTION .RESIDENT TO RESIDENT ALTERCATION 8/12/2019 . Further review revealed .DON (Director of Nursing) notified .Yes . Interview with the Facility Administrator on 10/23/19 at 11:17 AM, in the conference room, confirmed the facility failed to investigate the incident of abuse that occured on 8/12/19. Refer to F-600 and F-609

Based on review of medical record review and interview the facility failed to ensure the Tennessee Physician order [REDACTED].#283) of 24 residents reviewed. The findings include: Review of the Tennessee Physician order [REDACTED].To be valid. POST must be signed by a physician . Medical record review revealed Resident #283 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED]. Interview with Assistant Director of Nursing (ADON) #2 on 10/23/19 at 10:00 AM, on the 600 hallway, revealed POST forms .are to be filled out on admission by the resident or designated party .The original form (POST) goes on the chart and a copy goes in the physician box to be signed . Continued interview confirmed the physician failed to sign and date the resident's POST form.

Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for two residents (#19, #13), and failed to ensure a restraint was properly applied for one resident (#16) of thirty-two residents reviewed. The facility's failure to ensure a safety device was in place for resident #19 resulted in actual harm to the resident. The findings included: Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident expired at the facility on [DATE]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent for transfers, did not walk, and had not experienced a fall since the prior assessment. Medical record review of a Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Interdisciplinary Care Plan dated as reviewed on [DATE], revealed "...Risk for falls/injury related to weakness, balance problems, bil. (bilateral) AKA (Above the Knee Amputation)...Self Releasing Belt w/c (wheelchair)..." Medical record review of the [DATE] Physician's Recapitulation Orders revealed "...SRB (self releasing belt) while in w/c for positioning..." Medical record review of the nursing notes dated [DATE], at 1:00 p.m., revealed "Resident on floor. C/O (complaints of) pain lt (left) shoulder and elbow. T/O (telephone order) send to...ER (emergency room )..." Medical record review of an x-ray report of the left shoulder dated [DATE], revealed "...There is a fracture of the surgical neck of the left humerus..." Medical record review of an x-ray report of the pelvis dated [DATE], revealed "...Bones demonstrate severe diffuse osteopenia. Due to the severity of the osteopenia, fracture would be difficult to exclude. If more definitive evaluation is felt necessary, pelvis CT might be considered..." Medical record review of the nursing notes dated [DATE], at 5:25 p.m., revealed the resident returned to the facility. Medical record review of a nursing note dated [DATE], revealed " New orders for xray of (L) (left) hip..." Medical record review of a hospital History and Physical revealed the resident was admitted to the hospital on [DATE]. Continued review of the History and Physical revealed "...This patient had a fall in...nursing home a few days ago...was sent to the emergency room and treated and released. The x-ray of the pelvis was not clear on a fracture. It did recommend CAT (Computerized Axial Tommography) scan. The CAT scan was conducted and it was found the patient has an acute left hip fracture..." Medical record review revealed the resident returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of facility documentation revealed there were three witnesses involved at the time of the resident's fall on [DATE]: Certified Nursing Assistant (CNA) #3, Licensed Practical Nurse (LPN) #2, and LPN #3. Telephone interview on [DATE], at 10:45 a.m., with Licensed Practical Nurse (LPN) #3 revealed LPN #3 was at the nursing station at the time of the resident's fall. Interview on [DATE], at 10:50 a.m., with LPN #2, at the nursing station, revealed on [DATE], LPN #2 had been in the resident's room, after the resident had fallen, and heard CNA #3 say "It's all my fault I didn't put on...safety belt." Telephone interview on [DATE], at 10:30 a.m., with CNA #3 revealed CNA #3 was responsible for resident #19's care at the time of the fall on [DATE]. Continued interview revealed CNA #3 had not applied the resident's self releasing belt prior to the resident's fall, and confirmed the safety belt was not in place at the time of the resident's fall resulting in left hip and humerous fractures. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated [DATE], revealed " ...Problem...Risk for falls/injury related to dementia...Approaches...tab alarm in wheelchair..." Medical record review of a facility investigation dated [DATE], revealed "...Resident observed on floor...(no injury) does not know what happened...won't keep alarm on...says can turn it off...intervention...change to pressure pad alarm..." Medical record review of a facility investigation dated [DATE], revealed "...patient reaching out for spit cup and fell (no injury)...intervention...remove defective pressure pad alarm replace with new pressure pad alarm..." Interview on [DATE], at 8:55 a.m., with the Interim Director of Nursing, in the Director's office, confirmed the pressure pad alarm was not functioning at the time of the fall on [DATE]. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated [DATE], through [DATE], revealed "...Soft lap belt while in chair (wheelchair)..." Review of the application instructions for the lap belt/padded lap belt revealed, "...Bring the strap ends with loops down over the thighs between the seat and the wheelchair skirt guard...go around the back post and cross the straps behind the patient..." Observation on [DATE], at 2:00 p.m., with Licensed Practical Nurse (LPN) #4, revealed the resident in the hall seated in a wheelchair with a soft waist belt in place. Further observation revealed the left strap of the soft waist belt between the wheelchair arm rest and seat back of the wheelchair, and the right strap between the side of the wheelchair arm rest and wheelchair seat. Interview on [DATE], at 2:00 p.m., with LPN #4, in the hall, confirmed the lap belt had been applied incorrectly. C/O # C/O #