Every finding on record at Standing Stone Care and Rehab

Based on observation, interview, and facility policy review, the facility failed to ensure 1 of 2 medication carts observed was free of loose pills. Findings include: A facility policy titled, Storage of Medication, dated 01/2025, indicated, Policy - Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The policy also indicated, 16. Medication storage areas should be kept clean, well lit, organized and free of clutter. An observation of the medication cart at Nursing Station 2, on 05/13/2026 at 10:38 AM, revealed in the second drawer, under the medication bubble-pack cards, there was one loose round, yellow-colored pill and one loose oval, peach-colored pill. The observation revealed in the medication cart's third drawer, under the medication bubble-pack cards, there was one loose, round, white-colored pill. During a concurrent interview, the Infection Preventionist (IP) stated that the loose pills should not have been in the medication cart. The IP stated nurses were responsible for ensuring the carts were clean. During an interview on 05/14/2026 at 9:14 AM, the Director of Nursing (DON) stated she expected that medications no longer in use were stored in a secured area in specifically labeled locations and should not have been mixed in with other medications until they were disposed of or returned to the pharmacy. The DON stated nurses and nursing leadership were responsible for checking medication storage areas to ensure that medications out of service were destroyed or returned to the pharmacy.

Based on facility policy review, medical record review, observation, and interview, the facility failed to label a tube feeding formula appropriately for 1 resident (Resident #80) of 1 resident sampled for tube feeding. The findings include: Review of the facility's policy titled, Gastrostomy [tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications] Feeding Guidelines, revised 2/7/2023, revealed .Label bag with tube-feeding type, strength, and amount .include date, time, and initials . Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including Protein-Calorie Malnutrition, Dysphagia (difficulty swallowing), and Gastrostomy. Review of a Physician's Order for Resident #80 dated 2/12/2025, revealed .Enteral Feed .[name of tube feeding formula] at 40 ml/hr [milliliters per hour] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and had a feeding tube for nutrition. Review of the comprehensive care plan for Resident #80 revised 2/25/2025, revealed .use of enteral feeding .administer tube feeding formula as ordered . Review of the Medication Administration Record (MAR) for Resident #80 dated 3/2025, revealed the tube feeding formula [name of tube feeding formula] was administered on 3/2/2025. During an observation on 3/2/2025 at 11:47 AM, in Resident #80's room, revealed Resident #80 was receiving the tube feeding formula via (by way of) pump (device used to deliver an enteral tube feeding formula to a resident through a feeding tube). Further observation revealed the tube feeding formula for Resident #80 was not labeled or dated appropriately to include the type of formula, date, time, or the nurse's initials. During an interview on 3/2/2025 at 12:10 PM, in Resident #80's room, Licensed Practical Nurse (LPN) G stated the tube feeding formula for Resident #80 was initiated .on the previous shift . and should have been labeled and dated at that time. LPN G confirmed the tube feeding formula was not labeled or dated appropriately (to include the enteral formula information, date, time , and the nurse's initials). During an interview on 3/4/2025 at 7:47 AM, the Director of Nursing (DON) stated when an enteral tube feeding formula is initiated for a resident, the tube feeding formula should be labeled and dated appropriately to include the type of enteral formula, date, time, and nurse's initials. The DON confirmed the tube feeding formula for Resident #80 was not labeled appropriately on 3/2/2025.

Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive person-centered care plan related to Post Traumatic-Stress Disorder (PTSD) for 1 resident (Resident #25) of 2 residents reviewed for PTSD. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 2/9/2024, revealed .The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet resident's .mental and psychosocial needs that are identified in the comprehensive assessment . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, and PTSD. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and the resident had an active diagnosis of PTSD. Review of a Nurse Practitioner (NP) Psychiatry Progress Note for Resident #25 dated 2/3/2025, revealed the NP was following the resident for history of Depression, Anxiety, PTSD, Insomnia, and Parkinsons. Review of the comprehensive care plan dated 2/26/2025, revealed Resident #25 did not have a person-centered care plan developed for PTSD. During an interview on 3/3/2025 at 4:26 PM, MDS Coordinator A and MDS Coordinator B confirmed Resident #25 had an active diagnosis of PTSD and confirmed a person-centered care plan for PTSD was not developed for Resident #25.

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) to include an active mental health condition present upon admission for 1 resident (Resident #22) of 4 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASRR), revised 9/15/2023, revealed .PASARR is a federal requirement .be evaluated for serious mental illness .A negative Level I screen permits admission .and ends the PASARR process unless a possible serious mental disorder arises later .Referral should be made as soon as the criteria indicating such are evident . Review of a PASRR Level 1 screen outcome for Resident #22 dated 10/28/2024, revealed the resident did not have mental health conditions diagnosed or suspected. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Dementia, Post Traumatic Stress Disorder (PTSD), Muscle Weakness, and Kidney Failure. Review of a 5-day admission Minimum Data Set (MDS) assessment for Resident #22 dated 11/12/2024, revealed the resident had short-term and long-term memory impairment with severely impaired cognitive skills for daily decision making. Further review of the 5-day admission MDS assessment revealed Resident #22 had a diagnosis of PTSD. Review of the medical record revealed Resident #22 was diagnosed with a new mental health condition (Depression) on 1/20/2025. During a record review and interview on 3/3/2025 at 1:05 PM, the Infection Preventionist/ Staff Development Coordinator (IP/SDC) stated the Level 1 screen outcome for Resident #22 dated 10/28/2024, was the most recent referral to the state designated PASRR agency for this resident. During further interview the IP/SDC confirmed the PASRR Level 1 outcome did not include the diagnosis of PTSD, and also confirmed facility failed to refer Resident #22 to the state designated agency for PASRRS after identifying and admission diagnoses of PTSD and after a new mental health diagnosis of Depression was added.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility's direct care staff failed to immediately report allegations of staff on resident abuse which resulted in a delay of reporting abuse to the State Designated Authority for 1 resident (Resident #3) of 14 residents reviewed for abuse. The facility was cited at F-609 at a scope and severity of D as past noncompliance. Noncompliance began on 5/13/2024 and ended on 5/21/2024. The facility is not required to submit a Plan of Correction for F-609. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, dated 9/15/2023, revealed .Every Stakeholder shall immediately report any allegations of abuse .All such persons are encouraged to follow these reporting guidelines when they have reason to believe, that abuse, neglect, exploitation is occurring, has occurred, or plausibly may have occurred .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received .Any allegation of neglect, exploitation, mistreatment or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours . Review of medical records revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of the Right Upper Lobe Lung, Secondary Malignant Neoplasm of Lymph Nodes of the Head, Face and Neck, Secondary Malignant Neoplasm of Bone, Addison's Disease, Anxiety Disorder, Depression, Restless and Agitation, and Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 12 on the Brief Interview of Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Resident #3 required assistance of one or two persons for activities of daily living (ADLS). Review of the facility investigation dated 5/14/2024, revealed on 5/11/2024, between 10:30 PM-11:30 PM, Resident #3 reported allegations to Housekeeper (HK) A that the Environmental Services Supervisor (EVS) had made sexually explicit statements/sexual advances and a proposition to engage in sexual intercourse with the resident. Continued review of the timeline revealed . [HK A] attempted to change the subject and left the facility at the end of her shift without escalating or reporting any concerns [allegations] . Continued review revealed on 5/12/2024 at approximately 4:30 AM (approximately 6-7 hours after the initial allegation was reported to HK A) Resident #3 reported to Registered Nurse (RN) X vague, non-specific concerns related to being fearful of the EVS. RN X advised Resident #3 the Staff Development Coordinator (SDC) would speak to her about concerns on arrival to the facility at approximately 5:30 AM that morning (2 hours after the allegation was made). RN X did not report Resident #3's safety concerns to the Director of Nursing (DON), Administrator, or the abuse coordinator until 7:16 AM (2 hours and 46 minutes after the resident reported the allegation to her). Further review of the facility investigation revealed the SDC interviewed Resident #3 on 5/12/2024 at approximately 5:30 AM. During the SDC interview, Resident #3 informed the SDC of her concerns for HK A's safety and reported allegations the EVS had previously made sexual advances towards HK A which made her fearful of the EVS. Resident #3 did not report the allegation the EVS had made sexual comments or sexual propositions towards her at the time of the 1st interview on 5/12/2024 at 5:30 AM but did state she was fearful of the EVS. The SDC did not report Resident #3's concerns of being fearful to the DON until 7:26 AM. Continued review of the facility timeline and witness statements revealed on 5/13/2024 around 10:00 AM, Resident #3 spoke with the facility's medical director and alleged the EVS had propositioned her for sex. The Physician reported the allegations to the SDC, the attending hospice physician, and the facility's DON. Continued review revealed on 5/13/2024 at 1:37 PM, the DON re-interviewed Resident #3 who stated she felt sexually harassed by the EVS. The DON reported the allegations to the facility's corporate officials, the administrator, local police, the state ombudsman office, and to the State Agency (SA) on 5/13/2024 at 1:47 PM (over 48 hours after the initial allegations were made by Resident #3 to HK A). During an interview on 1/14/2025 at 10:20 AM, the former Administrator confirmed all staff were required to report abuse allegations immediately, through the chain of command, to the Administrator or Designee as soon as they were identified. The Administrator confirmed HK A failed to follow the facility's abuse policy on 5/11/2024 regarding Resident #3's allegations, which led to a delay in the facility leadership being made aware and the reporting of the allegation to the state designated authority within the 2 hour time frame. During an interview on 1/14/2025 at 11:05 AM, HK A stated on 5/11/2024 Resident #3 reported to her the EVS had propositioned Resident #3 for sex. HK A reported Resident #3 made several odd statements that morning (leading HK A to believe Resident #3 was confused) prior to the allegations about the EVS and confirmed she did not report Resident #3's allegations. HK A stated RN X who was working at the time of the allegation, entered the resident's room a few moments after she had exited and assumed Resident #3 would repeat the allegations to the nurse. HK A confirmed the allegations by Resident #3 were reported to her near the end of her shift on 5/11/2024 between 10:00 PM and 11:00 PM and she had not informed the facility of the allegations until after she was questioned by the SDC on the morning of 5/12/2024 (1 day after the allegations were made). During an interview on 1/14/2025 at 11:40 AM, the SDC stated she interviewed Resident #3 on the morning of 5/12/2024 around 5:30 AM after she arrived to work. The SDC stated at the time she initially interviewed Resident #3, she was not aware of the allegations of the sexual comments and sexual proposition by the EVS which was reported to HK A. The SDC stated RN X had informed her Resident #3 had reported concerns for her safety related to the EVS but was not given any specific details related to those concerns. The SDC stated initially Resident #3 made allegations she was fearful of the EVS because the EVS had made sexual advances towards HK A and she feared for HK A's safety. The SDC reported she informed the DON of the allegations and the DON assumed supervision of the investigation, which later revealed the additional allegations of sexual comments and proposition by the EVS to Resident #3 which was reported to HK A on 5/11/2024. The SDC stated she obtained written statements from all involved parties related to those allegations, which clarified the allegations and prompted the referral to the local police and the state agency for investigation. The allegations were reported to the state agency 2 days after Resident #3 made the initial report to HK A. The facility was cited as past non-compliance at F-609. Surveyors verified and validated the corrective action plan on site. The facility implemented the following corrective actions which were validated onsite by the surveyor on 1/14/2025 as follows: 1. On 5/13/2024 when the facility became aware of the full nature of the allegations the alleged perpetrator was immediately suspended. The facility conducted an ad hoc QA of the allegations and launched a full investigation which included interviews of all involved personnel and Resident #3. 2. The facility identified by investigative interviews conducted on 5/13/2024 HK had failed to report allegations of abuse immediately to facility administration and suspended HK pending outcome of the investigation as well. The facility suspended RN X for failure to launch an initial investigation immediately when Resident #3 informed her she feared the EVS. 3. The facility assessed all residents for potential impact of the allegations on 5/13/2024 and identified no other potential victims. Additionally, the facility interviewed multiple female staff as related to EVS with no negative findings. 4. The facility notified all authorities as required by law of the allegations once their true nature was identified within two hours of becoming aware of them on the afternoon of 5/13/2024. 5. The facility also performed skin assessments of all cognitively impaired elders with BIMS less than 8 on 5/13/2024 with no negative findings. 6. Resident #3 was examined by the hospice physician on 5/13/2024 who determined no signs of abuse were present, noted inconsistencies in Resident #3's allegations and mental status,and determined there was no evidence Resident #3 was abused as alleged and reported this to the facility IDT. The hospice physician's findings were conveyed to the facility medical director who also examined Resident #3 and concurred. Resident #3 was placed on increased monitoring as a precaution and the care plan was adjusted to reflect 2 persons in the room at all times and no male caretakers on 5/13/2024. 7. The family was contacted on 5/13/2024 for initial discussions related to the incident and additional follow up calls with the responsible party were completed on 5/15/2024 at the conclusion of the facility internal investigation, in which the facility findings and interventions put in place in response to the allegations were reviewed with the responsible party. 8. Resident #3 was examined by the Psychiatric Nurse Practitioner on 5/14/2024 with no new orders issued and no signs of mental duress present in Resident #3. The NP concurred with findings of both the hospice physician and medical director and changes to the care plan already in place. The facility also provided education to the resident council on escalation of abuse allegations on 5/14/2024. The resident council had no voiced concerns with EVS or abuse allegations to report to the facility. 9. The facility implemented a performance improvement plan (PIP) related to timely reporting of all potential abuse allegations to administration and the facility abuse prohibition policy on 5/13/2024, after consultation with Corporate officials was completed. Additional QA of the incident was performed on 5/14/2024, and root cause analysis of the incident was completed. All staff were required to be re-educated on the abuse policy and timely reporting requirements. Staff education began on 5/13/2024 and was completed on 5/21/2024. 10. The facility placed the incident on the Quality Assurance agenda for the following month after additional Quality Assurance Reviews of the incident were conducted on 5/15/2024. Follow up QA review of all interventions was performed on 5/21/2024 to ensure staff education was completed as directed. The facility also performed additional QA review of the incident and monitoring of the PIP on 6/5/2024 and again 6/10/2024. The facility continued to perform Quality Assurance Review of the incident through July 2024 with no further negative findings and no other instances of late abuse reporting detected. 11. EVS was terminated upon conclusion of the facility investigation on 5/15/2024. On 1/14/2025 the surveyor validated the corrective actions onsite by interview of 8 staff members all of whom were knowledgeable of the abuse prohibition and reporting requirements policy as well as internal mechanisms for reporting concerns with leadership by the corporate hot line. Interviews with the SDC and HK also confirmed they were suspended as reported and both completed re-education in relation to the incident and timely abuse reporting. RN X was no longer employed at the facility. Review of her personnel file showed RN X did complete training as required and was reinstated. On 1/14/2025 the surveyor reviewed additional resident council minutes from 7/2024 to 12/2024 showed no concerns with abuse or neglect at the facility. Review of complaint logs for the same period showed no other allegations of staff on resident sexual abuse. On 1/14/2025 the surveyor reviewed the facility corrective action records which were maintained in a binder specific to the complaint. Review of staff logs showed all staff members completed mandatory re-training by the dates specified as reported. On 1/14/2025 the surveyor completed reviews of personnel files for all staff members involved in the incident and verified retraining, corrective discipline and terminations as reported by the facility. On 1/14/2025 the surveyor reviewed the law enforcement initial report and unredacted investigation notes provided by local police as related to the incident. On 1/14/2025 the surveyor completed review of the facility root cause analysis and PIP which corroborated data in the education materials used to re-educate staff in relation to the facility's self-identified noncompliance and corrective actions.

Based on facility policy review, facility investigation documentation review, medical record review, observations, and interviews the facility failed to protect the residents' right to be free from physical abuse by another resident for 8 residents (Residents #5, #6, #7, #8, #10, #11, #14, and #15) of 14 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised [DATE], revealed .organizations intention to prevent the occurrence of abuse .all alleged Abuse, Neglect, exploitation, injuries of unknown origin, and Misappropriation of resident property is investigated .are reported immediately .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . 1. On [DATE], Resident #6 placed hands on Resident #5's chest and pushed Resident #5 backward in wheelchair. Review of the facility investigation dated [DATE], revealed an altercation between Resident #5 and Resident #6 had occurred. A Certified Nursing Assistant (CNA) overheard Residents #5 and #6 talking with a raised tone at the entrance of the residents' room and walked toward the room. The CNA stated she heard Resident #6 saying to Resident #5 .you cannot come in here; this is my room . Continued review revealed the CNA attempted to redirect Resident #6 and observed Resident #6 place both hands on Resident #5's chest and pushed the resident backwards in the wheelchair. Both residents were separated and assessed, no injuries were noted to either resident. Resident #6 was placed on 1 to 1 observation until transfer to Geriatric-Psychiatric (Geri-psych or Geropsych) for evaluation and treatment. Further review revealed .Resident to resident altercation was witnessed via [by way of] staff member and verified as having occurred . Resident #6 did not return to the facility after the hospitalization . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Dementia with Agitation, Foot Drop of Left Foot, Acquired Absence of Right Leg above Knee, and Peripheral Vascular Disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #5 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Review of a comprehensive care plan for Resident #5 dated [DATE], revealed .Resident involved in resident-to-resident altercation .Assist resident to move away from other residents as needed .Observe for triggers of inappropriate behaviors and alter environment as needed .Observe for unmet needs . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, Cerebral Infarction (Stroke), and Urinary Tract Infection. Review of the admission MDS assessment dated [DATE], revealed Resident #6 scored a 5 on the BIMS assessment which indicated severe cognitive impairment. Review of a comprehensive care plan for Resident #6 dated [DATE], revealed .Resident demonstrated inappropriate behaviors including .Resident-to-Resident altercation .Residents behaviors will not result in disruption of others environment .Observe for triggers of inappropriate behaviors and alter environment as needed .Observe for unmet needs . Multiple observations were made of Resident #5 at various times during the complaint investigation on [DATE]-[DATE], the resident participated in group activities in the secure unit. Resident #5 did not display disruptive or aggressive behavior during the observations. During an interview on [DATE] at 3:40 PM, Licensed Practical Nurse (LPN) B stated she could not recall details regarding Resident #6, however she stated Resident #5 did not display behaviors and was not aggressive towards other residents or staff during the times she had cared for Resident #5. During an interview on [DATE] at 9:30 AM, the former Administrator confirmed the physical altercation between Residents #5 and #6 was witnessed by staff, who had to intervene and separate the residents. 2. On [DATE], Resident #8 struck Resident #7 in the back resulting in a fall. Review of facility investigation documentation titled, Timeline and Summary of events, dated [DATE], revealed the Unit Manager/LPN M was notified of a physical altercation between Resident #7 and Resident #8 on the secure unit. Continued review revealed Resident #8 struck Resident #7 in the back, causing Resident #7 to fall in the dayroom of the secure unit. Resident #7 was not injured from the fall. The investigation documented Resident #7 stated Resident #8 had removed Resident 7's eyeglasses .Resident #8 does not wear corrective lenses . Witness statements corroborated Resident #8 does not wear eyeglasses and believed Resident #7 had taken his eyeglasses. The residents were separated immediately and placed on 1 to 1 supervision by the direct care staff until Resident #8 was transferred to a Geri-psych. hospital for evaluation and treatment. Resident #8 did not return to the facility after the hospitalalization. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Dementia with Behavioral Disturbance, Depression, and Insomnia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 scored a 9 on the BIMS assessment which indicated moderate cognitive impairment. Review of the comprehensive care plan for Resident #7 dated [DATE], revealed .This resident was involved in resident-to-resident altercation: Physical . with interventions in place. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Restlessness and Agitation, Depression, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, and Insomnia. Resident #8 was discharged from the facility on [DATE] to a local hospital for evaluation and treatment in a Geri-psychiatric Services unit and did not return to the facility. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 was rarely/never understood, the BIMS assessment could not be completed. Review of the comprehensive care plan for Resident #8 dated [DATE], revealed .This resident was involved in resident-to-resident altercation: Physical . with interventions in place. During an interview on [DATE] at 9:30 AM, the former Administrator confirmed the physical altercation was substantiated upon the facility's investigation between Resident #7 and Resident #8 and Resident #8 had struck Resident #7 resulting in a fall on [DATE]. 3. On [DATE], Resident #11 was observed striking Resident #10. Review of a facility reported investigation of a resident to resident altercation between Resident #11 and Resident #10 dated [DATE], revealed Resident #10 was heard yelling, a CNA entered the room and observed Resident #11 standing beside of Resident #10 striking the resident. The residents were immediately separated and assessed for injury with none noted. Neither of the residents were able to state what had occurred. Resident #11 was placed with 1 on 1 supervision until the resident was transferred to the hospital for inpatient Gero psych. evaluation on [DATE]. Resident #11 returned to the facility on [DATE]. Medical record review revealed Resident #10 admitted to the facility on [DATE], with diagnoses including Pneumonia, Diabetes Mellitus, Surgical Aftercare on the Digestive System, Dementia, Psychotic Disturbance, and Unspecified Intellectual Disabilities. Review of the admission MDS assessment dated [DATE], revealed Resident #10 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan dated [DATE], revealed Resident #10 had a behavioral care plan with interventions and monitoring implemented for mood state. During an interview on [DATE] at 2:45 PM, LPN L stated Resident #10 passed away in the facility on [DATE] under hospice services. Medical record review revealed Resident #11 admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, and Muscle Weakness. Review of the quarterly MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan dated [DATE], revealed Resident #11, had a behavioral care plan with interventions and monitoring implemented for medications for the diagnoses of Depression, Anxiety, and Insomnia. During an observation on [DATE] at 3:00 PM, revealed Resident #11 returned to her room with assistance by staff from an activity and no behaviors were noted. During an interview with CNA A on [DATE] at 3:05 PM, revealed Resident #11 was able to make her needs known and had not exhibited any behaviors toward other residents. During an observation on [DATE] at 2:40 PM, revealed Resident #11 interacted with other residents in the hallway, was calm, and no behaviors were exhibited. During an interview on [DATE] at 2:40 PM, Resident #11 denied an altercations with other residents. During an interview on [DATE] at 2:45 PM, LPN L stated Resident #11 had not exhibited any behaviors before the altercation or after returning from the hospital. During an interview on [DATE] at 8:15 AM, the former Administrator and current Administrator stated the physical altercations between Resident #10 and Resident #11were witnessed by facility staff and the facility's investigation was substantiated. The CNA and LPN that witnessed the altercation between Resident #10 and #11 on [DATE] were no longer employed by the facility and were unable to be reached by phone. 4. On [DATE], Resident #14 was observed by staff seated in the floor with Resident #15 yelling at him to get up so he could hit him again. Resident #14 was observed with redness to his chest and back of head. Review of a facility investigation of a resident to resident altercation dated [DATE], revealed LPN N was standing in the hallway when she heard a loud smack and something heavy hit the floor. LPN N entered the room and observed Resident #14 seated on the floor with Resident #15 standing beside of Resident #14 yelling for him to get up so he could hit him, again. The residents were separated and assessed for injury. Resident #14 was noted to have redness to the chest and back of head. Residents #14 and #15 were transferred to the hospital for evaluation. Resident #14 returned to the facility and Resident #15 was transferred to an inpatient Gero-psych. facility for evaluation. Medical record review revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia, Mood Disorder, Delusional Disorder, and Anxiety. Review of the medical record revealed Resident #14 was deceased . Review of the comprehensive care plan dated [DATE], revealed Resident #14 had a behavioral care plan dated [DATE], with the intervention of monitoring for adverse effects from the incident. Medical record review revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Dementia, Hydrocephalus (buildup of fluid deep in the brain), Aftercare following surgery on the Nervous System, history of Transient Ischemic Attack, and Agitation. Review of the admission MDS assessment dated [DATE], revealed Resident #15 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Review of the comprehensive care plan dated [DATE] and revised [DATE], revealed Resident #15 had a behavioral care plan which included 1 on 1 supervision and a hospitalization for evaluation of behaviors. During an observation on [DATE] at 4:00 PM and [DATE] at 8:25 AM, revealed Resident #15 was seated in a reclining wheelchair in the living area with other residents. He appeared calm with no behaviors or distress noted. During an interview on [DATE] at 9:45 AM, LPN B stated Residents #14 and #15 were roommates on the secure unit at the time of the altercation on [DATE]. LPN B stated both residents were ambulatory, had a diagnosis of Dementia and were confused. Continued interview revealed neither resident had exhibited aggressive behaviors toward others prior to the altercation or after Resident #15 returned from the hospital. During an interview on [DATE] at 8:15 AM, the former Administrator and current Administrator stated Resident #15 reported to the nurse he had hit Resident #14 and if he would stand up, he would hit him again. Continued interviews confirmed the physical altercations between Resident #14 and #15 were substantiated following the facility's investigations. 35460 Review of a facility reported investigation of a resident to resident altercation between Resident #11 and Resident #10 dated [DATE], revealed Resident #10 was heard yelling, a Certified Nurse Assistant (CNA) entered the room and saw Resident #11 standing beside of Resident #10 and was striking at her. The residents were immediately separated and assessed for injury with none noted. Neither of the residents were able to state what had occurred. The Licensed Practical Nurse (LPN) notified the physician, families, and administration. The state and local agencies were notified timely. Resident #11 was placed with 1:1 supervision until she was transferred to the hospital for evaluation. The resident was transferred to inpatient Gero psych on [DATE]. The investigation included witness statements, resident interviews and/or skin assessments (BIMS assessment less than 8) with no concerns identified. All staff received re-education on Abuse. The resident returned to the facility on [DATE]. Medical record review revealed Resident #10 admitted on [DATE], with diagnoses including Pneumonia, Diabetes Mellitus, Surgical Aftercare on the Digestive System, Dementia, Psychotic Disturbance, and Unspecified Intellectual Disabilities. Review of the admission MDS dated [DATE], revealed Resident #10 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan dated [DATE], revealed Resident #10 had a behavioral care plan with interventions and monitoring implemented for mood state. During an interview with LPN L on [DATE] at 2:45 PM, revealed Resident #10 passed away in the facility on [DATE]. Continued interview revealed the resident was on hospice services. The CNA and LPN that witnessed the altercation between Resident #10 and #11 were no longer employed by the facility and were unable to be reached by phone. Medical record review revealed Resident #11 admitted on [DATE], with diagnoses including Unspecified Dementia, Anxiety, and Muscle Weakness. Review of the quarterly MDS dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated she was cognitively intact. Review of the comprehensive care plan dated [DATE], revealed Resident #11, had a behavioral care plan with interventions and monitoring implemented for medications for the diagnoses of Depression, Anxiety, and Insomnia. Observation on [DATE] at 3:00 PM, revealed Resident #11 returned to her room with assistance from activities and was assisted to her bathroom. During an interview with CNA A on [DATE] at 3:05 PM, revealed Resident #11 was able to make her needs known and was both continent and incontinent at times. Continued interview revealed the CNA was unaware of any behaviors the resident had toward other residents. Observation on [DATE] at 2:40 PM, revealed Resident #11 interacted with other residents in the hallway, was calm, and no behaviors were noted. During an interview on [DATE] at 2:40 PM, Resident #11 denied recall of an altercation with other residents and reported no concerns with staff. During an interview with LPN L on [DATE] at 2:45 PM, revealed Resident #11 was alert and oriented. Continued interview revealed Resident #11 had not had any behaviors before the altercation or after returning from the hospital with medication changes. Review of a facility investigation of a resident to resident altercation dated [DATE], revealed LPN N was standing in the hallway when she heard a loud smack and then and heard something heavy hit the floor. Resident #14 was seated on the floor and Resident #15 was standing beside of him yelling for him (Resident #14) to get up so he could hit him again. The residents were separated and assessed for injury. Resident #14 was noted to have redness to his chest and back of head. The nurse notified the physician, families, and administration. Both residents were transferred to the hospital for evaluation. Resident #14 returned to the facility and Resident #15 was sent to inpatient Gero-psych. The state and local agencies were notified timely. The investigation included witness statements, resident interviews and/or skin assessments (BIMS assessment less than 8) with no concerns identified. All staff received re-education on Abuse. Medical record review revealed Resident #14 was admitted on [DATE], with diagnoses including Dementia, Mood Disorder, Delusional Disorder, and Anxiety. Review of the comprehensive care plan dated [DATE], revealed Resident #14 had a behavioral care plan dated [DATE], with the intervention of monitoring for adverse effects from the incident. Medical record review revealed Resident #15 was admitted on [DATE], with diagnoses including Dementia, Hydrocephalus (buildup of fluid deep in the brain), Aftercare following surgery on the Nervous System, history of Transient Ischemic Attack, and Agitation. Review of the admission MDS dated [DATE], revealed Resident #15 scored 3 on the BIMS assessment which indicated severe cognitive impairment. Review of the comprehensive care plan dated [DATE], revealed Resident #15 had a behavioral care plan dated [DATE] which included 1:1 supervision and hospitalization for evaluation of behaviors. Resident #14 was deceased . Observation on [DATE] at 4:00 PM, revealed Resident #15 was seated in a reclining wheelchair in the living area with other residents. He appeared calm with no distress noted. Observation on [DATE] at 8:25 AM, revealed Resident #15 was seated in the living area being assisted with breakfast. No behaviors noted. During an interview on [DATE] at 9:45 AM, with LPN B revealed Residents #14 and #15 were roommates on the secure unit at the time of the altercation, both residents were ambulatory, and had Dementia. Continued interview revealed neither resident had exhibited aggressive behaviors toward others prior to the altercation or after Resident #15 returned from the hospital. During an interview on [DATE] at 10:15 AM, with CNA D revealed Resident #14 and Resident #15 had never exhibited behaviors toward each other or others. Continued interview confirmed she was unaware of any other altercations for Resident #14 or Resident #15. During an interview on [DATE] at 8:15 AM, with the former Administrator and current administrator confirmed the physical altercations between Resident #10 and Resident #11, and the physical altercation between Resident #14 and #15 were substantiated following the investigations. The altercation between Resident #10 and Resident #11 was witnessed by staff. Resident #15 reported to the nurse he had hit Resident #14 and if he would stand up, he would hit him again.

Based on facility policy review, medical record review, and interview, the facility failed to obtain a Physician's order, for an indwelling urinary catheter or catheter care, for 1 of 3 sampled residents (Resident #1) reviewed. The findings include: Review of the facility's policy titled, General Medication Orders, revised 6/26/2018, revealed, .The purpose of this procedure is to establish uniform guidelines in the receiving and recording of the medication orders .Supervision by a Physician .1. A current list of orders must be maintained in the clinical record of each resident .2. Orders must be written and maintained in chronological order .6. Treatment Orders-When recording treatment orders, specify the treatment, location, frequency and duration of the treatment . Review of the facility's policy titled, Review of Physician Orders, reviewed 4/14/2021, revealed, .It is the standard of this facility that physician's orders are reviewed daily to ensure delivery of applicable care, tracking of change and condition and updating care plans are consistently provided .1. Physician orders be reviewed daily by nursing administration during the Clinical Meeting .2. New orders in the Electronic Medical Record (EMR), Care Plans, Dietary, etc. (similar items included) will be reviewed by the interdisciplinary team to ensure updates have occurred . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-Day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) assessment was not completed for Resident #1 due a short stay in the facility. Continued review revealed that Resident #1 required to limited to extensive assistance of one person with most ADLs (Activities of Daily Living). Continued review revealed that Resident #1 received 54 minutes of Physical Therapy (PT) on 8/26/2022. Continued review revealed Resident #1 required the use of an indwelling urinary catheter. Review of the Baseline Care plan revealed Resident #1 was care planned for health-related complications due to Has Disruption of Skin Surface related to a surgical wound with a JP (Jackson-[NAME]) Drain to Right Interior Upper Leg, Risk for Falls, Risk for Abnormal Bleeding due to Anticoagulant Usage, Pain, Risk for Impaired Skin, Self-Care Deficit, Nutritional Risk, Diabetes, Risk for Cardiovascular Complications, and other care areas, with appropriate goals, interventions, and updates, with no concern. Continued reviewed revealed no Baseline Care Plan for requiring a urinary catheter or urinary catheter care. Review of the facility's, Observation Detail List Report, dated 8/25/2022, revealed Resident #1 was admitted to the facility with an indwelling urinary catheter. Review of the facility's, Physician Order Report, dated 8/25/2022-8/28/2022, revealed Resident #1 had no Physician's orders for an indwelling urinary catheter or urinary catheter care. During an interview on 9/26/2022 at 4:19 PM, the Administrator confirmed there were no Physician's orders for an indwelling urinary catheter or urinary catheter care, for Resident #1.

Based on facility policy review, medical record review, and interview, the facility failed to develop and implement a Baseline Care Plan, within 48 hours of admission, for 1 of 3 sampled residents (Resident #1) reviewed. The findings include: Review of the facility's policy titled, Baseline Care Plan Policy, dated 9/23/2022, revealed, .Complete a Baseline Care Plan to promote continuity of care and communication among nursing home stakeholders, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission .1. Complete 48-hour Baseline Care plan, with the following .a. Goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MD (Medical Doctor) orders .ii. Dietary orders .iii. Therapy Services .iv. Social Services .v. Preadmission Screening and Resident Review (PASSR) recommendations .2. Baseline Care Plan will be a working tool for the first 48 hours .3. The Baseline Care Plan Summary will be reviewed and presented to the resident and/or representative prior to completion of the Comprehensive Care Plan .4. Provide a summary of the care plan to the resident and/or resident representative . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-Day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) assessment was not completed for Resident #1 due a short stay in the facility. Continued review revealed that Resident #1 required to limited to extensive assistance of one person with most ADLs (Activities of Daily Living). Continued review revealed that Resident #1 received 54 minutes of Physical Therapy (PT) on 8/26/2022. Continued review revealed Resident #1 required the use of an indwelling urinary catheter. Review of the Baseline Care plan revealed Resident #1 was care planned for health-related complications due to Has Disruption of Skin Surface related to a surgical wound with a JP (Jackson-[NAME]) Drain to Right Interior Upper Leg, Risk for Falls, Risk for Abnormal Bleeding due to Anticoagulant Usage, Pain, Risk for Impaired Skin, Self-Care Deficit, Nutritional Risk, Diabetes, Risk for Cardiovascular Complications, and other care areas, with appropriate goals, interventions, and updates, with no concern. Continued reviewed revealed no Baseline Care Plan for requiring a urinary catheter or urinary catheter care. Review of the facility's, Observation Detail List Report, dated 8/25/2022, revealed Resident #1 was admitted to the facility with an indwelling urinary catheter. During an interview on 9/26/2022 at 4:19 PM, the Administrator confirmed Resident #1 was admitted to the facility on [DATE] and there was no Baseline Care Plan completed for an indwelling urinary catheter or urinary catheter care. During a phone interview on 9/26/2022 at 5:30 PM, the Nurse Manager confirmed Resident #1's indwelling urinary catheter and catheter care should have been on his Baseline Care Plan. She stated, If there is no order, then we don't know to add it to the Baseline Care Plan. She stated that a Baseline Care Plan should be completed within 48 hours of admission to the facility.

Based on policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse for 1 of 3 sampled residents (Resident #3) reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, revised 7/6/2022, revealed, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The organization will include screening, training, prevention, identification, investigation, protection and reporting to provide protection for the health, welfare and rights of each resident residing in the facility .It is the organization's policy that the Facility Administrator, or his or her designee, will direct a reasonable investigation of each such alleged violation, unless he or she has a conflict of interest or is implicated in the alleged violation. The Facility Administrator is responsible to report the results of all investigations to applicable State agencies as required by Federal and State law. The Facility Administrator is the Facility's designated Abuse Coordinator, and any questions regarding the interpretation or implementation of this policy should be referred to him or her. In the case of a suspected crime as defined in the Elder Justice Act, refer to the applicable Elder Justice Act policy and procedures .Allegation of Abuse .Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred, or plausibly might have occurred .Neglect: Is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Deprivation of Goods and Services by Stakeholders: Abuse also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. In the cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s) .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made. If a State reporting requirement establishes a longer reporting time for certain unusual incidents other than abuse or neglect, that reporting time applies only to such incidents. In other words, all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately, as defined in this paragraph .E. Investigation Guidelines .1. The facility Administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse, injuries of unknown source, exploitation, or suspicions of a crime as defined in this document. The Facility Administrator may delegate some or all of the investigation as appropriate, but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident .Protection .3. Every Stakeholder shall immediately report any allegation of abuse, injury of unknown source, or suspicion of crime, as those terms are defined above .G. Reporting/Response .1. Every Stakeholder shall immediately report any allegation of abuse .Failure to report an allegation of abuse, injury of unknown origin or suspicion of crime may result in disciplinary action .Reporting Guidelines .Any abuse allegation must be reported to the State within 2 hours from the time the allegation was received .Any reasonable suspicion of a crime + serious bodily injury must be reported to the State and Police . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with readmission on 10/29/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored 15 on the BIMS (Brief Interview for Mental Status) assessment, which indicated intact cognition. Continued review revealed she required extensive to total assistance with most ADLs (Activities of Daily Living). Continued review revealed Resident #3 received daily Antipsychotic, Antianxiety, and Hypnotic Medications. Review of the facility's, Resident Progress Notes, for Resident #3, revealed a nursing note, dated 9/5/2022 at 9:30 PM, that stated, .Elder talking to nurse about things that MD (Medical Doctor) already aware of, such as lump in left breast and swollen labia. She continues talking while she is recording on her cell phone and says [Named CNA-Certified Nurse Assistant #3] hurt me today while she was giving me a shower. I asked her where she was hurt and she said her arm and that the shower sprayer was dropped on her. She also says she was not placed in the shower chair properly. She said water was sprayed in her face and got in her ear. No injuries noted. Reported to [Named Nurse Manager], nurse manager on call. I asked elder is she reported this to the day nurse or anyone when it happened and she said no. She says she is going to report to ADON (Assistant Director of Nursing) [Named ADON] tomorrow . During a phone interview on 9/26/2022 at 6:48 PM, RN (Registered Nurse) #1 stated she frequently provides care for Resident #3. She stated, Every time I am in her room, she reports something to me. She is difficult to care for sometimes. She throws things and screams and yells and says things that aren't true. When I went in her room on the 5th, she told me that [Named CNA #3] had hurt her arm and it happened when she showered her. I reported it to the on-call person. I told her when something like that happens, she needs to report it right when it happens and don't wait. During an interview on 9/26/2022 at 6:43 PM, the Administrator confirmed the allegation of abuse, made by Resident #3, on 9/5/2022, was not reported to the State Agency and no investigation, of the allegation, was completed by the facility. She stated, I would expect it to be reported. The Administrator stated that she was the Abuse Coordinator and that she expected staff to report any allegations of abuse, immediately to her. She stated any allegation of abuse must be reported to the State Agency within 2 hours of the allegation being made.

Based on policy review, medical record review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 of 3 sampled residents (Resident #3) reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, revised 7/6/2022, revealed, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The organization will include screening, training, prevention, identification, investigation, protection and reporting to provide protection for the health, welfare and rights of each resident residing in the facility .It is the organization's policy that the Facility Administrator, or his or her designee, will direct a reasonable investigation of each such alleged violation, unless he or she has a conflict of interest or is implicated in the alleged violation. The Facility Administrator is responsible to report the results of all investigations to applicable State agencies as required by Federal and State law. The Facility Administrator is the Facility's designated Abuse Coordinator, and any questions regarding the interpretation or implementation of this policy should be referred to him or her. In the case of a suspected crime as defined in the Elder Justice Act, refer to the applicable Elder Justice Act policy and procedures .Allegation of Abuse .Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred, or plausibly might have occurred .Neglect: Is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Deprivation of Goods and Services by Stakeholders: Abuse also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. In the cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s) .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made. If a State reporting requirement establishes a longer reporting time for certain unusual incidents other than abuse or neglect, that reporting time applies only to such incidents. In other words, all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately, as defined in this paragraph .E. Investigation Guidelines .1. The facility Administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse, injuries of unknown source, exploitation, or suspicions of a crime as defined in this document. The Facility Administrator may delegate some or all of the investigation as appropriate, but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident .Protection .3. Every Stakeholder shall immediately report any allegation of abuse, injury of unknown source, or suspicion of crime, as those terms are defined above .G. Reporting/Response .1. Every Stakeholder shall immediately report any allegation of abuse .Failure to report an allegation of abuse, injury of unknown origin or suspicion of crime may result in disciplinary action .Reporting Guidelines .Any abuse allegation must be reported to the State within 2 hours from the time the allegation was received .Any reasonable suspicion of a crime + serious bodily injury must be reported to the State and Police . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with readmission on 10/29/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored 15 on the BIMS (Brief Interview for Mental Status) assessment, which indicated intact cognition. Continued review revealed she required extensive to total assistance with most ADLs (Activities of Daily Living). Continued review revealed Resident #3 received daily Antipsychotic, Antianxiety, and Hypnotic Medications. Review of the facility's, Resident Progress Notes, for Resident #3, revealed a nursing note, dated 9/5/2022 at 9:30 PM, that stated, .Elder talking to nurse about things that MD (Medical Doctor) already aware of, such as lump in left breast and swollen labia. She continues talking while she is recording on her cell phone and says [Named CNA-Certified Nurse Assistant #3] hurt me today while she was giving me a shower. I asked her where she was hurt and she said her arm and that the shower sprayer was dropped on her. She also says she was not placed in the shower chair properly. She said water was sprayed in her face and got in her ear. No injuries noted. Reported to [Named Nurse Manager], nurse manager on call. I asked elder is she reported this to the day nurse or anyone when it happened and she said no. She says she is going to report to ADON (Assistant Director of Nursing) [Named ADON] tomorrow . During a phone interview on 9/26/2022 at 6:48 PM, RN (Registered Nurse) #1 stated she frequently provides care for Resident #3. She stated, Every time I am in her room, she reports something to me. She is difficult to care for sometimes. She throws things and screams and yells and says things that aren't true. When I went in her room on the 5th, she told me that [Named CNA #3] had hurt her arm and it happened when she showered her. I reported it to the on-call person. I told her when something like that happens, she needs to report it right when it happens and don't wait. During an interview on 9/26/2022 at 6:43 PM, the Administrator confirmed the allegation of abuse, made by Resident #3, on 9/5/2022, was not reported to the State Agency and no investigation, of the allegation, was completed by the facility. She stated, I would expect it to be reported. The Administrator stated that she was the Abuse Coordinator and that she expected staff to report any allegations of abuse, immediately to her. She stated any allegation of abuse must be reported to the State Agency within 2 hours of the allegation being made.

Based on policy review, medical record review, observation, and interview, the facility failed to report an allegation of abuse, within 2 hours, to the State Survey Agency for 1 of 3 sampled residents (Resident #1) reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, revised 5/8/2019, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored 3 on the BIMS (Brief Interview for Mental Status) assessment, which indicated severely impaired cognition. Review of the Facility Reported Incident (FRI), ID (Identification) Number 641, for Resident #1, revealed the date and time that the alleged incident occurred was on 3/31/2022 at 6:00 AM. Continued review revealed the DON (Director of Nursing) reported the incident to the State Agency on 3/31/2022 at 12:16 PM. During an interview on 5/3/2022 at 2:40 PM, the Administrator stated that she was the Abuse Coordinator. She stated that her were for staff to report any allegations of abuse immediately. She stated she was on vacation during the time the incident was reported, and the DON was in charge during that time. The Administrator confirmed that any allegation of suspected abuse was to be reported to the State Agency no later than 2 hours after the allegation was made. The Administrator confirmed that FRI number 641, for Resident #1, had a date and time of occurrence of 3/31/2022 at 6:00 AM and the date and time reported to the State Agency was 3/31/2022 at 12:16 AM. During an interview on 5/3/2022 at 2:48 PM, the DON stated that on 3/31/2022 at around 11:00 AM, she was notified of an allegation of abuse by the ADON. The DON stated that the ADON was made aware of the allegations by a staff member, after change of shift at 6:00 AM on 3/31/2022. The DON stated that as soon as she was notified of the allegation, she pulled over on the side of the road and used her laptop to report the incident to the State Agency. The DON confirmed that the occurrence date and time on FRI number 641 was 3/31/2022 at 6:00 AM and the reported date and time was 3/31/2022 at 12:16 PM.

Based on facility policy review, medical record review, observation and interview, the facility failed to treat 1 (#4) of 1 residents who required a indwelling urinary catheter with dignity related to not covering the resident's indwelling urinary catheter drainage bag with a privacy cover. The findings include: Review of the facility policy Resident Rights dated 8/16/18 (2018), revealed .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . Review of Resident #4's Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of BIMS revealed Resident #4 had a BIMS score of 15, indication no cognitive impairment. Review of physician orders revealed 7/20/2021 Foley Catheter to straight drainage bag. Dx: (Diagnosis) urinary retention. Special instructions: Privacy bag at all times. Observation on 7/27/2021 at 9:02 AM revealed Resident #4's catheter bag was not covered for privacy. Observation on 7/27/2021 at 9:17 AM revealed Resident #4's catheter bag was not covered for privacy. Observation on 7/27/2021 at 9:26 AM revealed Resident #4's catheter bag was not covered for privacy. During an observation and interview on 7/27/2021 at 9:49 AM with LPN #3, she confirmed Resident #4's indwelling urinary catheter bag was uncovered and confirmed the indwelling urinary catheter bag was supposed to be covered with privacy cover. During an interview on 7/27/2021 at 4:28 PM, with the DON (director of Nursing), when asked when a indwelling urinary catheter is present what would she see regarding the indwelling urinary catheter bag, she stated it could be in a fig leaf bag, then stated if the resident doesn't mind then there is no problem. During continued interview the DON refused to confirm a privacy bag was needed for dignity. During further interview the DON stated I don't know what the policy says. During an interview on 7/27/2021 at 4:43 PM, the Administrator stated it (the indwelling urinary catheter bag) was covered yesterday and she doesn't know what happened to it. During continued interview the Administrator confirmed it (uncovered indwelling urinary catheter) was a known dignity issue.

Based on facility policy review, medical record review, review of the facility fall investigation, and interview the facility failed to provide revised care plan for safety and supervision while sitting in a chair for 1 resident (#1) and failed to update the care plan interventions for previous falls for 1 resident (#2) of 3 residents reviewed. The findings included: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Discharge Assessment Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was discharged to an acute hospital. Continued review revealed the discharge was unplanned. Further review revealed Resident #1 had a short-term memory problem and was severely impaired for daily decision making. Continued review revealed no evidence of acute mental status change and no behavior symptoms noted. Further review revealed no hallucinations or delusions. Continued review revealed Resident #1 required extensive assistance with bed mobility, transfers. Required total assistance for locomotion on and off unit, dressing, eating, toilet use and bathing. Continued review revealed Resident #1 had a fall with major injury. Review of Resident #1's Event Report revealed: Date and Time of Event: .5/29/2021 at 09:45 AM .Pertinent Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Does resident exhibit or complain of pain related to the fall? No .On a scale of 0-10, how does resident rate intensity of pain if able or indicate based on observation. 0-No pain .Location of Injury: Skin tears x2 to right forearm-both approx. (approximately) 1/2 x 1/2 in. (inch), w (with)/'c' shaped skin flap intact . Review of [named] nurse statement dated 5/29/2021, revealed .This nurse on her way to administer another residents' meds in the dayroom noted this resident (Resident #1) to be falling forward out of chair. Unable to reach resident before she fell forward out of chair onto floor on right side. Assessed for injury with skin tears x2 to right forearm. No further injury noted. Res non-verbal status-0 s/s (signs and symptoms) of pain/discomfort noted on ROM (range of motion) Leg lengths equal. VSS (vital signs stable). Assisted to chair with ST (skin tear) cleansed with NS (normal saline) and steri-strips applied. MD notified with NOV (new order voiced) for orb tx. (treatment) x 2 wks (weeks). Family notified. DON (director of nursing) representative notified. CP (care plan) intervention initiated . Review of Resident #1's MD Communication Form dated 5/31/2021, revealed .Pain in Right leg, guards and grimaces, fall from chair 5/29/21 (2021) .when did symptom/issue start first noticed: 5/30/2021 .MD's response: Xray of Right leg [named] x-ray service . Review of Resident #1's Radiology Report revealed .Acute femoral neck fracture . Continued review revealed .MD made aware with new orders to send to [named] ER (emergency room ) for eval (evaluation) 5/31/21 (2021) . Review of SNF (skilled nursing facility)/NF (nursing facility) TO HOSPITAL TRANSFER FORM revealed .Date of Transfer: 5/31/2021 .Primary diagnosis (es) for admission: Systemic Lupus/Alzheimer's .CODE STATUS: Full .Key Clinical Information: R (right) Femoral neck fx (fracture) .USUAL FUNCTIONAL STATUS BEFORE THE ACUTE CHANGE IN CONDITION: Not ambulatory .Bladder function: incontinent, Bowel Function: Incontinent .USUAL MENTAAL STATUS/COGNITION FUNCTION BEFORE THE ACUTE CHANGE IN CONDITION: Alert, disoriented, but cannot follow simple instructions .ADLs (Activity of Daily Living) dependent in bathing, dressing, toileting, transfers, eating . Review of Resident #1's hospital records dated 6/7/2021 revealed .Chief Complaint/History of Present Illness: Right hip fracture with pinning, Dementia with Adult Failure to thrive-End of Life issues, DM (Diabetes Mellitus), Seizures, recurrent falls and injuries in setting of long-term care . Review of Resident #1's nurse practitioner's note dated 6/9/2021, revealed .Chief Complaint/History of Present Illness: Patient is being seen for readmit to the facility .She presented with bone fracture. In the right hip. It is described as acute. The symptom is sudden in onset. Mechanism of injury includes fall . Continued review revealed .Assessment and Plan: Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, Other Alzheimer's disease, Type 2 diabetes mellitus with [CONDITION(S)] .Monitor incision site for complications. Will follow ortho (orthopedic) specialist .Other Alzheimer's disease Chronic with BIMS 0/15. Continue to provide supervision for safety .Muscle Weakness (generalized), Continue to provide supportive care assist with ADLs . Review of Resident #1's care plan revealed no interventions for safety or supervision while up in a chair. Review of Resident #3's Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Coli]. Review of Resident #3's Quarterly MDS dated [DATE], revealed Resident #3 had a BIMS score of 00, which indicates Resident #3 was unable to complete the interview. Continued review revealed Resident #3 has inattention and disorganized thinking continuously with no fluctuation. Further review revealed Resident #3 required extensive assistance with bed mobility, locomotion on unit, dressing, eating, and toilet use with a 1-person physical assistance. Transfers required extensive assistance with 2-person physical assistance. Walk in room, corridor and personal hygiene required limited assistance with a 1-person physical assistance. Further review revealed no falls since admission/entry or re-entry or Prior Assessment. Review of Resident #3's fall reports dated 6/7/2021, 5/4/2021, 4/23/2021, 4/24/2021, 4/11/2021, 3/7/2021, 2/19/2021, 1/19/2021 and 1/1/2021 revealed no concerns. Review of care plan revealed 3 interventions not updated on care plan for falls on 3/7/2021, 2/19/2021 and 1/1/2021 included pressure pad to back while in chair, Pull Tab Alarm on Geri chair, add Dycem to chair. During an interview on 7/26/2021 at 1:30 PM, LPN (licensed practical nurse) #2 stated, I did take care of her, but she moved off of my hall to another hall, I was not there when she went out to the hospital. During continued interview LPN #2 stated she (Resident #1) had fallen out of the chair forward onto the floor and the CNA was unable to reach her in the dayroom. During further interview LPN #2 stated when she (Resident #1) was up, she (Resident #1) would be in front of the nurse's station where she was visible. During continued interview LPN #2 stated it was witnessed by me and a CNA, I saw her leaning forward but was unable to reach her. During further interview LPN #2 stated we didn't realize she broke her hip at first because she had full rotation of bilateral legs, no abnormality with no complaints of pain or grimacing. During continued interview LPN #2 stated we believed the only injury she had was a tiny skin tear. During further interview LPN #2 stated she (#1) fell forward and to the side and was laying on her side. It didn't even look like a hard fall Resident. During an interview on 7/27 at 8:44 AM, LPN #1 stated she had cared for Resident #1, she (Resident #1) had a chair that kept her reclined, she (Resident #1) was up most of the time. During an interview on 7/27/2021 at 12:44 PM LPN #3 stated I took care of her the day she passed and took care of her since she moved to the 300-hall. During continued interview LPN #3 confirmed [named resident] Resident #1 was not able to get up in a regular wheelchair to hold herself upright, she had a broda chair because it reclined back. During an interview on 7/27/2021 at 2:52 PM, the DON (director of nursing) stated [named resident] Resident #1 was declining long before her death, she fell out of a chair in the dayroom, I did not witness. During continued interview the DON stated She (Resident #1) did not c/o (complain of) pain and after a few days she began to have facial grimacing, so she was sent out for evaluation. During further interview the DON stated, when she (Resident #1) came back from the hospital, she was DNR/Comfort Care due to no G (gastrostomy) tube. During continued interview the DON stated, During further interview the DON stated, when a resident uses the broda chair it wouldn't be care planned. During continued interview the DON stated, it could still be just up in chair. During further interview when asked to tell me what you would see care planned related to surgery, the DON replied, should've had hip fracture or fracture added to that. During further interview when asked if she would say Resident #1's care plan was person centered? The DON confirmed they should be updating the care plan and added I'm not going to agree or disagree, things could be different. During continued interview the DON confirmed the advance directives portion of the care plan was not updated. During further interview the DON confirmed Supervision was not on the care plan. During an interview on 7/27/2021 at 3:00 PM, the DON was asked why the dates on Resident #3's newly printed care plan had changed. The DON stated, I updated it. When asked to print the care plan with the previously viewed dates, she stated I can't change it back.

Based on review of facility policy, medical record review, and interview the facility failed to obtain laboratory testing for International Normal Ratio (INR) [a blood test to monitor how well blood thinning medication is working] which resulted in 2 INR laboratory tests not obtained for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of a facility policy Physican Orders At-A-Glance Revised 11/6/2019, showed .8. Review new orders in daily clinical meeting .Review Facility Activity Report .Review Verify Orders page and verify orders, as needed . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 received Anticoagulation [medication used to thin the blood] since admission to the facility (2/5/2021). Review of the Baseline Care Plan showed .at risk for abnormal bleeding or hemorrhage [blood loss] because of anticoagulant usage . Approach included .Schedule lab tests as ordered by the physician to monitor coagulation . Review of the Physician Transfer Orders dated 2/5/2021, showed .check INR in 2 days and q [every] week . Review of the laboratory data showed the INR was drawn for Resident #1 on 2/11/2021, 2/26/2021, 3/1/2021 and 3/3/2021. The INR was not obtained on 2/7/2021 or the week of 2/15/2021-2/19/2021. During an interview on 3/31/2021 at 2:10 PM, the Direct of Nursing stated it was her expectation for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 4/1/2021 at 1:00 PM, the Medical Director stated the INR should have been obtained according to the physician orders.

Based on facility policy review, medical record review, and interview, the facility failed to protect the privacy of medical information for 3 residents (Resident #3, #4, and #5) of 5 residents reviewed for privacy. The findings include: Review of the facility policy titled, Responding to a Privacy or Security Incident, dated 4/25/2019, showed .The organization will investigate both privacy violations (or potential privacy violations) and security violations that involve protected health information or personal information .Examples of Potential Breaches .sending medical records to an unintended recipient .the compliance department will initiate an investigation .Determine if any unauthorized acquisition, access, use or disclosure has been mitigated including confirming if the information has been deleted or shredded .When a breach occurs, affected individuals will be notified in writing by certified mail at the last known address of the individual or personal representative . Review of the facility policy titled, Health Information Management, dated 6/5/2018, showed .The facility will safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information .Access to residents' medical records shall be limited to staff and consultants providing service to the resident . Record review showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was last re-admitted to the facility on [DATE]. Record review showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was last re-admitted to the facility on [DATE]. Record review showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 was last re-admitted to the facility on [DATE]. Review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an email dated 10/6/2020 at 11:09 AM, showed Resident #1's daughter was listed as a recipient of the email. The email was titled as Resident #4 was being readmitted to the facility. The email had an attachment which contained Resident #4's Physician Transfer Orders with [DIAGNOSES REDACTED]. Review of an email dated 10/6/2020 at 11:26 AM, showed Resident #1's daughter was listed as a recipient of the email. The email was titled Resident #5 was being readmitted to the facility. The email had an attachment which contained Resident #5's age, date of birth, medication list, laboratory results, diagnoses, and x-ray results. Review of an email dated 10/6/2020 at 12:23 PM, showed Resident #1's daughter was listed as a recipient of the email. The email was titled as Resident #3 was being readmitted to the facility. The email had an attachment which contained Resident #3's age, date of birth, physicians transfer orders, diagnoses, medication list, history and physical, x-ray results, and laboratory results. During a phone interview on 11/9/2020 at 5:45 PM, Resident #1's family member confirmed the Admissions Director had sent her emails containing other resident's information. Resident #1's family member stated the emails contained information about the residents returning from the hospital and stated she still had the emails. During an interview on 11/10/2020 at 9:16 AM, the Admissions Director confirmed she had sent resident information in an email to Resident #1's family member when attempting to send to a co-worker. She confirmed she then contacted the family member and had asked her to delete the information. She confirmed she was attempting to send the emails to a co-worker and clicked on the wrong name. She confirmed the emails contained discharge instructions for 3 other residents. She confirmed she then notified the Administrator per policy. During an interview on 11/10/2020 at 9:22 AM, the Administrator confirmed it was the facility's policy for the employee to notify the administrator when any breach in medical information is made. The facility then calls the person it was sent to and asks them to delete it. The administrator confirmed no further action had been taken. During an interview on 11/10/2020 at 12:08 PM, the Administrator confirmed the facility had not followed their policy to investigate the breach of resident information via emails which was inadvertently sent to Resident #1's family member.

Based on medical record review and interview, the facility failed to notify the Physician of the inability to start Intravenous (IV) Fluids for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], showed the resident had severe cognitive impairment. Review of a Nurse Practitioner (NP) progress note dated 10/1/2020, showed .Patient is being seen today for management of COVID and review of labs .She presented with [MEDICAL CONDITION] (high potassium) .The complaint is mild .She is very weak- not eating or drinking- I have started IV (intravenous) fluids .Patient stable with no distress . Review of a Resident Progress Note dated 10/1/2020, showed .NP visited with elder this am (morning) with N.O. (new order) noted to start of IV .IV attempted .times 3 attempts without success .RN (registered nurse) notified .stated he will attempt . Review of a Resident Progress Note dated 10/1/2020, showed .Spoke with elder's daughter .r/t (related to) N.O. of IV .stated that this nurse had tried 3 different times to obtain success was not able to obtain IV access .would have night shift nurse try and obtain IV access. She stated to have the night shift nurse call if unable to have IV started and they would decide 'what to do after that' . During a phone interview on 11/10/2020 at 10:27 AM, Licensed Practical Nurse (LPN) #1 confirmed she had provided care for Resident #1 on 10/1/2020. She confirmed the NP had seen Resident #1 that morning. LPN #1 also confirmed the resident had not been eating or drinking well and the NP had ordered for LPN #1 to start IV fluids. She stated she tried 3 times to start the IV but was unable to do so. She had asked a Registered Nurse (RN) to come try to get the IV started but he was busy and was unable to attempt to start the IV. At the end of her shift on 10/1/2020 at 6:00 PM the LPN asked the night shift nurse to attempt to start the IV fluids. LPN #1 stated she had not notified the Physician or the NP that she was unable to start the IV fluids, but she did notify the family. The family had said if the night shift was unable to start it for the facility to let them know .maybe I should have (notified the NP) but I just thought if somebody else could get it started .she (Resident #1) was stable and the family was ok with it .I thought if they (night shift) couldn't get it that they (night shift) would call (notify the physician or NP) . During a phone interview on 11/10/2020 at 11:45 AM , the NP confirmed she had gave an order to start IV fluids for Resident #1 on 10/1/2020 and she confirmed she was not aware the IV had not been started .I would have expected someone (the NP or the physician) to be notified if a doctor's order could not be done . The NP confirmed if the LPN had notified her that she was unable to start the IV fluids, she would have had the facility contact the family and if they desired, the NP would have sent the resident to the emergency department. The NP further confirmed if the resident had been sent to the emergency department sooner, it would not have changed the resident's prognosis. During an interview on 11/10/2020 at 12:42 PM, the Administrator confirmed she would have expected LPN #1 to have notified the NP the IV fluids were not able to be started on 10/1/2020 for Resident #1.

Based on review of a facility policy, review of a facility document, medical record review, and interviews, the facility failed to report a fall timely for 1 resident (Resident #1) of 3 residents reviewed for falls. The findings included: Review of the facility's policy titled, Falls, last reviewed on 11/6/2019 showed .If a fall occurs the following actions will be taken: .Evaluate resident including neuro checks, pain, Range of Motion, skin, joints, extremities vital signs .Evaluate resident each shift for 72 hours .Neuro Checks will be completed on residents that experience an unwitnessed fall or a fall that results in head trauma .Pain will be evaluated every shift for 72 hours .Notify physician and family and document notification in the Electronic Medical Record . Review of a facility document Occurrence Investigation dated 1/20/2020 showed .Resident had swelling of left knee and complaints of pain .Upon investigation it was determined that resident had a fall on 1/15/2020 sometime during the night and staff assisted back to bed .Due to miscommunication between staff the fall was not reported to the charge nurse and not documented .On night of 1/15/2020 2 CNAs (Certified Nursing Assistants) entered room resident noted on R (right) side of bed by the window on her knees, holding on to SR (side rail) with both hands 3 CNAs assisted resident back up into bed .Upon staff interview noted resident had a fall from bed on night of 1/15/2020. Resident had no complaints at that time. CNAs did not report to nurse . Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 11 indicating the resident had moderately impaired cognition. The resident required extensive assistance with bed mobility, dressing, personal hygiene, and required total assistance with toilet use. Medical record review of Resident #1's Resident Progress Note dated 1/18/2020 at 12:14 PM, showed .Elder complaining of left leg pain. On assessment left knee is swollen . Medical record review of Resident #1's radiology report dated 1/18/2020 showed .Results: Fracture distal femoral metaphysis, acute. It is new from (MONTH) 4, (YEAR). Bones are osteoporotic. Fracture not significantly displaced .Conclusion: Acute nondisplaced fracture distal femoral metaphysis. Marked [MEDICAL CONDITION] . During an interview on 2/14/2020 at 1:25 PM Licensed Practical Nurse (LPN) #1 stated .when I came in on (2/16/2020) the reporting nurse told me .(Resident #1) had her legs off the bed which was very odd for her because she didn't really move. She would move her arms but not legs. She just didn't move her lower extremities, she could she just didn't . During an interview on 2/18/2020 at 5:45 AM, CNA #1stated .I was with (CNA #2) and we heard .(Resident #1) screaming and .(CNA #3) ran to her room. I was right behind her .(Resident #1) was not in her bed she had her knees on the floor and she was holding on to the rail .She wasn't yelling anymore and we asked her if she was okay and she said yes .I didn't report the fall . During an interview with on 2/18/2020 at 6:05 AM CNA #2 stated .I heard .(Resident #1) yell out which wasn't unusual when I entered the room .(CNA #3) and (CNA #1) were already in the room .(Resident #1) was a little bit slid off the right side of the bed with both of her legs out of the bed .So I helped them situate her .I told (LPN #4) what I had seen . During an interview with on 2/18/2020 at 6:20 AM CNA #3 stated .(CNA #1) and I were making our rounds I heard her (Resident #1) scream so I went running to her room, I saw her on her knees and she was holding on to the bed rail .we got her on the bed. We should have gotten the nurse before we got her up but we didn't we were just focused on what was going on .I didn't tell anyone about the fall . During an interview with on 2/18/2020 at 6:35 AM LPN #4 stated .my first knowledge of her (Resident #1's) fall was after she was sent out. I was the nurse for the first half of the shift when the fall was supposed to have occurred . During an interview with the on 2/18/2020 at 2:30 PM the Director of Nursing (DON) stated .it was reported on Monday morning the 20th during morning meeting that she had a fracture .They (staff) notify the on call nursing manager of all falls, but we weren't aware of a fall until the 21st after she (Resident #1) was discharged . It was reported by (CNA #2) .When we did interviews with the 3 CNA's that were aware something had occurred both .(CNA #1) and (CNA #3) reported they had found her (Resident #1) on the floor on her knees holding on to the bed rail .(CNA #2) reported she had only seen her sitting on the side of the bed with her legs dangling .(CNA #2) was her (Resident #1's) assigned CNA .(CNA #2) said she did not report a fall because she was unaware of a fall but she did report observing her legs off the bed .(CNA #1 and CNA #3) assisted getting (Resident #1) off of the floor .they had not reported it because they thought .(CNA #2) would . During an interview on 2/18/2020 at 3:00 PM the DON confirmed the facility failed to report a fall for Resident #1 timely.

Based on review of facility policy, review of a facility investigation, medical record review, and interviews, the facility failed to provide incontinence care in a timely manner for 1 resident (#2) of 4 residents reviewed for incontinence care. The findings included: Review of a facility policy Disposable Products for Incontinence dated 5/23/18 revealed .Residents using briefs will be checked at least every two hours and as needed for incontinent episodes and removal/replacement of soiled briefs . Review of a facility investigation dated 12/12/19 revealed Certified Nursing Assistant (CNA) #4 reported at the beginning of his shift that Resident #2 reported she needed to be changed and the last time someone changed her was midnight (approximately 6 hours earlier). Continued review revealed a facility video recording showed a CNA entered the resident's room at 2:00 AM and exited at 2:02 AM. Further review revealed a Licensed Practical Nurse (LPN) entered the resident's room at 3:06 AM and exited at 3:07 AM. Continued review revealed the resident was not checked during the 4:00 AM - 5:00 AM resident rounds by staff. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged home on[DATE]. Medical record review of a 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored a 13 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 for transfers, ambulation, and toileting. Interview with CNA #4 on 1/2/20 at 11:00 AM, in the conference room, revealed .when I went in (Resident #2's room) that morning .(Resident #2) told me she hadn't been changed since midnight. I had to change her entire bed. She was soaked she had also had a loose bowel movement. The bed was wet to her feet but it was clear and there wasn't any brown dried rings .she was just soaked. I don't think she was changed during the last round on night shift. It didn't look like it had been there any longer than that . Telephone interview with LPN #6 on 1/2/20 at 1:25 PM revealed .unless I answered her (Resident #2's) call light I wouldn't have routinely gone back in her room, but I would have expected that (CNA #5) would have checked on her during her last round between 4:00 AM and 5:00 AM . Telephone interview with CNA #5 on 1/2/20 at 2:15 PM revealed .the last time I was in her (Resident #2's) room I asked her if she need to be changed and she said no. I thought she would ring her call light if she needed to be changed. I check on incontinent residents every 2 hours and usually stick my head in to check on the residents that are continent or residents who will use their call light, but if you say the camera video shows the last time I was in her room was 2:00 AM then I must not have checked her during my last round . Interview with the Administrator on 1/6/20 at 1:55 PM, in the conference room, revealed .when she voiced her concern about not being changed I asked her if she had turned on her call light and she had said she had not. Theoretically yes she should have been checked on every 2 hours, but with alert and oriented residents there is the expectation they will use their call light and report they need to be changed .it would have been my expectation the CNA would have checked on her during her last round between 4:00 AM and 5:00 AM, however I viewed the camera video and .(CNA #5) did not go back into her room after 2:00 AM. She was offered incontinence care at 2:00 AM, but did not need to be changed and the nurse checked on her at 3:06 AM . Continued interview confirmed the resident was not provided incontinence care in a timely manner.

Based on medical record review, review of facility investigations, review of facility documents, interview, and observation, the facility failed to provide dementia care to prevent escalation of behaviors for 4 residents (#6, #4, #3, #7) of 9 residents with Dementia reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #6's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident had verbal behavioral symptoms directed toward others 1 to 3 days during the assessment period. Medical record review of Resident #6's Comprehensive Care Plan revised 9/22/19 revealed, .Behavioral: At risk and or active behavior problems: Physically Abusive, Verbally Abusive, Resists Care, As evidenced by: yelling at staff, resists eating and taking medication, multiple delusions and swatting at staff .Anticipate needs and provide them before the resident becomes overly stressed .Explain care to resident in advance .Invite and encourage activity programs consistent with residents interest .Re-approach resident later when he becomes less agitated .Reinforce positive behavior . Medical record review of Resident #6's Nurses' Progress Note dated 9/27/19 at 2:32 AM, revealed .Elder has been getting in and out of bed frequently this shift yelling help me, help me, would not let CNA (Certified Nursing Assistant) change bed linens after elder urinated in the bed . Medical record review of Resident #6's Nurses' Progress Note dated 9/27/19 at 10:39 PM, revealed .Elder very agitated, slapping at CNAs when changing elder's clothes, yelling out frequently . Medical record Review of Resident #6's Nurses' Progress Note dated 9/29/19 at 8:32 PM, revealed .Resident had increased anxiety and attempted to follow 2 sons out of room during their visit r/t (related to) wanting to see his spouse .able to redirect resident from seeing spouse and gave nightly medications without complications. Assisted to bed without difficulty . Medical record review of Resident #6's care plan revealed it was revised on 10/8/19 with .Geri-psych (geriatric psychiatric facility) to eval (evaluate) . Medical record review of Resident # 6's Nurses' Progress Note dated 10/9/19 at 8:35 PM, revealed .Resident had one on one contact with his roommate this shift. Resident was screaming and yelling at roommate whom did not understand what all the commotion was and was hit for not responding quickly enough . Review of a facility investigation dated 10/9/19 revealed CNA #5 was walking down the hall and heard a lot of noise coming from a room. CNA #5 entered the room and saw Resident #6 screaming at Resident #5 about the thing spitting cold air and then Resident #6 hit Resident #5 in the chest. Review of an Event Report dated 10/9/19 revealed Resident to resident altercation .resident (#5) was struck by his roommate (Resident #6) .roommate (Resident #5) was yelling at the resident (#6) and the resident (#6) didn't understand and his roommate (Resident #5) struck him .What precipitated the altercation .the air conditioner .Immediate Actions .separation of residents and room change . Medical record review revealed Resident #6's care plan was revised on 10/9/19 with .Consult with telehealth psych (psychiatric) services and medication adjustment provided .Change to a private room . Interview with CNA #5 on 11/4/19 at 12:20 PM, in the conference room, revealed .CNA had asked me to help her. I came out of a room and I heard a commotion in their room (Resident #6 and #5). I think (Resident #5) was up going to the bathroom. I heard (Resident #6) yelling at (Resident #5) to turn that machine that was blowing that cold air out. I looked in the room and saw (Resident #6). (Resident #6) was sitting on the side of his bed and when (Resident #5) walked by him, he hit (Resident #5) in the chest. (Resident #5) didn't understand what (Resident #6) wanted him to do and (Resident #6) was agitated because (Resident #5) didn't understand him . Continued interview revealed (Resident #6) didn't have the strength to hit him hard .he meant to hit him . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Interview with the Administrator on 11/7/19 at 2:00 PM, in the conference room, confirmed Resident #6 was witnessed deliberately hitting Resident #5 in the chest. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan dated 8/16/17 revealed .Active and/or at risk for Behavior Problems Has hx (history of) and potential for rejection of care, delusions and wandering behaviors .Anticipate care needs and provide them before the resident becomes overly stressed .Invite and encourage activity programs consistent with residents interest .Re-approach resident later, when she becomes agitated .when resident has a delusional episodes, redirect and reorient as able . The care plan was revised on 12/5/17 with . Address wandering behavior by walking with resident, redirect from inappropriate area, and engage in diversional activity . Review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. The resident had delusions, verbal behavioral symptoms directed toward others, rejection of care, and wandering, occurring 1 to 3 days during the assessment period. Review of a facility investigation dated 10/8/19 revealed Resident #4 hit Resident #3 on 10/8/19. Resident #4 approached the nurse and stated .there was a man in that woman's room and she wanted the cops called. The nurse went to the room and removed Resident #3 from the room. Upon exiting the room Resident #4 hit Resident #3. Review of a facility Incident Report dated 10/8/19 revealed .(Resident #3) was wandering into another resident's room .(Resident #4) noticed this and became agitated, screaming at (Licensed Practical Nurse (LPN) #8) that she needed to get him out and she was going to call the police. As (LPN #8) was assisting (Resident #3) out of other Elder's room and came to doorway (Resident #4) from the hall punched his arm .when interviewed (Resident #3) had stated 'she goosed me and it felt good' . Resident #4's care plan was revised on 10/8/19 with .At risk and/or active behavior problems: Physically/Verbally Abusive, refusing care and wandering as evidenced by: hitting/punching other elders verbally abusive towards staff and others .Intervene as needed to protect the rights and safety of others, approach in calm manner, divert attention, remove from situation and take to another location as needed .Investigate/Monitor need for psychological/psychiatric services .Monitor behavior episodes and attempt to determine underlying causes .Provide non-confrontational environment for care .Place elder on 15 minute checks for 24 hours to monitor behaviors .Obtained order to increase [MEDICATION NAME] (benzodiazepine given for anxiety) . Medical record review revealed Resident #3 was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Care Plan dated 6/25/19 and revised 8/21/19 revealed .Behavioral At risk and/or active behavior problems of being combative due to dx (diagnosis) of Dementia .Administer and monitor the effectiveness and side effects of medications .Anticipate care needs and provide them before the resident becomes overly stressed. Provide music for the elder to listen to when becoming overly stressed .divert attention, remove from situation and take to another location as needed . Review of Resident #3's Quarterly MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Continued review revealed the resident had verbal behavior symptoms directed toward others, other behavioral symptoms not directed toward others, and wandering, occurring 1 to 3 days during the assessment period. Resident #3's care plan was revised on 9/24/19 with .At risk and/or active behavior problems: Verbally abusive and Wandering as evidenced by yelling out loudly cussing .Address wandering behavior by walking with resident; redirect from inappropriate areas; engage in diversional activities .explain care to resident in advance in terms resident can understand .Monitor need for psychological/psychiatric services .Provide non-confrontational environment for care .Re-approach later when he becomes less agitated .Report changes in behavioral status to MD . Observation of Resident #4 on 11/5/19 at 7:00 AM, in the Dining Room on Station 2, revealed the resident seated at a dining room table in a wheelchair. She was seated with 3 other residents and was pleasantly conversing with residents and staff. Observation of Resident #3 on 11/6/19 at 9:20 AM, in the hallway outside of his room, revealed the resident seated in a wheelchair. The resident was pleasant and no fearful or anxious behaviors were identified. The resident was self-propelling small distances in the hall but did not attempt to enter any resident rooms. Interview with LPN #8 on 11/5/19 at 10:55 AM, in the conference room, revealed the LPN was at the nurses' desk when Resident #4 came to the desk and said there is a man in that woman's room and I want the cops called. She (Resident #4) came from station 2 so I went down toward station 2 looking in rooms. The first room I came to (Resident #3) was in the room. He had gotten his wheelchair tangled up with another wheelchair. It looked like he had tried to turn around but got tangled up with a wheelchair in the room. The 2 ladies in the room were both sleeping and neither of them even knew he was in there. I got him untangled. As I was wheeling him out of the door, she (Resident #4) was sitting just out of my sight on the right side, outside the door. When I wheeled him (Resident #3) out, she (Resident #4) came up and with a closed fist and hit him (Resident #3) on his right upper arm. I pushed his wheelchair out of her reach. (Resident #4) said 'I didn't hit him' and I said '(Resident #4) I saw you'. Interview with the Administrator on 11/7/19 at 2:15 PM, in the conference room, confirmed Resident #4 was witnessed deliberately hitting Resident #3. Resident #3 had not been prevented from wandering into other female residents' room. Medical record review of Resident #4's Nurses' Progress Note dated 10/14/19 at 5:41 PM, revealed .Resident (with) increased behaviors of being verbally aggressive towards other residents. Attempted to roll towards another resident threatening to 'throw my hot coffee on you.' Separated and redirected resident away and made attempts to calm. Resident at another time attempted to swing out to hit another resident in the face, did not connect and was removed and redirected away with attempts to calm . Medical record review of Resident #4's Nurses' Progress Note dated 10/19/19 revealed .Res (Resident) (with) increased anxiety this shift. Res pacing hallways (in wheelchair) upset 'looking for her moma (momma) and daddy' .Res crying/yelling out 'oh Jesus come to me, Help me Jesus!' Fretting, wringing hands, frowned expression. Stating 'I'm just so nervous, I don't know what to do!' Res verbally aggressive (with) other res stating 'you don't belong here, Get outta here!' . Review of a facility investigation dated 10/28/19 revealed the Quality of life Director (QOLD) stated .when (Resident #7) was rolling up to the table (Resident #4) stated 'look here, here comes pumpkin head' and she (Resident #4) tried to make a slap at (Resident #7). (Resident #7) then smacked back at her and the two began swatting at each other both making physical contact . Continued review revealed the facility Administrator had viewed the facility camera and it did not appear the residents had hit hard and the residents were not close in proximity to each other. Both residents had been involved in resident to resident altercations previously. Medical record review of Resident #4's Care Plan revealed it was revised on 10/29/19 with .Psych NP (Psychiatric Nurse Practitioner) to eval (evaluate) and treat as indicate .Psych recommendation to discontinue [MEDICATION NAME] (antipsychotic medication) and start Rispirdol ([MEDICATION NAME] - antipsychotic medication) . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Resident #7's Comprehensive Care Plan dated 5/4/18 revealed .Active and/or at risk for Behavior Problems: History and potential for aggressive behaviors during care d/t (due to) loss of independence wandering noted by nursing .Report to physician changes in behavioral status .Address wandering behavior by walking with resident .redirect from inappropriate area, engage in diversional activity .Provide opportunities for positive interaction, attention stop and talk with him as passing by .Administer and monitor the effectiveness and side effects of medications . Continued review revealed the care plan was revised on 5/17/19 with .altercation with another elder hit her on the arm .separated elder and sent to be evaluated by (geriatric psychiatric facility) . Medical record review of Resident #7's Quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. The resident had physical behavior directed toward others, rejection of care, and wandering, occurring 1 to 3 days during the assessment period. Interview with the QOLD on 11/4/19 at 1:55 PM, in the conference room, revealed We were getting ready to play Jingo in the Dining Room. (Resident #4) was in the dining room setting at the back table with the other residents, and (Resident #7) entered the dining room, start rolling to the back table. They just don't appear to like each other. I've heard her (Resident #4) tell him (Resident #7) to get out of the dining room before and usually he just ignores her. Occasionally he might say something back, but they haven't been physically aggressive and I keep an eye on them. She said 'look here, here comes pumpkin head.' When she did, his eyes got big and I turned around to start toward them. But by then she had smacked at him, then he smacked back at her. They smacked back and forth and I said 'stop' and they both stopped. Interview with the interim Director of Nursing (DON) on 11/4/19 at 4:10 PM, in the conference room, revealed (Resident #4) was the aggressor. She struck at him first. His was a defensive reaction not an aggressive behavior. Interview with the Administrator on 11/7/19 at 1:30 PM, in the conference room, revealed Resident #4 was witnessed calling Resident #7 an inappropriate name and willfully striking out at Resident #7, and in defending himself they did make physical contact. Continued interview confirmed Resident #4 was the aggressor.

Based on facility policy review and interview, the facility failed to implement an Antibiotic Stewardship program for 67 of 67 residents residing in the facility. The findings include: Review of facility policy Antibiotic Stewardship dated 11/7/18 revealed .The organization has developed an antibiotic stewardship program that will facilitate the responsible use of antibiotics, improve resident safety, reduce healthcare costs and potentially impact rates of antibiotic resistance. Our Antibiotic Stewardship Program (ASP) will promote the appropriate use of antibiotics for the correct indication, dose, and duration; and monitor resident outcomes including adverse events . Telephone interview with the Medical Director on 9/24/19 at 10:19 AM revealed he was not aware of an Antibiotic Stewardship Program at the facility. Interview with the Director of Nursing (DON) on 9/24/19 at 10:30 AM, in the Administrator's office, revealed the facility was unable to provide documentation of an Antibiotic Stewardship Program. Telephone interview with the Consulting Pharmacist on 9/24/19 at 11:03 AM revealed the Pharmacist comes to the facility monthly and looks at new antibiotics and culture sensitivity. Continued interview confirmed .I don't discuss .my audits or any findings I may have . Further interview confirmed he was aware of the Antibiotic Stewardship Program and the regulations. Interview with the Administrator and DON on 9/24/19 at 11:28 AM, in the Administrator's office, confirmed the facility did not have an Antibiotic Stewardship Program.