Every finding on record at Sunny Hill Care Center

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to answer call lights in a timely manner for 2 of 3 residents reviewed for staffing concerns(Residents #22 and #23). The facility reported a census of 52 residents. Findings:1. Minimum Data Set (MDS) assessment tool, dated 1/23/26, listed diagnoses for Resident #23 which included difficulty walking, weakness, and a history of falling. The MDS stated the resident required partial to moderate assistance with chair to bed and toilet transfers and substantial to maximal assistance with walking. The MDS listed the resident's Brief Interview for Mental Status(BIMS) as 12 out of 15, indicating moderately impaired cognition. On 3/3/26 at 9:06 a.m., Resident #23 stated call lights took more than 30 minutes. He stated that he looked at the clock to time it. He stated it made him feel miserable to sit and wait. A Care Plan entry, dated 11/20/15, stated the resident had an activity of daily living impairment and required assistance with walking, eating, and toileting. The resident's Location Section Activation Report listed the following call light wait times for Resident #23 which exceeded 15 minutes during the period of 2/18/26 to 3/4/26:2/25/26 8:16 a.m. 29 minutes 2/25/26 2:03 p.m. 16 minutes2/27/26 7:52 a.m. 21 minutes2/28/26 11:55 a.m. 18 minutes3/2/26 5:51 p.m. 20 minutes The facility policy Call Light Accessibility and Timely Reports, dated 2025, stated all staff were responsible for responding to activated call lights and directed staff to listen to the resident's request and respond accordingly. The policy did not include a time frame in which staff should answer lights. On 3/5/26 at 10:22 a.m., Staff B Certified Nursing Assistant(CNA) stated the second shift struggled with call lights. She stated at times in the mornings, call lights could exceed 15 minutes. On 3/5/26 10:43 a.m., Staff E Registered Nurse(RN) stated there could be call light wait times which exceeded 15 minutes. On 3/5/26 at 10:56 a.m., the Administrator stated that mornings and supper times could be busy with regard to answering call lights. She stated many residents wanted up at the same time. She stated she expected staff to answer call lights within 15 minutes. 2. The MDS dated [DATE] for Resident #22 included diagnosis of fibromyalgia, weakness difficulty walking, need for assistance, anxiety and depression. The BIM's score for Resident #22 indicated moderate cognitive impairment On 3/2/26 at 1:56 PM Resident #22 relayed felt staffing could improve, relayed pushed the call light and can be a half hour or more, stated it varied shifts, felt wait time depended on time of day and/ or staff mood.Call light report for Resident #22 dated 2/18/26 to 3/4/26showed Resident #2s call light response time exceeded 15 minutes during the period of 2/18/26 to 3/4/26: 2/18/26 5:59 a.m. 33 minutes2/19/26 3:21 p.m. 21 minutes 2/20/26 9:27 a.m. 28 minutes2/23/26 5:52 a.m. 32 minutes 2/23/26 9:46 a.m. 34 minutes2/25/26 9:55 a.m. 22 minutes 2/26/26 9:31 a.m. 34 minutes2/27/26 7:20 a.m. 21 minutes 2/27/26 8:40 a.m. 21 minutes2/28/26 7:33 a.m. 21 minutes3/1/26 9:34 a.m. 21 minutes3/1/26 8:36 a.m. 43 minutes3/2/26 9:20 a.m. 19 minutes 3/3/26 2:07 p.m. 21 minutes On 3/5/26 at 9:41 AM, Staff D, Housekeeping verbalized housekeepers don't carry walkie talkies. CNA staff have walkie talkies and are alerted to activated call lights. Staff D reported appropriate response time is less than five minutes. Staff D reported residents have voiced to her that staff are slow to respond to activated call lights. Staff D informs the resident to speak with the nurse of the administrator about the response time. On 3/5/26 at 10:00 AM, Staff F, CNA verbalized activated call lights come across screens at the nurse's station, east hall and southeast hall and over the walkie talkies. Staff F reported in resident rooms the activated call light will flash a light. Staff F verbalized appropriate response time is 15 minutes for the room call light and 5 minutes for the bathroom call light. Staff F acknowledge activated call lights exceed 15 minutes if staff are really busy and depends on how the day is going. Staff F reported residents have voiced concerns for slow response time to her. On 3/5/26 at 10:05 AM, Staff G, Activity Assistant/CNA reported staff have walkie talkies and activated call lights are announced over the walkie talkie. Staff G verbalized appropriate response time to be under 5 minutes. Staff G verbalized call lights had exceeded 15 minutes at times. On 3/5/26 at 10:22 AM, Staff H, CNA verbalized activated call lights exceed 15 minutes sometimes in the morning due to getting everyone up for breakfast. Staff H reported Resident #22 voiced concerns to her about slow response time of activated call lights. Staff H reported she apologized to Resident #22 and explained they assist as soon as they can. On 3/5/26 at 10:45 AM, Staff E, RN reported staff are alerted to activated call lights via the walkie talkies. Staff E verbalized appropriate response times is less than 15 minutes. Staff E verbalizes the system announces extended wait time which indicates an activated call light exceeded 15 minutes for response. Staff E acknowledged activated call lights exceed 15 minutes response time at times. Staff E verbalized any one can respond to activated call lights. On 3/5/26 at 10:56 AM, the Director of Nursing (DON) stated staff have pagers connected to the call light monitors located at the nurse's station, East Hall, and Southeast Hall. The DON verbalized activated call lights shouldn't exceed 15 minutes. The DON hadn't heard of any activated call lights exceeding 15 minutes recently. The DON verbalized call light records are reviewed when residents voice concerns with slow response time. On 3/5/26 at 11:07 AM, Staff I, CNA reported activated call lights should be responded to as soon as possible. Staff I reported staff are alerted at the time a light is activated and again at 5 and 10 minute intervals. Staff I reported if the activated call light exceeds 15 minutes, staff receive alerts for extended wait time. Staff I acknowledged activated call lights exceed 15 minutes around breakfast and lunch due to not enough caregivers to go around.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to prime an insulin(an injectable medication used to lower blood sugar) pen prior to administration for 1 of 1 residents observed for insulin(Resident #32). The facility reported a census of 52 residents. Findings:1. The Minimum Data Set (MDS) assessment tool, dated 12/19/25, listed diagnoses for Resident #32 which included diabetes (a disease which caused fluctuations in blood sugar), heart failure, and shortness of breath. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The 1/13/26 Care Plan entries stated the resident had diabetes and directed staff to administer diabetes medication as ordered by the doctor. The March 2026 Medication Administration Record (MAR) listed an order for Tresiba (a type of insulin) FlexTouch Pen-injector 100 units/milliliter (ml) 40 units in the morning. The Tresiba Flextouch Instructions For Use, retrieved from https://www.novo-pi.com/tresiba.pdf#IFU on 3/4/26, stated prior to dialing up the ordered dose of the insulin, staff should dial the dose selector to 2 units, hold the pen with the needle pointed upwards, and hold the dose button until the counter showed 0. A drop of insulin should appear at the needle tip. If a drop of insulin was not seen, staff should repeat the process. The facility procedure Insulin Injection, dated 2026, directed staff to dial the pen to 2 units and push the plunger to release air in the needle.On 3/4/26 at 8:06 a.m., Staff A Registered Nurse (RN) placed a new needle on Resident #32's Tresiba insulin pen and dialed the pen to 40 units. Staff A did not prime the needle prior to setting the dose. Staff A then prepared the resident's Novolog (a type of insulin) from a vial. She then picked up both the Tresiba pen and the Novolog syringe and when asked, stated she was ready to administer the insulin. When queried as to if she primed the pen prior to dialing up the 40 units, Staff A set the dial back to 0, primed the pen with 2 units, and then set the dial to 40 units again. Staff A stated she did not think she primed the pen before. On 3/4/26 at 3:27 p.m., the Director of Nursing(DON) stated staff should prime insulin pen needles prior to administration. She stated she would carry out education with staff regarding this. On 3/5/26 at 11:00 a.m., Staff C RN stated that she primed insulin pens prior to dialing up the dose.

Based on clinical record review, resident interview, family interview, staff interviews and policy review, the facility failed to ensure a safe transfer for 1 of 3 residents reviewed (Resident #5) . Staff attempted to transfer from the recliner to wheel chair and did not utilize a gait belt (Resident #5). The resident fell and sustained a non-displaced humeral fracture (left arm). The facility reported a census of 48 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed diagnosis of heart disease, stroke, hemiplegia or hemiparesis referring to left side paralysis. The MDS coding reflected dependence on transfer from a bed or chair. The Brief Interview of Mental Status (BIMS) assessment scored 12 out of 15 indicated moderately cognitive impairment. The MDS documented that the resident was last admitted from a stay at a general hospital on 7/5/25.The Care Plan for Resident #5 documented focus area with initiated date of 12/13/24 for Resident #5 revealed potential for falls secondary to generalized weakness, decreased mobility, and poor safety related to history of stroke, noted left side is flaccid. The goal, not to sustain major injury should a fall occur. The Care Plan also included Resident #5 had impaired function, use of a wheel chair, able to use a hemi walker (provides stability of one hand) with transfer and with assistance as needed. A mechanical lift can be used, if the resident is weak, lift required to and from bed. A Witness Statement dated 6/27/25 at 2:35 PM by CNA Staff C, documented went in Residents #5 room with Staff D, to transfer resident from recliner to wheelchair , resident sat before wheel chair was placed behind him, resident was having trouble pivoting his weak side, fell to the floor on his weak side, nurse called and other aids to assist helping resident up. Resident #5 seemed to be ok after being assessed by the nurse. A Witness Statement dated 6/27/25 at 2:45 PM by CNA Staff C, documented, additional information, included, Resident #5 in recliner chair, went to get him up and both (CNA Staff C & D) got on each side of the resident, went to lift under arm, resident stood, asked resident to turn and sit, he couldn't move his foot and bad side and sat too soon, was still holding under left side and he fell with me landing on top of him on his left side, other staff rolled him to his back, left arm was stuck under him until rolled over. A Witness Statement dated 6/27/25 at 2:35 PM by CNA, Staff D, documented was working with new CNA, Staff C and were transferring Resident #5 from recliner to the wheel chair, the resident had trouble pivoting his weak side and resident sat too soon before the wheel chair was in place. Resident #5 fell to the floor on his weak side, summoned a nurse and another aide to assist helping resident up. Relayed, Resident #5 seemed okay after being assessed by the nurse.A Witness Statement dated 6/27/25 at 2:15-2:45 PM by CNA, Staff E, documented was summoned for help, walked in and Resident #5 was on the floor leaning on CNA, Staff C, said needed help getting Resident #5 off the floor. Called for the nurses, RN, Staff A responded, came in and CNA, Staff D said Resident sat before the wheel chair was behind him and fell to the ground. RN, Staff A asked if he was lowered and both said no, the resident was too heavy. RN, Staff A did the exam, CNA's used a mechanical lift to assist residents up.The Incident report dated 6/27/25 at 2:35 PM documented by Registered Nurse (RN) Staff A relayed Resident #5 was being assisted out of his recliner to get into his wheel chair, all assistive devices in place, two staff assisting, resident pivoting to get into the wheel chair, resident was trying to sit down, the wheel chair was not quite in place. The aids were able to ease the resident to the floor onto his left, weak side. Resident #5 complained of left shoulder pain, is stroke side and is normal. Range of Motion (ROM) to lower extremities and right arm also were Within Normal Limits (WNL), did not hit head when eased to the floor. Staff assisted him up with the use of mechanical lift into wheel chair, ROM assessed again and all WNL, no complaints of any increase in pain, said it was his fault, he didn't wait, reassurance given and discussed possibly trying therapy again, replied would try anything, vital signs assessed and noted. Resident voiced, did not stand good for the girls. A Progress Note dated 6/27/25 at 5:16 PM written by RN, Staff A relayed resident #5 was being assisted out of his recliner to wheelchair, all assistive devices in place, two staff assisting when Resident #5 pivoting to sit, wheel chair was not quite in place. CNA's able to ease to the floor onto left side, weak side, did complain of pain to left shoulder area but, is the stroke side and is normal, ROM was WNL, did not hit head when eased to the floor, assisted up with mechanical lift in wheel chair, ROM again WNL, no complaints increase in pain. Resident #5 said felt at fault, didn't wait, reassurance given and discussed trying therapy again, Vital signs assessed, provider notified, emergency contact notified included therapy discussion and therapy notification. A Progress Note dated 6/27/25 at 8:30 PM written by RN, Staff B documented, called to room at 7:50 PM, resident in severe pain with any touch or movement to left arm, Resident #5 reported pain earlier to the nurse during assessment an scheduled pain medications had been given, rated pain at a 10 out of 10, yelled out in pain and jerked when ROM assessed, radial pulse palpable, no visible deformity observed. Resident #5 stated, is ok as long as not touched, rolled or moved. Contacted on call provider, ordered to send for evaluation, contacted family representative, and ambulance for transport. An Emergency Department (ED) Note, dated 6/27/25 at 8:50 PM documented Resident #5 brought to ED due to a fall from the wheel chair while transferring. Documented Resident #5 stated after he fell a staff member landed on him and now has upper left arm pain. Exam included x-rays revealed left shoulder concerning for possible surgical neck fracture, placed in a sling discussed close follow up with orthopedics for reevaluation of left shoulder, discharged in good condition. A Progress Note from Orthopedics dated 7/10/25 dated 2:20 PM revealed here for evaluation of left shoulder injury from a fall, significant pain at left shoulder, was seen in ED diagnosed with proximal humerus fracture, placed in a sling, moderate to severe pain, worse with manipulation. Also documented, x-rays show a nondisplaced proximal humerus fracture in overall acceptable alignment. An interview on 8/20/25 12:11 PM with Resident #5 relayed had a fall and broke my shoulder, reported about four staff came in to help, was getting up to the floor to walk, had the hemi- walker, then there were too many feet and got tangled up, was not sure how exactly, was trying to hold myself up, remembered going down, relayed a CNA thought had fallen on my shoulder, went to the hospital, x-rayed it, got a sling to hold my arm, had two doctor appointments after that included more x-rays. Resident #5 further relayed the doctor said it's getting better, it does feel better, pretty much back to the way it was before the fall. An interview on 8/20/25 at 1:37 with CNA, Staff D relayed recollection of Resident #5 fall, had assisted resident up with CNA Staff C to pivot from recliner to the wheel chair. The wheelchair was not positioned as needed, Resident #5 leg started to drag, needed to sit and was real sudden, we fell to the ground with him, not on him. Resident 5 fell to the side, was holding on an arm and think just went to my knees, and CNA #C did the same, went on knees, did not hit anything, we were not hurt, when the nurse came in the resident said his arm did not hurt anymore, was as usual, was really surprised when came to work the next day and found he went to the hospital. Discussed the gait belt, CNA, Staff D relayed a gait belt was not used and haven't made that mistake again. CNA, Staff D stated, was perhaps overwhelmed that day, was busy, call lights were crazy and was training new staff. An Interview on 8/20/25 at 4:00 PM with Registered Nurse (RN) Staff B, recollection of 6/27/25 relating to Resident #5 fall. Relayed, New CNA, Staff C said Resident #5 fell on the left side, landing on left arm and proceeded to fall on the resident. Staff C relayed resident reported left arm pain and felt that was ignored. Resident #5 did complain of severe left arm pain. Staff B reported had spoke with CNA, Staff C who was present during fall, Staff C relayed Resident #5 did fall, and was not lowered. Resident #5 was sent to the ED and was diagnosed with a fracture of the left arm. An interview on 8/20/25 at 5:30 PM by RN, Staff A, relayed recollection of Resident #5 fall on 6/27/25 stated was called to residents room related to fall, Certified Nurse Aids (CNA) present, Staff C and Staff D, Recalled Staff C was on the left side of the recliner, Resident #5 was lying on left arm, his stroke side, observed quickly, the CNAs said used a gait belt but did not see a gait belt, it was not on. The wheel chair was there, the quad cane to support his arm was there. CNA Staff C and Staff D relayed were pivoting and the wheel chair was not in place and both said had eased residents to the floor. They did statements. The resident was reassured, determined did not hit head, assessed range of motion and vital signs. Resident #5 wanted up, checked him first, did say discomfort on the left side, was nothing unusual, used the mechanical lift to the wheel chair, assessed again, was WNL, no unusual restricted movement, palpated shoulder , watched his face, looked for verbal and nonverbal. Resident #5 agreed to therapy discussed at the time, went to the meal as usual, wheeled himself to supper as per his usual, ate as per his usual, didn't chart all that was just his usual. RN, Staff A relayed had called spouse and talked about therapy for an intervention. CNA's did witness statements, was not sure if had personally read them. RN, Staff A recalled the CNA's were able to lower Resident #5 to the floor, was guided with the use of a gait belt and thought perhaps due to adrenaline the resident did not feel pain right away, was aware hours later complained of increased pain and did go to the emergency room. An Interview on 8/21/25 at 12:28 PM, CNA, Staff F relayed recollection of Resident # 5 fall on 6/27/25, stated was called to help because Resident #5 was on the floor, while transferring he sat too soon. Discussed gait belt use, responded is supposed to use a gait belt, had not seen that a gait belt was used for Resident #5. The next shift RN wanted details on the fall since Resident #5 was complaining of a lot of pain. CNA, Staff C relayed the resident was not lowered to the floor instead had fell. Relayed it was bothersome when heard Resident #5 had a fracture and wasn't sent to the hospital until later. Relayed knew CNA's supposed to use a gait belt and to my knowledge was not used and seemed like they were trying to cover something up. Relayed the new CNA, Staff C never came back to work after the incident. An Interview on 8/21/25 at 12:07 PM with Resident #5 emergency contact revealed resident said was getting up in the wheel chair with two staff. Relayed the CNA, Staff C stopped in the room, was worried about the resident and relayed had fallen on him, not sure if that was reported but, that's what the CNA said. Relayed Resident #5 cannot recall exact specifics, had been using a sling, seeing an orthopedic doctor and seemed to be better. An Interview on 8/21/25 at 11:12 PM with the DON on gait belts and policy, relayed gait belts are to be used for all transfers unless documented otherwise for instance has a resident that refuses and is care planned. Gait belts are part of the uniform, and are in residents' rooms for staff convenience as well to be used with resident transfers. The DON relayed staff should use a gait belt with Resident #5 transfers. A Policy titled Gait Belt Usage provided, undated, documented all employees providing direct resident care are required to utilize a gait belt whenever hands on assistance is needed for resident transfer and or ambulation unless otherwise contraindication. The gait belt can serve as a handle to grasp if a resident begins to fall, this can help to prevent the fall or control the resident's descent.

Based on staff interview, resident interview, CMS-2567 (Centers for Medicare and Medicaid Services) report, facility policy, and Quality Assurance Performance Improvement Plan (QAPI) the facility failed to ensure an effective QAPI process to address inclusion of residents in care planning process per a previously identified deficiency on the facility's prior recertification. The facility reported a census of 47 residents. Findings include: The CMS-2567 form referring to the facilities recertification survey outcome dated 12/8/22 revealed a deficient practice, lacked resident participation in quarterly interdisciplinary meetings for care planning. The facility correction response dated 1/1/23 included invitations would be given to residents. 1. The Minimum Data Set (MDS) assessment for Resident #31 dated 12/6/24 included a cognitive assessment, The Brief Interview for Mental Status (BIMS) scored 15 out of 15 indicated residents' cognition as intact. In an interview on 2/3/25 at 9:51 AM Resident #31 queried about care plan meetings, if they had participated in plan of care discussions or discussion of goals, or any related meeting. Resident relayed they did not know anything about that, and had not been to a meeting. 2. The Minimum Data Set (MDS) assessment for Resident #38 dated 11/11/24 included a cognitive assessment, The Brief Interview for Mental Status (BIMS) scored 15 out of 15 indicated the resident cognition intact. In an interview on 2/3/25 at 10:14 AM Resident #38 asked about care planning, if they had participated in plan of care discussions or discussion of goals, or any related meeting. Resident relayed they could not recall any such participation or meeting with staff. In an interview on 2/4/25 at 3:12 PM the Administrator relayed, they felt the 2019 influenza epidemic impacted the formal meeting process and had a plan in place to improve processes. The Administrator acknowledged a previous citation occurred during 12/8/22 annual survey regarding lack of resident invite/participation in the care planning process. The facility policy titled Care Plan Development Process Dated 2022 documented, the resident, and/or their representative is an important part of the care planning team. They will be made aware of the date and time of each interdisciplinary care meeting. The facility provided QAPI plan documented, the purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may continually improve quality outcomes and experiences for all stakeholders. Included, Quality section, We strive to deliver the best outcomes for each of our residents while complying with the regulations that govern long-term care. We are dedicated in providing the highest level of quality, resident satisfaction, staff satisfaction, and regulatory compliance.

Based on resident interview, staff interviews, record review, and policy review the facility failed to ensure resident participation option in quarterly interdisciplinary team meetings for care planning for 2 of 5 residents reviewed regarding care plan meetings (Residents #31 & #38). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #31 dated 12/6/24 included diagnoses of anemia, heart failure, peripheral vascular disease, anxiety, and depression. The MDS listed the Resident's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating intact cognition. A Care Conference Summary form dated 9/5/24 for Resident #31 revealed a column of discussion topics and comments. The form included a column to identify resident discussion, if agreed or disagreed that was left blank. Signature lines for staff in attendance included written staff names along with Resident #31 name written on resident signature line. The boxes to identify if resident agreed, disagreed, or understood was disregarded, not completed. In an interview on 2/3/25 at 9:51 AM Resident #31 queried about Care Plan meetings, if they had participated in the plan of care discussion or discussion of goals, or any related meeting. Resident #31 relayed they did not know anything about that, they had not been to a meeting. 2. The Minimum Data Set (MDS) assessment for Resident #38 dated 11/11/24 included diagnoses of anemia, atrial fibrillation, inflammatory bowel disease, and obstructive uropathy. The MDS listed the Resident's BIMS score of 15 out of 15 indicating intact cognition. A Care Conference Summary form dated 11/7/24 for Resident #38 revealed a column of discussion topics and comments. The form included a column to identify resident discussion, if agreed or disagreed, it had a vertical line drawn through. Signature line for staff in attendance included written staff names, Resident #38 was written on the signature line. The boxes to identify if resident agreed, disagreed, or understood was disregarded, not completed. In an interview on 2/3/25 at 10:14 AM Resident #38 was asked about care planning, if they had participated in plan of care discussion or discussion of goals, or any related meeting. Resident relayed they could not recall any such discussion or meeting with staff. In an interview on 2/4/25 at 3:12 PM with the Administrator regarding Care Plan process and review of the care conference summary document for Resident # 38 the administrator reported a new process was implemented last month to include resident invitation for a formal meeting. Agreed the previous Director of Nursing was not following the best practice of resident inclusion. The administrator relayed they felt that Coronavirus had impacted formal meetings and had a plan in place to change the processes. The facility policy titled Care Plan Development Process dated 2022 documented, the resident, and/or their representative is an important part of the care planning team. They will be made aware of the date and time of each interdisciplinary care meeting.

Based on record review, staff interview, and policy review the facility failed to notify the Long-Term Care Ombudsman of discharge/transfer of residents as required for 1 of 4 residents reviewed who were discharged or transferred from the facility (Resident #15). The facility reported a census of 47 residents. Findings include: Review of the Minimum Date Set assessments dated 4/7/24 and 10/6/24 revealed Resident #15 had unplanned discharges to the hospital. Resident #15 reentered the facility on 4/9/24 and 10/9/24. The electronic medical record census list for Resident #15 revealed hospitalization s from 4/7/24-4/9/24 and 10/6/24-10/9/24. Review of the Discharge Tracking form for Long-Term Care Ombudsman communication lacked documentation of Resident #15's discharges to the hospital on 4/7/24 and 10/6/24 as required by federal regulation. In an interview on 2/6/25 at 10:35 AM, the Administrator reported they maintain the Discharge Tracking form which is used for the Ombudsman's notification. Information is obtained from reports within the electronic medical record as well as by hand. The Administrator acknowledged the lack of Resident #15 for the months of April and October. The policy Admission, Discharge, and Transfer: Ombudsman Notification, dated 2018, stated the facility will notify the Long-Term Care Ombudsman of all monthly discharges.

Based on clinical record review, policy review, resident interview, and staff interview, the facility failed to provide monitoring and timely assistance to transfer off the toilet for 1 of 3 residents reviewed for supervision (Resident #1). The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 9/13/24, listed diagnoses for Resident #1 which included amyotrophic lateral sclerosis (ALS-a progressive neurological disease that affected the nerve cells in the brain and spinal cord), heart failure, and diabetes. The MDS stated the resident was dependent on staff to transfer on and off the toilet and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. 7/1/17 Care Plan entries stated the resident was dependent on staff for transfers and position changes, and utilized a mechanical lift. On 11/25/24 at 12:36 p.m., Resident #1 stated staff left him on the toilet for 2.5 hours. He stated his body hurt when he sat on the toilet but it subsided after staff assisted him off the toilet. He stated staff changed the call light batteries but it did not reset properly. On 11/25/24 at 1:28 p.m. Staff A CNA stated during shift change, staff assisted the resident to the toilet and they did not see the call light turn back on. She stated she heard a banging and found the resident (in the bathroom). She stated he was pretty upset and the staff all felt bad about it. They let him know the call light did not work and it was not intentional. On 11/25/24 at 1:52 p.m., Staff E Certified Nursing Assistant (CNA) stated on the day of the incident, other staff told her they assisted the resident to the toilet. She never heard the call light go off and assumed someone else assisted him. She stated the call light was on in the bathroom but did not show up on the walkie talkies. On 11/25/24 at 2:27 p.m. Staff B Registered Nurse (RN) stated around 2:00 p.m. Staff C CNA and Staff D CNA assisted the resident onto the toilet. She stated they found him around 4:00 p.m. She stated earlier in the day, she changed the call light battery and tested it and it worked. She stated after they found him on the toilet, the call light did not work. She stated the resident was angry and sad about the incident. On 11/25/24 at 2:58 p.m., the Administrator stated staff changed the battery the day of the incident but it malfunctioned. She stated they spoke to the manufacturer and they believed it was a one time incident. On 11/26/24 at 10:46 a.m., Staff C CNA stated she assisted the resident to the toilet with Staff D. She stated Staff D remained at the facility after this but she went home. She stated as far as she knew, everything was taken care of. On 11/26/24 at 12:33 p.m., the Director of Nursing (DON) stated staff needed to complete constant rounding and the staff who assisted the resident to the bathroom should check on the resident. She stated they carried out education regarding this after the incident. The facility policy Nursing Toileting, revised 2024, stated staff would assist resident with toileting according to their individualized plan of care and stated if a resident required toileting, staff would check on them for safely at a minimum of every 15 minutes.

Based on clinical record review, resident, family and staff interviews, and facility policy review, the facility failed to appropriately provided an assessment and interventions for the necessary care and services for a resident after a fall on 11/30/23. The nursing staff failed to provide a thorough assessment for the resident, and three hours after the fall, the next Shift Nurse assessed the resident and found an inward rotation of the left leg and associated severe pain. The resident transported to the local hospital, found to have suffered a fractured left hip, and then transferred to a tertiary hospital for higher level of care and surgical hip repair (Resident #8). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) dated for 11/23/23 for Resident #8 revealed diagnoses of osteoporosis, osteoarthritis, muscle weakness, and required moderate assistance for bed-to-chair and toilet transfers, toilet hygiene and did not walk 10 feet due to medical condition or safety concerns. The MDS identified that Resident #8 had 2 or more fall since last MDS assessment. Resident #8 used a wheelchair for mobility. The Brief Interview for Mental Status (BIMS) score of 11 out of 15, which suggested a slightly impaired cognition. A Care Plan with a focus area dated 10/3/23, documented that Resident #8 with an Activity of Daily Living (ADL) deficit due to a history of falls, osteoarthritis and osteoporosis which put her at risk for further falls. An intervention dated 10/29/21, Resident #8 independent to the bathroom, aware when she needed to go to the bathroom, and needed staff assistance with on & off toilet and also with peri care. An intervention added on 11/23/21 for fall prevention - a note was placed on Resident #8's bathroom door to remind not to have pedals on the wheelchair when going in and out of the bathroom and she could be without her pedals as she could propel self with use of her arms. During an interview on 2/6/24 at 9:22 AM, Resident #8 stated she needed help to the bathroom. During an interview on 2/6/24 at 9:22 AM, Resident #8's family member stated she had a concern that her mother was listed as independent and when she asked for help, the staff did not help her to the bathroom because she was independent. The family member stated, she is here for assistance. She stated that her mother had fallen and fractured her hip trying to get herself into the bathroom. The Progress Notes Incident Note dated 11/30/23 at 4:49 PM revealed: a. Nurse was called to Resident #8's bathroom, another resident saw her slide out of her wheelchair. b. Resident was sitting in front of wheelchair, back against wall, knees bent and wearing nonskid socks. c. No injury noted, Range of Motion (ROM) and neuro checks within normal limits (WNL). d. Resident #8 was assisted by 2 staff onto the toilet. e. Resident #8 activated the call light when finished, could not bear weight, transferred to wheelchair assist of 2 staff. f. Fax to provider and family notified. The Nurses Progress Note dated 11/30/23 at 8:36 PM (over 3 hours since the fall) for Resident #8 revealed: a. Resident in bed complaining of pain at a rate of 10 out of 10 in her left hip. b. Scheduled pain medication and pain cream given with no relief. c. Did not allow staff to check ROM due to pain. d. Resident #8 stated I think my leg is broke. e. Call placed to provider, report given, order received to transport to the Emergency Department. The Nurses Progress Notes dated 12/1/23 at 11:55 AM for Resident #8 revealed: a. Received a call from local hospital Social Worker and informed of Resident #8 was transferred to a tertiary hospital. b. Resident #8 had surgical repair of hip fracture. c. Resident #8 will return to the local hospital for recovery. The Incident Report dated 11/30/23 revealed: a. Resident #8 fell out of wheelchair during a self-transfer to the toilet. b. Neuro and ROM WNL. c. Resident #8 was unable to bear weight. d. 2 person transfer to the toilet and to wheelchair. During an interview on 2/7/24 at 10:21 AM, Staff D, Certified Medication Aide (CMA) stated before Resident #8 fell and fractured her hip, she was listed as independent but would activate her call light for assistance. Staff D stated she would go and help her to the bathroom. During an interview on 2/7/24 3:04 PM Staff F, Licensed Practical Nurse (LPN) stated after a fall, the nurses responds right away and assesses the resident and checks the vital signs. Staff F stated she was not sure what happened with Resident #8, but she would sit on the edge of her wheelchair. Resident #8's roommate had turned on the call light and Resident #8 was on her butt on the floor with her knees bent. Staff F stated Staff H, Certified Nursing Assistant (CNA) Coordinator, helped to stand Resident #8 as it took 2 people to stand Resident #8 back into the wheelchair for safety. Staff F stated Resident #8 was able to wheel herself to the dining room where she had continued her assessments. Staff F stated Resident #8 was in the dining room at the end of her shift. Staff F stated We do not assess them when they are in the wheelchair after the initial ROM assessment unless they complain. Staff F stated she just watched to see if Resident #8 was in pain and she had a routine pain medication so she was not offered more due to denying pain. Staff F stated Resident #8's pulse usually ran high so she was not concerned. During an interview on 2/8/24 at 9:16 AM, Staff G, CNA stated she had worked day shift on 11/30/23 and Resident #8 was an assist of 1 person. Resident #8's room door was closed, and when she had entered the room, found Resident #8 in the bathroom with her back against the wall and her feet toward the toilet. Staff G stated the Resident #8 said that she was trying to go to the bathroom, Staff G called Staff F, LPN, but she was busy on the unit so she saw Staff H, CNA Coordinator, and asked her to come to help. Resident #8 stated she needed to get up unless we wanted to clean up a mess, so I put the belt on her and we stood her up, turned her, and pulled her pants down and sat her on the toilet. Staff G stated she did not remember seeing any bruises on Resident #8 and she denied pain. Staff G stated Resident #8 was unable to bear weight and normally she could, so Staff H assisted, and used an EZ Stand Lift (a sit-to-stand mechanical lift) to stand her so she could be cleaned and transferred her to the wheelchair. Staff G stated Staff H left the room, so she waited about 10 minutes with Resident #8 for Staff F, LPN to arrive, who assessed her vital signs and asked if she was in pain and again she denied pain. Staff G stated she told Staff F how she found her and that they had to use the Sara lift to get her into the wheelchair. Staff G explained she did not see the nurse check Resident #8's arms or legs since she assessed her in the chair. Staff G stated Resident #8 is related to her family and does not complain about pain, just when the coffee is cold. Staff G reported that Resident #8 used her arms to propel her wheelchair and her toes to move herself into the dining room. Staff G did not remember seeing Staff F assess Resident #8 in the dining room and felt like she had assisted Resident #8 back to bed after she ate and would have used the EZ Stand Lift to return her to bed. During an interview on 2/8/24 at 9:44 AM, Staff H, CNA Coordinator, stated she worked on 11/30/23. Resident #8 was listed as an independent but she needed assistance with ADL's. Staff H stated Resident #8 able to stand and hold the rail. Staff H stated she was assisting in the south hall when Staff G, CNA asked for assistance with Resident #8. Staff H stated she did not remember assisting Resident #8 to the toilet but did remember using the EZ Stand to get her from the toilet to the wheelchair due to the resident's fear of falling again. Staff H stated Staff F, LPN came in to assess Resident #8 after she was in the wheelchair and did see Staff F take Resident #8's vital signs but did not remember her checking her arms or legs. Staff H stated Staff F did check Resident #8's vitals again in 15 minutes but did not see Staff F doing her vitals in the dining room. Staff H stated she felt like she assisted Resident #8 back to bed and would have used an EZ Stand Lift. Policy titled Resident Safety Accidents and Incidents dated 2021 revealed: a. Ensure all residents accidents and incidents are properly assessed and reviewed. b. The charge nurse shall promptly initiate and document investigation of the accident or incident. c. Data to be placed on the Report of Incident/Accident: - The date and time the accident or incident took place and the nature of the injury/illness (e.g., bruise, fall, nausea, etc.); - The circumstances surrounding the accident or incident where the accident or incident took place; - The name(s) of witnesses and their accounts of the accident or incident; - The injured person's account of the accident or incident; - The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; - The date/time the injured person's family was notified and by whom and the condition of the injured person, including his/her vital signs; - The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); - Any corrective action taken and follow-up information; - Other pertinent data as necessary or required; and the signature and title of the person completing the report. d. Submit the report to the Director of Nursing (DON). Review of the Quality Assurance and Performance Improvement (QAPI) Rapid Improvement Summary dated 11/30/23, reviewed on date 12/4/24 revealed: a. Resident #8 was independent slid out of chair, using improper self-transferring technique. b. Evaluated room set up, no concerns. c. Evaluated Resident #8's equipment, no concerns. d. Referral to therapy. Interview 2/6/24 at 11:00 AM, Staff I, Assistant Director of Nursing (ADON), stated her expectations are the nurses will follow policies, Physician Orders and perform complete assessments after a resident fall.

Based on observation, clinical record review, resident and staff interviews, the facility failed to follow through with Physician Orders for 1 of 15 residents reviewed (Resident #13). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed a diagnosis of Urinary Tract infections (UTI), neuromuscular dysfunction of the bladder and stroke with left sided paralysis and required assistance of one person for toileting, hygiene and an indwelling catheter was identified. Resident #13's Brief Interview for Mental Status (BIMS) score, 15 out of 15 indicated intact cognition. The Care Plan dated 7/18/23 directed Nursing Staff to care for the catheter every shift and to follow the Physician Orders in regards to flushing and changing the catheter. The Discharge Order from a local hospital dated 1/16/24 identified the resident with a suprapubic catheter. During an interview on 2/5/24 at 1:45 PM, Resident #13 stated he had a suprapubic catheter and had been an ongoing problem of spasms and Urinary Tract Infections (UTI) for him. Resident #13 stated the nurse told him she couldn't do anything without an order to care for it. During an observation on 2/6/24 at 9:36 AM, Staff A, Registered Nurse (RN) provided Resident #13's suprapubic catheter care and catheter irrigation. Staff A withdrew 60 milliliters (ml) of clear fluid into a catheter tipped syringe from a cup. Staff A removed a plastic vial of 0.9% Sodium Chloride from her pocket to show what she was using for the irrigation (flush). Staff A disconnected the catheter from the catheter tubing, wiped with alcohol and connected the syringe and flushed the fluid into the resident. Resident #13 requested Staff A to clean the site and catheter. Staff A stated there was no order for site cleansing, but she had an alcohol wipe and swiped over the catheter site and failed to cleanse the catheter tubing. During an interview on 2/6/24 at 9:50 AM Staff A, RN stated she could not find a bottle of Acidic Acid in the treatment cart to flush Resident #13's catheter with. Staff A stated It's on me. Observation on 2/6/24 at 9:50 AM, Staff C, Certified Medication Aide (CMA) opened a drawer in the medication cart that revealed 400 ml of acidic acid in a bottle. Staff A, RN did not go back to Resident #13's room to complete the flush correctly. Follow up interview on 2/6/24 at 10:00 AM, Resident #13 stated the staff fail to provide perineal care and suprapubic catheter care in mornings and at night, they just empty the catheter bag and flush the catheter. During an interview on 2/6/24 at 2:07 PM, Staff B, CNA stated the CNA's empty the catheter bag and change it over to the leg bag in the morning and back to the large catheter bag ay bedtime. Staff B stated, we do not touch the catheter or the spot on the abdomen, we just wash the abdomen and put on lotion, but not near the site. During an interview on 2/8/24 at 1:13 PM, Staff D, Certified Nursing Assistant (CNA) stated when a resident has a suprapubic catheter, the CNA's empty the catheter bag but do not clean the catheter at the site, the nurses complete that task. The Medication Administration Record (MAR) dated February 2024 revealed: a. Acetic Acid Irrigation Solution 0.25 % (Acetic Acid), use 100 ml via irrigation in the morning for a flush in the catheter once daily. b. Documentation on 2/6/24 showed the number 9 written down and directed to see Progress Notes. c. There was no documentation in the Progress Notes regarding the catheter. Policy titled Suprapubic Catheter Care dated 2018 revealed: a. To prevent skin irritation around the stoma site and to prevent Urinary Tract Infection (UTI). b. Wash around catheter site with soap and water. c. Wash the outer part of the catheter tube with soap and water. d. Inspect the stoma site and skin around the stoma for redness or skin breakdown. e. Document in the Resident Medical Record. Policy titled Catheter Care dated 4/2023 revealed: a. The purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. b. Physician's Order for catheterization should include the reason/indication for catheterization, frequency and type of irrigation if necessary. c. Perineal care is to be given twice daily in the morning and evening. Perineal care consists of washing the perineal area and catheter with clean, warm, soapy water or disposable cleansing wipes followed by rinsing the area. d. Drainage bag is to be emptied at the end of each shift (or more often if needed) by emptying into a labeled, measured graduate with the total documented in the clinical record

Based on observation, clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide catheter care for 1 of 3 residents reviewed (Resident #13). The facility reported a census of 49 residents. Findings Include: During an interview on 2/5/24 at 1:45 PM, Resident #13 stated he had a suprapubic catheter and had been an ongoing problem of spasms and Urinary Tract Infections (UTI) for him. Resident #13 stated the nurse told him she couldn't do anything without an order to care for it. During an observation on 2/6/24 at 9:36 AM, Staff A, Registered Nurse (RN) provided Resident #13's suprapubic catheter care and catheter irrigation. Staff A withdrew 60 milliliters (ml) of clear fluid into a catheter tipped syringe from a cup. Staff A removed a plastic vial of 0.9% Sodium Chloride from her pocket to show what she was using for the irrigation (flush). Staff A disconnected the catheter from the catheter tubing, wiped with alcohol and connected the syringe and flushed the fluid into the resident. Resident #13 requested Staff A to clean the site and catheter. Staff A stated there was no order for site cleansing, but she had an alcohol wipe and swiped over the catheter site and failed to cleanse the catheter tubing. During an interview on 2/6/24 at 9:50 AM Staff A, RN stated she could not find a bottle of Acidic Acid in the treatment cart to flush Resident #13's catheter with. Staff A stated It's on me. Observation on 2/6/24 at 9:50 AM, Staff C Certified Medication Aide (CMA) opened a drawer in the medication cart that revealed 400 ml of acidic acid in a bottle. Staff A, RN did not go back to Resident #13's room to complete the flush correctly. Follow up interview on 2/6/24 at 10 AM, Resident #13 stated the nursing staff do not provide perineal care and suprapubic catheter care in mornings and at night, they just empty the catheter bag and flush the catheter. During an interview on 2/6/24 at 2:07 PM, Staff B, CNA stated the CNA's empty the catheter bag and change it over to the leg bag in the morning and back to the large catheter bag ay bedtime. Staff B stated, We do not touch the catheter or the spot on the abdomen, we just wash the abdomen and put on lotion, but not near the site. During an interview on 2/8/24 at 1:13 PM, Staff D, CNA stated when a resident has a suprapubic catheter, the CNA's empty the catheter bag but do not clean the catheter at the site, the nurses complete that task. The Discharge Order from Unity Point dated 1/16/24 identified the suprapubic catheter. Baseline Care Plan dated 1/16/24 identified Resident #13 with a suprapubic catheter. The Medication Administration Record (MAR) dated February 2024 revealed: a. Acetic Acid Irrigation Solution 0.25 % (Acetic Acid) Use 100 ml via irrigation in the morning for a flush in the catheter once daily. b. Documentation on 2/6/24 showed the number 9 written down and directed to see Progress Notes. c. There was no documentation in the Progress Notes regarding the catheter. Policy titled Suprapubic Catheter Care dated 2018 revealed: a. To prevent skin irritation around the stoma site and to prevent Urinary Tract Infection (UTI). b. Wash around catheter site with soap and water. c. Wash the outer part of the catheter tube with soap and water. d. Inspect the stoma site and skin around the stoma for redness or skin breakdown. e. Document in the Resident Medical Record. Policy titled Catheter Care dated 4/2023 revealed: a. The purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. b. Physician's Order for catheterization should include the reason/indication for catheterization, frequency and type of irrigation if necessary. c. Perineal care is to be given twice daily in the morning and evening. Perineal care consists of washing the perineal area and catheter with clean, warm, soapy water or disposable cleansing wipes followed by rinsing the area. d. Drainage bag is to be emptied at the end of each shift (or more often if needed) by emptying into a labeled, measured graduate with the total documented in the clinical record.

Based on clinical record review, staff interview, and facility policy review, the facility failed to limit as needed (PRN) psychotropic medications to 14 days without a rationale from the provider to extend the medication for 1 of 5 residents reviewed for unnecessary medications (Resident #7). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) for Resident #7 dated 11/5/23 documented a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. The MDS further revealed the resident had diagnosis including anxiety, non-Alzheimer's dementia and other depressive disorders. The Care Plan initiated 5/15/23 identified Resident #7 with the potential for altered mood function with occasional episodes of mood dysfunction and behaviors and directed staff to administer antianxiety medication (scheduled and PRN) and observed for effectiveness and side effects. Review of the November 2023 Medication Administration Record (MAR) for Resident #7 revealed an order for Lorazepam (antianxiety medication) every 8 hours as needed for anxiety with a start date 11/1/23. The MAR further revealed the resident received PRN Lorazepam on the following dates without documentation in the clinical record to extend the PRN psychotropic medication past 14 days after initiation: a. On 11/16/23. b. On 11/17/23. c. On 11/18/23. d. On 11/19/23. e. On 11/20/23. f. On 11/21/23. During an interview 2/8/24 at 10:46 AM, the Administrator acknowledged Resident #7 had been administered PRN Lorazepam 6 times after it had exceeded 14 days without a rationale to continue. Review of facility policy dated 2019 and titled, Drug Regimen Review, documented the continued use of medication should be according to current standards of practice but the Physician may determine by documentation of clinical rationale if reductions might impair function of the resident, exacerbate underlying medical conditions or worsen the psychiatric disorder.

Based on clinical record review, Resident Group and staff interviews, observations and facility policy review, the facility failed to maintain an environment free of psychosocial and physical abuse by not identifying and/or reporting abuse immediately but not later than 2 hours- if the alleged violation involves abuse or results in serious bodily injury. Staff B, Certified Nursing Assistant (CNA) reportedly grabbed a resident's hands and made her hit herself in her face on early morning of 7/4/23 (Resident #8). This was not reported until 7/14/23. Staff B reportedly was yelling at a resident and grabbed her wrists early morning of 7/3/23. This was not reported (Resident #9). Both residents were cognitively impaired. During the investigation, staff reported other incidents that they did not report as well (Resident #10 and Resident #13). This failure to report possible abuse in a timely manner created an immediate jeopardy (IJ) to the health and safety of the residents. The facility reported a census of 54 residents. On 9/28/23 at 1:20 PM, the Iowa Department of Inspections, Appeals and Licensing (DIAL)staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility beginning on 7/4/23 when the incident was not reported on to DIAL. The facility staff removed the immediacy on 9/28/23 and decreased the scope to E, after the facility staff completed the following: a. All staff were educated on 9/28/23 which includes review of the Abuse Policy, reporting abuse and conducting an abuse investigation. b. Immediately began educating staff on the abuse policy, with an emphasis on the reporting procedures for abuse. c. Facility Administrator and Director of Nursing (DON), monitored staff and residents for signs of abuse and or failure to report. This included visual observation, short interviews with staff to ensure abuse identification, and reporting procedures were understood. Findings Include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #8 included non-Alzheimer's dementia and schizophrenia. A Brief Interview for Mental Status (BIMS) documented as being unable to complete. The MDS identified the resident's cognitive skills for daily decision making was severely impaired. Resident #8 required extensive assist of 2 staff for bed mobility, transfer, dressing and toilet use. A Care Plan with a Focus Area initiated on 2/9/23, directed staff that Resident #8 displayed mood and behavior problems related to diagnosis of schizophrenia and unspecified dementia with agitation, diagnosis of adjustment disorders with mixed anxiety and depressed mood. This Care Plan had interventions initiated on 2/9/23, that directed staff to: a. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, encourage as much participation/interaction by the resident as possible during care activities. b. Give clear explanation of all care activities prior to and as they occur during each contact. c. If resident resists with Activities of Daily Living (ADL's), reassure resident, leave and return 5-10 minutes later and try again. d. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. e. Provide resident with opportunities for choice during care provision. f. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. A Progress Note with a late entry date for 7/14/23, documented that Resident #8's son spoken to regarding an allegation of abuse. The incident was explained and questions were answered. It documented that the son voiced understanding. There were no documented Progress Notes dated 7/4/23. 2. An MDS dated [DATE], documented that Resident #9's diagnoses included non-Alzheimer's dementia. A BIMS documented a score of 15 out of 15, which indicated intact cognition. This MDS documented Resident #9 usually understood others and usually could make herself understood. The resident identified independent for transfers and locomotion on and off the unit and required limited assist of 1 for toilet use. An MDS dated [DATE], documented Resident #9's BIMS score was 12 out of 15, which indicated moderately impaired cognition. This MDS documented that Resident #9 usually understood others, usually could make herself understood and had non-traumatic brain disfunction. A Care Plan with a Focus Area initiated on 3/23/20, directed staff that Resident #9 had potential for impaired cognitive and communication function related to her diagnosis of multi system atrophy and dementia. This can affect her speech at times and her decision making. This Care Plan had interventions initiated on 3/23/20, that directed staff to: a. Assist Resident #9 with her decision making and ensure safety to highest extent possible. b. Allow adequate time to respond, repeat as necessary. Do not rush. Request clarification from her to ensure understanding. c. Face when speaking. Make eye contact. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. d. Continue to engage Resident #9 in communication with cares and interactions. e. Use calm approach when assisting her with her ADL functions. There were no documented Progress Notes dated 7/3/23. 3. An MDS dated [DATE], documented diagnoses for Resident #10 included non-Alzheimer's dementia. A BIMS score for Resident #10 was 00, which indicated severe cognitive impairment. Resident #10 identified totally dependent on 2 staff for bed mobility, dressing and toilet use. A Care Plan for Resident #10 had a Focus Area dated as initiated on 3/23/22, that directed staff that Resident #10 had physical behaviors and verbal outbursts toward the staff when they are assisting with his ADLs related to his diagnosis of dementia and anxiety. This Care Plan had interventions initiated on 3/23/22, that directed staff to: a. Encourage as much participation/interaction by Resident #10 as possible during care activities. b. Give clear explanation of all care activities prior to and as they occur during each contact. c. If Resident #10 is resistive with ADLs, reassure resident, leave and return 5-10 minutes later and try again. 4. An MDS dated [DATE], documented diagnoses for Resident #13 included Traumatic Brain Injury. Resident #13 BIMS score was 15 which indicated intact cognition. This resident required extensive assist of 1 for dressing, which included the putting on and removing of TED hose (compression stockings). A Care Plan with for Resident #13 had a Focus area dated as initiated on 4/5/22, that directed staff that Resident #13 has an ADL self-care performance deficit related to history of falls at home and issues with chronic and acute pain at times, advanced age and history of arthritis. The Care Plan had interventions initiated on 4/5/22, directed staff to allow sufficient time for dressing and undressing. Staff will need to assist this resident with all his dressing needs of upper and lower extremities as needed. Extensive assistance at times due to limitations with his arthritis. On 9/21/23 at 1:00 p.m., during a Resident Group Meeting the residents present were asked if they had been neglected or abused or if they had seen any other residents being neglected or abused. Resident #13 stated there was a guy and a girl that worked in the middle of the night. He stated the guy just didn't have any patience with Resident #13. Resident #13 stated he didn't remember the situation specifically but remembered being very unhappy with the male staff member. Resident #13 stated the man no longer worked at the facility. Resident #13 was unable to recall the male staff member's name. On 9/26/23 at 4:49 p.m., Staff A, Certified Nurse Aide (CNA), stated that on 7/4/23 at 1:00 a.m., she and Staff B, CNA were doing rounds. Staff A stated that they had went into Resident #8's room to check and change the resident. Staff A stated that typically if there were 2 people one of them would just hold Resident #8's hands and hold them up away from the adult brief. Staff A stated that Staff B grabbed this resident's hands pretty quick and it triggered Resident #8. Resident #8 then called Staff B the devil. Staff A said that Staff B got this look on his face like a 'well I'll show you' kind of look. She stated that Staff B then pushed Resident #8's hands up into her face and that's hard to do. Staff A continued that it was hard to just hold this resident's hands out of the way, let alone move her hands. Staff A stated that Staff B pushed this resident's hands up into her face causing her to hit herself. Staff A stated that this resident kind of like yelled/wailed 'oh my god you hit me in my mouth'. Staff A stated that Staff B told Resident #8 that she 'hit herself'. Staff A stated she then hurried up and got Staff B out of there. Staff A stated that Staff B didn't say anything to Staff A after they left the room and Staff A didn't say anything to Staff B. Staff A stated she really didn't know what to say. Staff A stated she wasn't sure who to report it to since Staff B's spouse was the Supervisor. Staff A added that a couple of weeks prior to this incident, Staff B had told this resident very sternly, like how you would talk to a child, to 'be an adult'. Staff A stated she thought Resident #8 was swatting out at the time. Staff A stated that this resident was kind of modest and reported since this incident, staff have been going in 1 staff member at a time. Staff A explained this resident would say things like 'stop looking at my body'. Staff A said that they've learned that she does much better with one person. Staff A acknowledged she didn't report this incident right away. Staff A reported she knew of another incident that was reported where a resident was flicked in the ear. She stated that another CNA had reported this to Staff C, Certified Medication Aide (CMA)-CMA/CNA Coordinator who was also Staff B's spouse. Staff A stated that they changed the report from flicked him in the ear to brushed his ear when she was getting him ready. Staff A explained Staff C was in charge of the CNAs and educates the CNAs if they need education. Staff A stated that she should have reported the incident earlier, but she had written a letter to the Administrator and put it in her mailbox. Staff A stated the next day the letter was gone. Staff A stated that she had heard that Staff C and the Assistant Director of Nursing (ADON) were going around and asking others if they had ever seen Staff B act out toward residents. Staff A reported she had not seen Staff B ever lay hands on a resident before but he would lash out at staff. She stated that Staff B would go into a resident's room, like an independent resident who would want help with compression stockings and creams on. Staff B stated that Resident #13 was independent and Staff B would get really snippy with Resident #13. Staff A said she had not heard Staff B say anything to Resident #13, but Staff B came out and told Staff A that he (Staff B) had told Resident #13 that he was independent and needed to do those things for himself. Staff A stated this happened approximately 2 weeks before the incident with Resident #8. Staff A reported she didn't know that the Administrator didn't get her letter. Staff A stated Staff D, reported she had seen Staff B do stuff like this all the time. Staff A explained that Staff D said she hadn't reported anything because Staff B's spouse was Staff D's Supervisor. Staff A stated that there was a fear of retaliation with reporting and she didn't know if they would do anything about it anyway, since they changed the other report. On 9/27/23 at 10:00 a.m., the Administrator stated she had the DON write up the incident with coaching and counseling and her assessment on Resident #9. The Administrator found this incident happened the day before the Facility Self-Reported Incident of Staff B with Resident #8. On 9/27/23 at 10:15 a.m., Resident #9 was propelling her wheelchair with her feet into her room. This resident was pleasant and smiled. She gave permission to enter her room and to ask her questions. Resident #9 stated that she did not have any issues with staff. She said sometimes her roommate can be annoying. When asked if any staff had grabbed her wrists or yelled at her, she said she didn't remember anything like that happening. On 9/27/23 at 10:35 a.m., the Director of Clinical Services and the Administrator requested to talk about the incident between Resident #9 and Staff B. The following discussed: a. There was no assurance of separation between Resident #9. b. This happened in an open space and Staff B could have stepped away. c. Staff B proceeded to argue/yell at this resident instead of using a different therapeutic approach. d. There was no assessment of Resident #9 documented, as Staff F did not assess Resident #9. e. No documentation of the whole incident nor was there follow up to it until the Administrator asked the DON to write up the coaching and counseling for Staff B and the assessment of Resident #9 that was provided on this day. f. Other residents were out in the dining room at the time of this incident and there was no follow up with them. g. Resident #9 had impaired cognition and short-term memory loss, but the DON stated that Resident #9 denied anything happening and did not look into this further. h. The incident between Staff B and Resident #9 happened the day before the incident between Staff B and Resident #8 happened. If the incident between Staff B and Resident #9 would have been properly investigated and reported to the State Agency, the other incident may not have happened. i. The facility allowed Staff B to work with dependent adults until the incident was reported on 7/14/23 and Staff B was terminated. The Director of Clinical Services and the Administrator acknowledged all of the above concerns and had no further questions. On 9/27/23 at 12:16 p.m., Staff F, Registered Nurse (RN), when asked if she had any concerns with how the staff have treated residents, she answered that she had notified the DON of a concern she had. She stated that Staff B had an incident with Resident #9. Staff F stated that Resident #9 was up in the middle of the night and she went toward the fire alarm but there was also a light switch next to it. Staff F stated she told Resident #9 'no, don't do that'. Staff F stated that Staff B and Resident #9 verbally got into it and Resident #9 said she was going to hit Staff B. Staff F stated that Staff B went to stop Resident #9 who was in a wheelchair. Staff F stated that Staff B took his hands and put them on this resident's wrists so she couldn't hit. Staff F stated she told them both to quit and they both quit but they were still screaming at each other. Staff F stated this took place in the dining room. Staff F stated she didn't recall what date this happened on but it was around 4:00 a.m. in the morning. Staff F stated Staff B then went outside. Staff F stated that sometimes staff B would get short with people in general. Staff F said she couldn't give any examples. Staff F stated she did not have her notes, but the DON had a copy of them. On 9/27/23 at 2:18 p.m., Staff D stated she had talked with the Administrator at work. Staff D said she had seen Staff B holding down Resident #10 in bed and happened probably a year ago. She stated she had asked Staff B to stop and maybe see if they could get someone else to come into the room, and Staff B said 'no, let's just get it done'. Staff D stated she had reported this to Staff C. Staff D explained that when she would work with Resident #10 she would explain to him what she was doing and Resident #10 would not get agitated. Staff D stated that Staff B would just want to get things done and go into residents' rooms and rush and not do things correctly. Staff D reported she had also seen Staff B holding down Resident #8 in bed while trying to do cares. Staff B stated that she had been in both rooms by herself and both residents are absolutely fine if you explain what you are doing and not rush through. Staff D stated that it was not common practice to hold down Resident #8's hands and had never seen that happen, until sometime in June. Staff D explained she didn't report this incident, as she started to feel like why report it because nothing gets done with it. Staff D stated she definitely felt like it was excessive force, almost like a restraint. and she mentioned it to one of the, Charge Nurses on the night shift, Staff E, Registered Nurse (RN). Staff D stated that Staff E was the only one who actually felt like it needed to be taken further. Staff D stated she wrote down both of the instances and gave it to Staff E. Staff D stated they talked with the Director of Clinical Services and the Chief Operations Officer about the situations. Staff D stated she felt like she needed to report these things as she was someone taking the Dependent Adult Abuse (DAA) training. Staff D stated she felt like Staff C tried to cover up for Staff B because she worked in the office. Staff D stated that Staff B was working at a new place and it kind of worried her that Staff B was allowed to take care of people. On 9/27/23 at 3:31 p.m., the DON stated she had found out about the recent abuse complaint about a day after the Administrator and the Director of Clinical Services found out about it. She stated her only thought was why would Staff A wait so long to report it. The DON stated she personally felt bad for Staff B, just because of his compassion that he had for the elderly. The DON stated that if she witnessed something like that they would be fired immediately. The DON stated she didn't know if Staff A was making it up, but stated she knew that Staff B liked things a certain way. She stated, for example if he went to work and staff hadn't taken the trash out, he would be upset about it. The DON stated that one night that happened when she was working and she just said to him just go ahead and take the trash out, and he did. The DON stated she did not know anything about Resident #10 being held down on his bed. She stated that Resident #10 was a hard resident to do cares on. The DON stated that Staff F called the DON sometime between May and July, she'd have to look at her phone to see when, as she didn't write it down. The DON said that Staff F had woke the DON up. The DON stated she was told it had to do with Resident #9. The DON stated that Staff B was in Resident #9's room and the resident got mad at Staff B and she tried to slap him in his face. The DON believed that Staff F had written the DON a note. Resident #9 was sitting at southeast door looking out at the garden, that morning when the DON came in. The DON stated she didn't remember what time it was. The DON stated she had looked at Resident #9's skin and wrists and didn't see anything. The DON stated she had asked her if anything happened last night, anything with staff, did you wake up and something happen with the staff, and Resident #9 said no. The DON asked her if there was anything she wanted to report and Resident #9 said no. The DON stated that she thought she talked with Staff B, later that day. The DON stated she thought Resident #9 was a poopy mess and staff B was trying to help her, because that was a normal situation for her. The DON thought that Resident #9 scared Staff B as Resident #9 was a strong lady and she could hurt him. The DON thought Resident #9 was trying to hit him and he just kind of put his hand up and kind of tried to stop her from hitting him. The DON thought they were in Resident #9's room and Staff B was trying to help change her. The DON stated she would look for the note that Staff F had wrote but did not know if she had it. When asked if this incident could have happened in the dining room as that is what Staff F had reported, the DON said yes. The DON stated she remembered that now. Asked the DON if Resident #9 could give an accurate interview. The DON acknowledged that Resident #9 had moderately impaired cognition and short-term memory problems as well. The DON thought Staff F separated Staff B from Resident #9. This DON was pretty sure Staff B was already gone from the facility by the time the DON arrived as she had to call him later. She stated when she talked with Staff B, he said 'yeah, I'm not going to be the one who tells her to turn off the light switch.' The DON stated Resident #9 could get mad pretty quickly. When asked if staff should argue with residents, she said no. When asked if there was room to back away from Resident #9 if she said she was going to hit him, the DON said yes at that time of night in the dining room there would have been plenty of room. When asked if Resident #9 had ever pulled the fire alarm, the DON said no. The DON said she didn't formally coach or counsel Staff B. She said that she just talked with him about it. She will look to see if she can find when the call came in, what date and time. On 9/28/23 at 8:48 a.m., Staff F stated that she found the note that she left for the DON. She stated she had sent a text around 4:00 a.m. in the morning to the DON. The DON text back and said to leave a note and she would follow up in the morning. When asked about separating Staff B and Resident #9, Staff F stated that Resident #9 went to her room after the incident. Staff F stated she did not see Staff B go back down toward Resident #9's room. Staff F stated she had let the DON know about Resident #9 saying her wrists hurt, and the DON told Staff F that she would assess Resident #9 when she got in, so Staff B did not assess Resident #9. Staff F said that after the incident she started medication pass, so couldn't ensure that Staff B didn't go into Resident #9's room. On 9/28/23 at 5:30 p.m., Staff C stated that she had never received a report from another CNA regarding Staff B (spouse) holding a resident down. She stated if she did receive a report of this, she would report it on even though if it was family. She stated she would encourage reporting of any question of abuse be reported on to a nurse not her. She stated she had worked for many years at the facility and that the facility important to her and she really cared for the residents and would never do anything to jeopardize their safety. On 10/2/23 at 3:16 p.m., the Director of Clinical Services (DCS) stated that the Administrator called and said they had a report of abuse. The DCS told the Administrator she would help with investigations. They called Staff B in and interviewed him. They then interviewed Staff A. The DCS assessed Resident #8. The DCS stated it had been a while but she thought it was worth a shot to ask Resident #8 if she remembered anything, and Resident #8 did not. Staff B demonstrated what happened with Resident #8. The DCS stated that she would be Resident #8, and Staff B was to show the DCS what happened. Staff B batted at the DCS's arms but never grabbed her on her wrists like what was reported. Staff B was angry and made a comment that he felt like he was being targeted. Staff B didn't mention any names of who he would have been targeted by. The DCS stated they suspended him right away as they wanted to remove him from the situation until it was investigated. She stated it was a pretty brief interview and that Staff B was pretty angry as it was the 2nd time he had been suspended for a similar situation. Another combative resident was trying to hit Staff B and he was holding his hands so that the resident could not hit him. She stated they talked with Staff A and basically Staff A repeated what her statement was- Resident #8 was trying to be combative with Staff B. Staff B held her wrists and was wiggling her hands. Staff A told this DCS and the Administrator that she heard Resident #8 say you hit me and Staff B said no I didn't, you hit yourself. Staff A had written a statement. As soon as the Administrator was notified of the situation, it was investigated. The DCS stated it was hard to say if there was a letter put into the mailbox, but the Administrator never got a letter. Nothing was ever found and it's a pretty secure mailbox, she thought a key was needed to open it and no letter was found. The DCS stated that no one had said anything to her about being uncomfortable with reporting to their supervisor. She stated that if staff were in the nursing department, they should report to the DON. On 10/2/23 at 3:38 p.m., the Administrator stated she received a call from employee Staff E, saying that Staff A had approached her with this incident and she wasn't sure how to handle it. This happened the morning of 7/4/23 and both Staff A and Staff E had worked that night into the morning of 7/4/23. Staff E reported that there was an incident between Staff A, Staff B and Resident #8. The Administrator stated she then spoke to Staff A and brought her in to do her statement. Staff A told the Administrator that the morning of 7/4/23, Staff B was assisting Staff A with cares. Staff B had Resident #8's hands and Resident #8 said she was going to hit Staff B when Staff B took her hands and waved them around in her face. Staff A could not tell me if she actually saw him hit Resident #8. Staff A had told the Administrator that what Staff A heard was Resident #8 saying 'I'm going to hit you' and Staff B kind of waving Resident #8's hands around in her face. Resident #8 then said 'you hit me' and then Staff B left the room. Staff A told the Administrator that Staff B said 'no you hit yourself' because he had her hands. The Administrator stated that it was hard to find out the actual facts. The Administrator stated that they needed to suspend Staff B immediately until they could fully investigate the situation and she did not like hearing about this incident. She stated that was not who they were. She stated that the Director of Clinical Services was with her through this interview and pretty much through the whole thing. She stated after she got Staff A's statement, they let Staff B know that he was suspended and that there was an investigation, and then reported it to the State Agency. This Administrator said they then talked to Staff E and Staff F, their night nurses about Staff B's behavior and at that point they decided that Staff B needed to be terminated. Neither Staff E nor Staff F were aware of the 4th of July incident. The Administrator asked about other incidents and they did not say anything further to the Administrator about knowledge of other incidents. Neither of them said there was anything they had seen that was reportable. They both said Staff B had a short fuse but had no specific incidents. The Administrator stated that Staff F did not mention the incident with Resident #9. The Administrator stated they then brought Staff B in and terminated him. Staff B stated he didn't know what they were talking about and he wouldn't sign the discipline sheet because he didn't agree with it. The Administrator stated that Staff B told them he had no recollection of any incident. The Administrator reported she would not suggest that staff would hold on to residents' hands. The Administrator stated they started educating for staff to put hands up and shield yourself but not to actually hold resident's hands down. They educated on reassurance, re-approaching, using another staff to try as well for interventions. She said that was the end of their investigation. She stated they did education on reporting and types of abuse. The Administrator stated that the month of August was focused on education on abuse, reporting, who to report to, and those who are at high risk for abuse. The Administrator stated they had to go through with the CNAs who their Supervisor was and that it wasn't Staff C, it was the ADON and before that it was the DON. A handwritten note provided by Staff F written to the DON and the Administrator and dated 7/3/23 at 4:03 a.m., documented the following: An incident between Staff B and Resident #9 was witnessed by herself (Staff F) at 4:03 a.m., on 7/3/23 in the dining room. There were 3 other residents in the dining room as well as Resident #9. Staff F was standing at the medication cart and saw the commotion initiated between the 2. The light was off on the southwest side of the dining room. Resident #9 went to turn on the light switch by the fire alarm. In the dark it looked like she was going to pull the alarm, and Staff F asked her not to, so Resident #9 turned on the light. Staff B asked Resident #9 why did you turn that on, and she said he's (one of the other residents) was in the dark. The resident was asleep and had chosen to be there. Resident #9 began to holler at Staff B. Staff B answered her and then Resident #9 said 'I am going to hit you'. Staff B replied 'no you are not'. Resident #9 raised her hands toward his face which Staff B raised his hands grasping her wrists. Resident #9 was hollering, and Staff F told them to stop. They separated and Resident #9 was encouraged to go to her room, which she did. Staff F did speak with Staff B about needing not to respond to her outbursts. A review of the July's schedule revealed that Staff B worked the following nights shifts (10 p.m. to 6 a.m.): a. On 7/2/23. b. On 7/4/23. c. On 7/5/23. d. On 7/6/23. e. On 7/7/23. f. On 7/10/23. g. On 7/11/23. h. On 7/12/23. i. On 7/13/23. An Abuse Policy updated on 10/2022 directed the following: a. Purpose: To ensure all residents are protected from the threat of abuse and all allegations of abuse are properly investigated. b. Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. Employee Screening: The facility shall screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. The facility will not employ or otherwise engage individuals who: (i) Have been found guilty of resident abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into a State nurse aide registry concerning resident abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Training of Employees: Upon initial employment, each employee shall be provided with a copy of the facility's policies and procedures relating to abuse identification and reporting requirements. Within six months [TRUNCATED]

Based on clinical record review, resident and staff interviews and facility policy review, the facility failed to take steps to prevent further potential abuse by not conducting a thorough investigation of an alleged violation. Staff B, Certified Nurse Assistant (CNA) reportedly was yelling at a resident and grabbed her wrists early morning of July 3rd (Resident #9). The facility asked Resident #9, who was cognitively impaired if anything happened the night before and she said no. The Director of Nursing (DON) acknowledged this resident did have cognitive impairment and had short term memory loss. The DON talked with Staff B. No documentation was done for either of these conversations, nor was a thorough investigation completed. Three residents were present at the time of the incident and were not interviewed. Two of the residents had intact cognition. A through internal investigation was not done or documented. The next day it was reported that Staff B caused another resident to hit herself in the face (Resident #8). The facility reported a census of 54 residents. On 9/28/23 at 1:20 PM, the Iowa Department of Inspections and Appeals and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility beginning on 7/3/23 when the incident was not reported on to the facility's Administrator or DIAL. The facility staff removed the immediacy on 9/28/23 and decreased the scope to E, after the facility staff completed the following: a. All staff were educated on 9/28/23 which includes review of the Abuse Policy, reporting abuse and conducting an abuse investigation. b. Immediately began educating staff on the abuse policy, with an emphasis on the reporting procedures for abuse. c. Facility Administrator and Director of Nursing (DON), monitored staff and residents for signs of abuse and or failure to report. This included visual observation, short interviews with staff to ensure abuse identification, and reporting procedures were understood. Findings Include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #8 included non-Alzheimer's dementia and schizophrenia. A Brief Interview for Mental Status (BIMS) documented as being unable to complete. The MDS identified the resident's cognitive skills for daily decision making was severely impaired. Resident #8 required extensive assist of 2 staff for bed mobility, transfer, dressing and toilet use. A Care Plan with a Focus Area initiated on 2/9/23, directed staff that Resident #8 displayed mood and behavior problems related to diagnosis of schizophrenia and unspecified dementia with agitation, diagnosis of adjustment disorders with mixed anxiety and depressed mood. This Care Plan had interventions initiated on 2/9/23, that directed staff to: a. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, encourage as much participation/interaction by the resident as possible during care activities. b. Give clear explanation of all care activities prior to and as they occur during each contact. c. If resident resists with Activities of Daily Living (ADL's), reassure resident, leave and return 5-10 minutes later and try again. d. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. e. Provide resident with opportunities for choice during care provision. f. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. A Progress Note with a late entry date for 7/14/23, documented that Resident #8's son spoken to regarding an allegation of abuse. The incident was explained and questions were answered. It documented that the son voiced understanding. There were no documented Progress Notes dated 7/4/23. 2. An MDS dated [DATE], documented that Resident #9's diagnoses included non-Alzheimer's dementia. A BIMS documented a score of 15 out of 15, which indicated intact cognition. This MDS documented Resident #9 usually understood others and usually could make herself understood. The resident identified independent for transfers and locomotion on and off the unit and required limited assist of 1 for toilet use. An MDS dated [DATE], documented Resident #9's BIMS score was 12 out of 15, which indicated moderately impaired cognition. This MDS documented that Resident #9 usually understood others, usually could make herself understood and had non-traumatic brain disfunction. A Care Plan with a Focus Area initiated on 3/23/20, directed staff that Resident #9 had potential for impaired cognitive and communication function related to her diagnosis of multi system atrophy and dementia. This can affect her speech at times and her decision making. This Care Plan had interventions initiated on 3/23/20, that directed staff to: a. Assist Resident #9 with her decision making and ensure safety to highest extent possible. b. Allow adequate time to respond, repeat as necessary. Do not rush. Request clarification from her to ensure understanding. c. Face when speaking. Make eye contact. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. d. Continue to engage Resident #9 in communication with cares and interactions. e. Use calm approach when assisting her with her ADL functions. There were no documented Progress Notes dated 7/3/23. On 9/26/23 at 4:49 p.m., Staff A, Certified Nurse Aide (CNA), stated that on 7/4/23 at 1:00 a.m., she and Staff B, CNA were doing rounds. Staff A stated that they had went into Resident #8's room to check and change the resident. Staff A stated that typically if there were 2 people one of them would just hold Resident #8's hands and hold them up away from the adult brief. Staff A stated that Staff B grabbed this resident's hands pretty quick and it triggered Resident #8. Resident #8 then called Staff B the devil. Staff A said that Staff B got this look on his face like a 'well I'll show you' kind of look. She stated that Staff B then pushed Resident #8's hands up into her face and that's hard to do. Staff A continued that it was hard to just hold this resident's hands out of the way, let alone move her hands. Staff A stated that Staff B pushed this resident's hands up into her face causing her to hit herself. Staff A stated that this resident kind of like yelled/wailed 'oh my god you hit me in my mouth'. Staff A stated that Staff B told Resident #8 that she 'hit herself'. Staff A stated she then hurried up and got Staff B out of there. Staff A stated that Staff B didn't say anything to Staff A after they left the room and Staff A didn't say anything to Staff B. Staff A stated she really didn't know what to say. Staff A stated she wasn't sure who to report it to since Staff B's spouse was the Supervisor. Staff A added that a couple of weeks prior to this incident, Staff B had told this resident very sternly, like how you would talk to a child, to 'be an adult'. Staff A stated she thought Resident #8 was swatting out at the time. Staff A stated that this resident was kind of modest and reported since this incident, staff have been going in 1 staff member at a time. Staff A explained this resident would say things like 'stop looking at my body'. Staff A said that they've learned that she does much better with one person. Staff A acknowledged she didn't report this incident right away. Staff A reported she knew of another incident that was reported where a resident was flicked in the ear. She stated that another CNA had reported this to Staff C, Certified Medication Aide (CMA)-CMA/CNA Coordinator who was also Staff B's spouse. Staff A stated that they changed the report from flicked him in the ear to brushed his ear when she was getting him ready. Staff A explained Staff C was in charge of the CNAs and educates the CNAs if they need education. Staff A stated that she should have reported the incident earlier, but she had written a letter to the Administrator and put it in her mailbox. Staff A stated the next day the letter was gone. Staff A stated that she had heard that Staff C and the Assistant Director of Nursing (ADON) were going around and asking others if they had ever seen Staff B act out toward residents. Staff A reported she had not seen Staff B ever lay hands on a resident before but he would lash out at staff. She stated that Staff B would go into a resident's room, like an independent resident who would want help with compression stockings and creams on. Staff B stated that Resident #13 was independent and Staff B would get really snippy with Resident #13. Staff A said she had not heard Staff B say anything to Resident #13, but Staff B came out and told Staff A that he (Staff B) had told Resident #13 that he was independent and needed to do those things for himself. Staff A stated this happened approximately 2 weeks before the incident with Resident #8. Staff A reported she didn't know that the Administrator didn't get her letter. Staff A stated Staff D, reported she had seen Staff B do stuff like this all the time. Staff A explained that Staff D said she hadn't reported anything because Staff B's spouse was Staff D's Supervisor. Staff A stated that there was a fear of retaliation with reporting and she didn't know if they would do anything about it anyway, since they changed the other report. On 9/27/23 at 10:00 a.m., the Administrator stated she had the DON write up the incident with coaching and counseling and her assessment on Resident #9. The Administrator found this incident happened the day before the Facility Self-Reported Incident of Staff B with Resident #8. On 9/27/23 at 10:15 a.m., Resident #9 was propelling her wheelchair with her feet into her room. This resident was pleasant and smiled. She gave permission to enter her room and to ask her questions. Resident #9 stated that she did not have any issues with staff. She said sometimes her roommate can be annoying. When asked if any staff had grabbed her wrists or yelled at her, she said she didn't remember anything like that happening. On 9/27/23 at 10:35 a.m., the Director of Clinical Services and the Administrator requested to talk about the incident between Resident #9 and Staff B. The following discussed: a. There was no assurance of separation between Resident #9. b. This happened in an open space and Staff B could have stepped away. c. Staff B proceeded to argue/yell at this resident instead of using a different therapeutic approach. d. There was no assessment of Resident #9 documented, as Staff F did not assess Resident #9. e. No documentation of the whole incident nor was there follow up to it until the Administrator asked the DON to write up the coaching and counseling for Staff B and the assessment of Resident #9 that was provided on this day. f. Other residents were out in the dining room at the time of this incident and there was no follow up with them. g. Resident #9 had impaired cognition and short-term memory loss, but the DON stated that Resident #9 denied anything happening and did not look into this further. h. The incident between Staff B and Resident #9 happened the day before the incident between Staff B and Resident #8 happened. If the incident between Staff B and Resident #9 would have been properly investigated and reported to the State Agency, the other incident may not have happened. i. The facility allowed Staff B to work with dependent adults until the incident was reported on 7/14/23 and Staff B was terminated. The Director of Clinical Services and the Administrator acknowledged all of the above concerns and had no further questions. On 9/27/23 at 12:16 p.m., Staff F, Registered Nurse (RN), when asked if she had any concerns with how the staff have treated residents, she answered that she had notified the DON of a concern she had. She stated that Staff B had an incident with Resident #9. Staff F stated that Resident #9 was up in the middle of the night and she went toward the fire alarm but there was also a light switch next to it. Staff F stated she told Resident #9 'no, don't do that'. Staff F stated that Staff B and Resident #9 verbally got into it and Resident #9 said she was going to hit Staff B. Staff F stated that Staff B went to stop Resident #9 who was in a wheelchair. Staff F stated that Staff B took his hands and put them on this resident's wrists so she couldn't hit. Staff F stated she told them both to quit and they both quit but they were still screaming at each other. Staff F stated this took place in the dining room. Staff F stated she didn't recall what date this happened on but it was around 4:00 a.m. in the morning. Staff F stated Staff B then went outside. Staff F stated that sometimes staff B would get short with people in general. Staff F said she couldn't give any examples. Staff F stated she did not have her notes, but the DON had a copy of them. On 9/27/23 at 3:31 p.m., the DON stated she had found out about the recent abuse complaint about a day after the Administrator and the Director of Clinical Services found out about it. She stated her only thought was why would Staff A wait so long to report it. The DON stated she personally felt bad for Staff B, just because of his compassion that he had for the elderly. The DON stated that if she witnessed something like that they would be fired immediately. The DON stated she didn't know if Staff A was making it up, but stated she knew that Staff B liked things a certain way. She stated, for example if he went to work and staff hadn't taken the trash out, he would be upset about it. The DON stated that one night that happened when she was working and she just said to him just go ahead and take the trash out, and he did. The DON stated that Staff F called the DON sometime between May and July, she'd have to look at her phone to see when, as she didn't write it down. The DON said that Staff F had woke the DON up. The DON stated she was told it had to do with Resident #9. The DON stated that Staff B was in Resident #9's room and the resident got mad at Staff B and she tried to slap him in his face. The DON believed that Staff F had written the DON a note. Resident #9 was sitting at southeast door looking out at the garden, that morning when the DON came in. The DON stated she didn't remember what time it was. The DON stated she had looked at Resident #9's skin and wrists and didn't see anything. The DON stated she had asked her if anything happened last night, anything with staff, did you wake up and something happen with the staff, and Resident #9 said no. The DON asked her if there was anything she wanted to report and Resident #9 said no. The DON stated that she thought she talked with Staff B, later that day. The DON stated she thought Resident #9 was a poopy mess and staff B was trying to help her, because that was a normal situation for her. The DON thought that Resident #9 scared Staff B as Resident #9 was a strong lady and she could hurt him. The DON thought Resident #9 was trying to hit him and he just kind of put his hand up and kind of tried to stop her from hitting him. The DON thought they were in Resident #9's room and Staff B was trying to help change her. The DON stated she would look for the note that Staff F had wrote but did not know if she had it. When asked if this incident could have happened in the dining room as that is what Staff F had reported, the DON said yes. The DON stated she remembered that now. Asked the DON if Resident #9 could give an accurate interview. The DON acknowledged that Resident #9 had moderately impaired cognition and short-term memory problems as well. The DON thought Staff F separated Staff B from Resident #9. This DON was pretty sure Staff B was already gone from the facility by the time the DON arrived as she had to call him later. She stated when she talked with Staff B, he said 'yeah, I'm not going to be the one who tells her to turn off the light switch.' The DON stated Resident #9 could get mad pretty quickly. When asked if staff should argue with residents, she said no. When asked if there was room to back away from Resident #9 if she said she was going to hit him, the DON said yes at that time of night in the dining room there would have been plenty of room. When asked if Resident #9 had ever pulled the fire alarm, the DON said no. The DON said she didn't formally coach or counsel Staff B. She said that she just talked with him about it. She will look to see if she can find when the call came in, what date and time. On 9/28/23 at 8:48 a.m., Staff F stated that she found the note that she left for the DON. She stated she had sent a text around 4:00 a.m. in the morning to the DON. The DON text back and said to leave a note and she would follow up in the morning. When asked about separating Staff B and Resident #9, Staff F stated that Resident #9 went to her room after the incident. Staff F stated she did not see Staff B go back down toward Resident #9's room. Staff F stated she had let the DON know about Resident #9 saying her wrists hurt, and the DON told Staff F that she would assess Resident #9 when she got in, so Staff B did not assess Resident #9. Staff F said that after the incident she started medication pass, so couldn't ensure that Staff B didn't go into Resident #9's room. On 10/2/23 at 3:16 p.m., the Director of Clinical Services (DCS) stated that the Administrator called and said they had a report of abuse. The DCS told the Administrator she would help with investigations. They called Staff B in and interviewed him. They then interviewed Staff A. The DCS assessed Resident #8. The DCS stated it had been a while but she thought it was worth a shot to ask Resident #8 if she remembered anything, and Resident #8 did not. Staff B demonstrated what happened with Resident #8. The DCS stated that she would be Resident #8, and Staff B was to show the DCS what happened. Staff B batted at the DCS's arms but never grabbed her on her wrists like what was reported. Staff B was angry and made a comment that he felt like he was being targeted. Staff B didn't mention any names of who he would have been targeted by. The DCS stated they suspended him right away as they wanted to remove him from the situation until it was investigated. She stated it was a pretty brief interview and that Staff B was pretty angry as it was the 2nd time he had been suspended for a similar situation. Another combative resident was trying to hit Staff B and he was holding his hands so that the resident could not hit him. She stated they talked with Staff A and basically Staff A repeated what her statement was- Resident #8 was trying to be combative with Staff B. Staff B held her wrists and was wiggling her hands. Staff A told this DCS and the Administrator that she heard Resident #8 say you hit me and Staff B said no I didn't, you hit yourself. Staff A had written a statement. As soon as the Administrator was notified of the situation, it was investigated. The DCS stated it was hard to say if there was a letter put into the mailbox, but the Administrator never got a letter. Nothing was ever found and it's a pretty secure mailbox, she thought a key was needed to open it and no letter was found. The DCS stated that no one had said anything to her about being uncomfortable with reporting to their supervisor. She stated that if staff were in the nursing department, they should report to the DON. On 10/2/23 at 3:38 p.m., the Administrator stated she received a call from employee Staff E, saying that Staff A had approached her with this incident and she wasn't sure how to handle it. This happened the morning of 7/4/23 and both Staff A and Staff E had worked that night into the morning of 7/4/23. Staff E reported that there was an incident between Staff A, Staff B and Resident #8. The Administrator stated she then spoke to Staff A and brought her in to do her statement. Staff A told the Administrator that the morning of 7/4/23, Staff B was assisting Staff A with cares. Staff B had Resident #8's hands and Resident #8 said she was going to hit Staff B when Staff B took her hands and waved them around in her face. Staff A could not tell me if she actually saw him hit Resident #8. Staff A had told the Administrator that what Staff A heard was Resident #8 saying 'I'm going to hit you' and Staff B kind of waving Resident #8's hands around in her face. Resident #8 then said 'you hit me' and then Staff B left the room. Staff A told the Administrator that Staff B said 'no you hit yourself' because he had her hands. The Administrator stated that it was hard to find out the actual facts. The Administrator stated that they needed to suspend Staff B immediately until they could fully investigate the situation and she did not like hearing about this incident. She stated that was not who they were. She stated that the Director of Clinical Services was with her through this interview and pretty much through the whole thing. She stated after she got Staff A's statement, they let Staff B know that he was suspended and that there was an investigation, and then reported it to the State Agency. This Administrator said they then talked to Staff E and Staff F, their night nurses about Staff B's behavior and at that point they decided that Staff B needed to be terminated. Neither Staff E nor Staff F were aware of the 4th of July incident. The Administrator asked about other incidents and they did not say anything further to the Administrator about knowledge of other incidents. Neither of them said there was anything they had seen that was reportable. They both said Staff B had a short fuse but had no specific incidents. The Administrator stated that Staff F did not mention the incident with Resident #9. The Administrator stated they then brought Staff B in and terminated him. Staff B stated he didn't know what they were talking about and he wouldn't sign the discipline sheet because he didn't agree with it. The Administrator stated that Staff B told them he had no recollection of any incident. The Administrator reported she would not suggest that staff would hold on to residents' hands. The Administrator stated they started educating for staff to put hands up and shield yourself but not to actually hold resident's hands down. They educated on reassurance, re-approaching, using another staff to try as well for interventions. She said that was the end of their investigation. She stated they did education on reporting and types of abuse. The Administrator stated that the month of August was focused on education on abuse, reporting, who to report to, and those who are at high risk for abuse. The Administrator stated they had to go through with the CNAs who their Supervisor was and that it wasn't Staff C, it was the ADON and before that it was the DON. On 10/3/23 at 11:49 p.m., Staff E stated that Staff A had come to her with concerns and Staff A made a report on what she witnessed. She said she had to ask Staff B to leave the room. She said that Resident #8 was yelling and Staff B didn't handle it well. Staff E thought that Staff B put his hand over her mouth, or something like that and he scared Resident #8. Staff A stated that she wanted to let Staff E know because Staff A had reported it and nothing had been done, and asked if Staff E would help her handle this. Staff E stated that they then went into the Nurse's Office and called the Administrator. Staff E thought it was around 5:00 in the morning. She stated that Staff B was not working that night. Staff E wrote out a statement with exactly how Staff A had worded it to Staff E. She stated that it was an allegation that Staff A had reported at an earlier date to a nurse and then she wrote a statement out and put it in the Administrator's mailbox. Staff E talked to the Administrator about it and the Administrator said she had not received the statement. Staff E stated Staff A's statement was that Staff B took Resident #8's arm and kind of put it in her chest and then rubbed her hands in her face. Staff E stated it was almost like he was making fun of Resident #8. Staff E stated that Staff A did not say who the other nurse was that she reported this incident to. Staff E stated the only other night nurse was Staff F, RN. Staff E stated that she physically, herself never saw any actual abuse. Staff E stated that Staff B's temperament upon hire showed lack of education and that Staff B's ability to understand Alzheimer's disease and dementia was limited. She stated that Staff B was a new CNA right out of school and seemed to really have no grasp that the residents with dementia actually didn't know what they were doing. Staff E said that Staff B would get frustrated and walk outside and she had told him before to go outside because he seemed stressed out. Staff B stated there was an incident before that involved Staff B and it was unfounded. Staff E stated there was a lot of education after that incident on dementia training. A handwritten note provided by Staff F written to the DON and the Administrator and dated 7/3/23 at 4:03 a.m., documented the following: An incident between Staff B and Resident #9 was witnessed by herself (Staff F) at 4:03 a.m., on 7/3/23 in the dining room. There were 3 other residents in the dining room as well as Resident #9. Staff F was standing at the medication cart and saw the commotion initiated between the 2. The light was off on the southwest side of the dining room. Resident #9 went to turn on the light switch by the fire alarm. In the dark it looked like she was going to pull the alarm, and Staff F asked her not to, so Resident #9 turned on the light. Staff B asked Resident #9 why did you turn that on, and she said he's (one of the other residents) was in the dark. The resident was asleep and had chosen to be there. Resident #9 began to holler at Staff B. Staff B answered her and then Resident #9 said 'I am going to hit you'. Staff B replied 'no you are not'. Resident #9 raised her hands toward his face which Staff B raised his hands grasping her wrists. Resident #9 was hollering. Staff F told them to stop. They separated and Resident #9 was encouraged to go to her room, which she did. Staff F did speak with Staff B about needing not to respond to her outbursts. A review of the July's schedule revealed that Staff B worked the following nights shifts (10 p.m. to 6 a.m.): a. On 7/2/23. b. On 7/4/23. c. On 7/5/23. d. On 7/6/23. e. On 7/7/23. f. On 7/10/23. g. On 7/11/23. h. On 7/12/23. i. On 7/13/23. An Abuse Policy updated on 10/2022 directed the following: a. Purpose: To ensure all residents are protected from the threat of abuse and all allegations of abuse are properly investigated. b. Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. Investigation Protocols: Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident: 1. Review documentation in resident record (including review of assessment if resident injury). 2. Assess the resident for injury if the allegation involves physical or sexual abuse; 3. Provide proper notifications to primary care provider, responsible party, etc. 4. Attempt to obtain witness statements (oral and/or written) from all known witnesses. 5. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections & Appeals. This written report shall be forwarded to the Department within five days of the initial report. Initial/Immediate Protection During Facility Investigation: Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances (3) separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents.

Based on clinical record review, Resident Group and staff interviews, observation and facility policy review, the facility failed to ensure residents were free from abuse when facility staff did not follow their policy of reporting, investigating and protecting the residents from abuse. Through interviews with various staff, it was found that staff did not report their concerns of potential abuse (Residents #8, #10, and #13) or reported their concerns to the Director of Nursing (DON) allowing a thorough investigation to follow (Resident #9). The facility reported a census of 54 residents. Findings Include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #8 included non-Alzheimer's dementia and schizophrenia. A Brief Interview for Mental Status (BIMS) documented as being unable to complete. The MDS identified the resident's cognitive skills for daily decision making was severely impaired. Resident #8 required extensive assist of 2 staff for bed mobility, transfer, dressing and toilet use. A Care Plan with a Focus Area initiated on 2/9/23, directed staff that Resident #8 displayed mood and behavior problems related to diagnosis of schizophrenia and unspecified dementia with agitation, diagnosis of adjustment disorders with mixed anxiety and depressed mood. This Care Plan had interventions initiated on 2/9/23, that directed staff to: a. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, encourage as much participation/interaction by the resident as possible during care activities. b. Give clear explanation of all care activities prior to and as they occur during each contact. c. If resident resists with Activities of Daily Living (ADL's), reassure resident, leave and return 5-10 minutes later and try again. d. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. e. Provide resident with opportunities for choice during care provision. f. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. A Progress Note with a late entry date for 7/14/23, documented that Resident #8's son spoken to regarding an allegation of abuse. The incident was explained and questions were answered. It documented that the son voiced understanding. There were no documented Progress Notes dated 7/4/23. 2. An MDS dated [DATE], documented that Resident #9's diagnoses included non-Alzheimer's dementia. A BIMS documented a score of 15 out of 15, which indicated intact cognition. This MDS documented Resident #9 usually understood others and usually could make herself understood. The resident identified independent for transfers and locomotion on and off the unit and required limited assist of 1 for toilet use. An MDS dated [DATE], documented Resident #9's BIMS score was 12 out of 15, which indicated moderately impaired cognition. This MDS documented that Resident #9 usually understood others, usually could make herself understood and had non-traumatic brain disfunction. A Care Plan with a Focus Area initiated on 3/23/20, directed staff that Resident #9 had potential for impaired cognitive and communication function related to her diagnosis of multi system atrophy and dementia. This can affect her speech at times and her decision making. This Care Plan had interventions initiated on 3/23/20, that directed staff to: a. Assist Resident #9 with her decision making and ensure safety to highest extent possible. b. Allow adequate time to respond, repeat as necessary. Do not rush. Request clarification from her to ensure understanding. c. Face when speaking. Make eye contact. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. d. Continue to engage Resident #9 in communication with cares and interactions. e. Use calm approach when assisting her with her ADL functions. There were no documented Progress Notes dated 7/3/23. 3. An MDS dated [DATE], documented diagnoses for Resident #10 included non-Alzheimer's dementia. A BIMS score for Resident #10 was 00, which indicated severe cognitive impairment. Resident #10 identified totally dependent on 2 staff for bed mobility, dressing and toilet use. A Care Plan for Resident #10 had a Focus Area dated as initiated on 3/23/22, that directed staff that Resident #10 had physical behaviors and verbal outbursts toward the staff when they are assisting with his ADLs related to his diagnosis of dementia and anxiety. This Care Plan had interventions initiated on 3/23/22, that directed staff to: a. Encourage as much participation/interaction by Resident #10 as possible during care activities. b. Give clear explanation of all care activities prior to and as they occur during each contact. c. If Resident #10 is resistive with ADLs, reassure resident, leave and return 5-10 minutes later and try again. 4. An MDS dated [DATE], documented diagnoses for Resident #13 included Traumatic Brain Injury. Resident #13 BIMS score was 15 which indicated intact cognition. This resident required extensive assist of 1 for dressing, which included the putting on and removing of TED hose (compression stockings). A Care Plan with for Resident #13 had a Focus area dated as initiated on 4/5/22, that directed staff that Resident #13 has an ADL self-care performance deficit related to history of falls at home and issues with chronic and acute pain at times, advanced age and history of arthritis. The Care Plan had interventions initiated on 4/5/22, directed staff to allow sufficient time for dressing and undressing. Staff will need to assist this resident with all his dressing needs of upper and lower extremities as needed. Extensive assistance at times due to limitations with his arthritis. On 9/21/23 at 1:00 p.m., during a resident meeting the residents present were asked if they had been neglected or abused or if they had seen any other residents being neglected or abused. Resident #13 reported there was a guy and a girl that worked in the middle of the night. He stated the guy just didn't have any patience with him. Resident #13 stated he didn't remember the situation specifically but remembered being very unhappy with the male staff member. Resident #13 stated the man no longer worked at the facility and unable to recall the male staff member's name. On 9/26/23 at 4:49 p.m., Staff A, Certified Nurse Aide (CNA), stated that on 7/4/23 at 1:00 a.m., she and Staff B, CNA were doing rounds. Staff A stated that they had went into Resident #8's room to check and change the resident. Staff A stated that typically if there were 2 people one of them would just hold Resident #8's hands and hold them up away from the adult brief. Staff A stated that Staff B grabbed this resident's hands pretty quick and it triggered Resident #8. Resident #8 then called Staff B the devil. Staff A said that Staff B got this look on his face like a 'well I'll show you' kind of look. She stated that Staff B then pushed Resident #8's hands up into her face and that's hard to do. Staff A continued that it was hard to just hold this resident's hands out of the way, let alone move her hands. Staff A stated that Staff B pushed this resident's hands up into her face causing her to hit herself. Staff A stated that this resident kind of like yelled/wailed 'oh my god you hit me in my mouth'. Staff A stated that Staff B told Resident #8 that she 'hit herself'. Staff A stated she then hurried up and got Staff B out of there. Staff A stated that Staff B didn't say anything to Staff A after they left the room and Staff A didn't say anything to Staff B. Staff A stated she really didn't know what to say. Staff A stated she wasn't sure who to report it to since Staff B's spouse was the Supervisor. Staff A added that a couple of weeks prior to this incident, Staff B had told this resident very sternly, like how you would talk to a child, to 'be an adult'. Staff A stated she thought Resident #8 was swatting out at the time. Staff A stated that this resident was kind of modest and reported since this incident, staff have been going in 1 staff member at a time. Staff A explained this resident would say things like 'stop looking at my body'. Staff A said that they've learned that she does much better with one person. Staff A acknowledged she didn't report this incident right away. Staff A reported she knew of another incident that was reported where a resident was flicked in the ear. She stated that another CNA had reported this to Staff C, Certified Medication Aide (CMA)-CMA/CNA Coordinator who was also Staff B's spouse. Staff A stated that they changed the report from flicked him in the ear to brushed his ear when she was getting him ready. Staff A explained Staff C was in charge of the CNAs and educates the CNAs if they need education. Staff A stated that she should have reported the incident earlier, but she had written a letter to the Administrator and put it in her mailbox. Staff A stated the next day the letter was gone. Staff A stated that she had heard that Staff C and the Assistant Director of Nursing (ADON) were going around and asking others if they had ever seen Staff B act out toward residents. Staff A reported she had not seen Staff B ever lay hands on a resident before but he would lash out at staff. She stated that Staff B would go into a resident's room, like an independent resident who would want help with compression stockings and creams on. Staff B stated that Resident #13 was independent and Staff B would get really snippy with Resident #13. Staff A said she had not heard Staff B say anything to Resident #13, but Staff B came out and told Staff A that he (Staff B) had told Resident #13 that he was independent and needed to do those things for himself. Staff A stated this happened approximately 2 weeks before the incident with Resident #8. Staff A reported she didn't know that the Administrator didn't get her letter. Staff A stated Staff D, reported she had seen Staff B do stuff like this all the time. Staff A explained that Staff D said she hadn't reported anything because Staff B's spouse was Staff D's Supervisor. Staff A stated that there was a fear of retaliation with reporting and she didn't know if they would do anything about it anyway, since they changed the other report. On 9/27/23 at 10:00 a.m., the Administrator stated she had the DON write up the incident with coaching and counseling and her assessment on Resident #9. The Administrator found this incident happened the day before the Facility Self-Reported Incident of Staff B with Resident #8. On 9/27/23 at 10:15 a.m., Resident #9 was propelling her wheelchair with her feet into her room. This resident was pleasant and smiled. She gave permission to enter her room and to ask her questions. Resident #9 stated that she did not have any issues with staff. She said sometimes her roommate can be annoying. When asked if any staff had grabbed her wrists or yelled at her, she said she didn't remember anything like that happening. On 9/27/23 at 10:35 a.m., the Director of Clinical Services and the Administrator requested to talk about the incident between Resident #9 and Staff B. The following discussed: a. There was no assurance of separation between Resident #9. b. This happened in an open space and Staff B could have stepped away. c. Staff B proceeded to argue/yell at this resident instead of using a different therapeutic approach. d. There was no assessment of Resident #9 documented, as Staff F did not assess Resident #9. e. No documentation of the whole incident nor was there follow up to it until the Administrator asked the DON to write up the coaching and counseling for Staff B and the assessment of Resident #9 that was provided on this day. f. Other residents were out in the dining room at the time of this incident and there was no follow up with them. g. Resident #9 had impaired cognition and short-term memory loss, but the DON stated that Resident #9 denied anything happening and did not look into this further. h. The incident between Staff B and Resident #9 happened the day before the incident between Staff B and Resident #8 happened. If the incident between Staff B and Resident #9 would have been properly investigated and reported to the State Agency, the other incident may not have happened. i. The facility allowed Staff B to work with dependent adults until the incident was reported on 7/14/23 and Staff B was terminated. The Director of Clinical Services and the Administrator acknowledged all of the above concerns and had no further questions. On 9/27/23 at 12:16 p.m., Staff F, Registered Nurse (RN), when asked if she had any concerns with how the staff have treated residents, she answered that she had notified the DON of a concern she had. She stated that Staff B had an incident with Resident #9. Staff F stated that Resident #9 was up in the middle of the night and she went toward the fire alarm but there was also a light switch next to it. Staff F stated she told Resident #9 'no, don't do that'. Staff F stated that Staff B and Resident #9 verbally got into it and Resident #9 said she was going to hit Staff B. Staff F stated that Staff B went to stop Resident #9 who was in a wheelchair. Staff F stated that Staff B took his hands and put them on this resident's wrists so she couldn't hit. Staff F stated she told them both to quit and they both quit but they were still screaming at each other. Staff F stated this took place in the dining room. Staff F stated she didn't recall what date this happened on but it was around 4:00 a.m. in the morning. Staff F stated Staff B then went outside. Staff F stated that sometimes staff B would get short with people in general. Staff F said she couldn't give any examples. Staff F stated she did not have her notes, but the DON had a copy of them. On 9/27/23 at 2:18 p.m., Staff D stated she had talked with the Administrator at work. Staff D said she had seen Staff B holding down Resident #10 in bed and happened probably a year ago. She stated she had asked Staff B to stop and maybe see if they could get someone else to come into the room, and Staff B said 'no, let's just get it done'. Staff D stated she had reported this to Staff C. Staff D explained that when she would work with Resident #10 she would explain to him what she was doing and Resident #10 would not get agitated. Staff D stated that Staff B would just want to get things done and go into residents' rooms and rush and not do things correctly. Staff D reported she had also seen Staff B holding down Resident #8 in bed while trying to do cares. Staff B stated that she had been in both rooms by herself and both residents are absolutely fine if you explain what you are doing and not rush through. Staff D stated that it was not common practice to hold down Resident #8's hands and had never seen that happen, until sometime in June. Staff D explained she didn't report this incident, as she started to feel like why report it because nothing gets done with it. Staff D stated she definitely felt like it was excessive force, almost like a restraint. and she mentioned it to one of the, Charge Nurses on the night shift, Staff E, Registered Nurse (RN). Staff D stated that Staff E was the only one who actually felt like it needed to be taken further. Staff D stated she wrote down both of the instances and gave it to Staff E. Staff D stated they talked with the Director of Clinical Services and the Chief Operations Officer about the situations. Staff D stated she felt like she needed to report these things as she was someone taking the Dependent Adult Abuse (DAA) training. Staff D stated she felt like Staff C tried to cover up for Staff B because she worked in the office. Staff D stated that Staff B was working at a new place and it kind of worried her that Staff B was allowed to take care of people. On 9/27/23 at 3:31 p.m., the DON stated she had found out about the recent abuse complaint about a day after the Administrator and the Director of Clinical Services found out about it. She stated her only thought was why would Staff A wait so long to report it. The DON stated she personally felt bad for Staff B, just because of his compassion that he had for the elderly. The DON stated that if she witnessed something like that they would be fired immediately. The DON stated she didn't know if Staff A was making it up, but stated she knew that Staff B liked things a certain way. She stated, for example if he went to work and staff hadn't taken the trash out, he would be upset about it. The DON stated that one night that happened when she was working and she just said to him just go ahead and take the trash out, and he did. The DON stated she did not know anything about Resident #10 being held down on his bed. She stated that Resident #10 was a hard resident to do cares on. The DON stated that Staff F called the DON sometime between May and July, she'd have to look at her phone to see when, as she didn't write it down. The DON said that Staff F had woke the DON up. The DON stated she was told it had to do with Resident #9. The DON stated that Staff B was in Resident #9's room and the resident got mad at Staff B and she tried to slap him in his face. The DON believed that Staff F had written the DON a note. Resident #9 was sitting at southeast door looking out at the garden, that morning when the DON came in. The DON stated she didn't remember what time it was. The DON stated she had looked at Resident #9's skin and wrists and didn't see anything. The DON stated she had asked her if anything happened last night, anything with staff, did you wake up and something happen with the staff, and Resident #9 said no. The DON asked her if there was anything she wanted to report and Resident #9 said no. The DON stated that she thought she talked with Staff B, later that day. The DON stated she thought Resident #9 was a poopy mess and staff B was trying to help her, because that was a normal situation for her. The DON thought that Resident #9 scared Staff B as Resident #9 was a strong lady and she could hurt him. The DON thought Resident #9 was trying to hit him and he just kind of put his hand up and kind of tried to stop her from hitting him. The DON thought they were in Resident #9's room and Staff B was trying to help change her. The DON stated she would look for the note that Staff F had wrote but did not know if she had it. When asked if this incident could have happened in the dining room as that is what Staff F had reported, the DON said yes. The DON stated she remembered that now. Asked the DON if Resident #9 could give an accurate interview. The DON acknowledged that Resident #9 had moderately impaired cognition and short-term memory problems as well. The DON thought Staff F separated Staff B from Resident #9. This DON was pretty sure Staff B was already gone from the facility by the time the DON arrived as she had to call him later. She stated when she talked with Staff B, he said 'yeah, I'm not going to be the one who tells her to turn off the light switch.' The DON stated Resident #9 could get mad pretty quickly. When asked if staff should argue with residents, she said no. When asked if there was room to back away from Resident #9 if she said she was going to hit him, the DON said yes at that time of night in the dining room there would have been plenty of room. When asked if Resident #9 had ever pulled the fire alarm, the DON said no. The DON said she didn't formally coach or counsel Staff B. She said that she just talked with him about it. She will look to see if she can find when the call came in, what date and time. On 9/28/23 at 8:48 a.m., Staff F stated that she found the note that she left for the DON. She stated she had sent a text around 4:00 a.m. in the morning to the DON. The DON text back and said to leave a note and she would follow up in the morning. When asked about separating Staff B and Resident #9, Staff F stated that Resident #9 went to her room after the incident. Staff F stated she did not see Staff B go back down toward Resident #9's room. Staff F stated she had let the DON know about Resident #9 saying her wrists hurt, and the DON told Staff F that she would assess Resident #9 when she got in, so Staff B did not assess Resident #9. Staff F said that after the incident she started medication pass, so couldn't ensure that Staff B didn't go into Resident #9's room. On 9/28/23 at 5:30 p.m., Staff C stated that she had never received a report from another CNA regarding Staff B (spouse) holding a resident down. She stated if she did receive a report of this, she would report it on even though if it was family. She stated she would encourage reporting of any question of abuse be reported on to a nurse not her. She stated she had worked for many years at the facility and that the facility important to her and she really cared for the residents and would never do anything to jeopardize their safety. On 10/2/23 at 3:16 p.m., the Director of Clinical Services (DCS) stated that the Administrator called and said they had a report of abuse. The DCS told the Administrator she would help with investigations. They called Staff B in and interviewed him. They then interviewed Staff A. The DCS assessed Resident #8. The DCS stated it had been a while but she thought it was worth a shot to ask Resident #8 if she remembered anything, and Resident #8 did not. Staff B demonstrated what happened with Resident #8. The DCS stated that she would be Resident #8, and Staff B was to show the DCS what happened. Staff B batted at the DCS's arms but never grabbed her on her wrists like what was reported. Staff B was angry and made a comment that he felt like he was being targeted. Staff B didn't mention any names of who he would have been targeted by. The DCS stated they suspended him right away as they wanted to remove him from the situation until it was investigated. She stated it was a pretty brief interview and that Staff B was pretty angry as it was the 2nd time he had been suspended for a similar situation. Another combative resident was trying to hit Staff B and he was holding his hands so that the resident could not hit him. She stated they talked with Staff A and basically Staff A repeated what her statement was- Resident #8 was trying to be combative with Staff B. Staff B held her wrists and was wiggling her hands. Staff A told this DCS and the Administrator that she heard Resident #8 say you hit me and Staff B said no I didn't, you hit yourself. Staff A had written a statement. As soon as the Administrator was notified of the situation, it was investigated. The DCS stated it was hard to say if there was a letter put into the mailbox, but the Administrator never got a letter. Nothing was ever found and it's a pretty secure mailbox, she thought a key was needed to open it and no letter was found. The DCS stated that no one had said anything to her about being uncomfortable with reporting to their supervisor. She stated that if staff were in the nursing department, they should report to the DON. On 10/2/23 at 3:38 p.m., the Administrator stated she received a call from employee Staff E, saying that Staff A had approached her with this incident and she wasn't sure how to handle it. This happened the morning of 7/4/23 and both Staff A and Staff E had worked that night into the morning of 7/4/23. Staff E reported that there was an incident between Staff A, Staff B and Resident #8. The Administrator stated she then spoke to Staff A and brought her in to do her statement. Staff A told the Administrator that the morning of 7/4/23, Staff B was assisting Staff A with cares. Staff B had Resident #8's hands and Resident #8 said she was going to hit Staff B when Staff B took her hands and waved them around in her face. Staff A could not tell me if she actually saw him hit Resident #8. Staff A had told the Administrator that what Staff A heard was Resident #8 saying 'I'm going to hit you' and Staff B kind of waving Resident #8's hands around in her face. Resident #8 then said 'you hit me' and then Staff B left the room. Staff A told the Administrator that Staff B said 'no you hit yourself' because he had her hands. The Administrator stated that it was hard to find out the actual facts. The Administrator stated that they needed to suspend Staff B immediately until they could fully investigate the situation and she did not like hearing about this incident. She stated that was not who they were. She stated that the Director of Clinical Services was with her through this interview and pretty much through the whole thing. She stated after she got Staff A's statement, they let Staff B know that he was suspended and that there was an investigation, and then reported it to the State Agency. This Administrator said they then talked to Staff E and Staff F, their night nurses about Staff B's behavior and at that point they decided that Staff B needed to be terminated. Neither Staff E nor Staff F were aware of the 4th of July incident. The Administrator asked about other incidents and they did not say anything further to the Administrator about knowledge of other incidents. Neither of them said there was anything they had seen that was reportable. They both said Staff B had a short fuse but had no specific incidents. The Administrator stated that Staff F did not mention the incident with Resident #9. The Administrator stated they then brought Staff B in and terminated him. Staff B stated he didn't know what they were talking about and he wouldn't sign the discipline sheet because he didn't agree with it. The Administrator stated that Staff B told them he had no recollection of any incident. The Administrator reported she would not suggest that staff would hold on to residents' hands. The Administrator stated they started educating for staff to put hands up and shield yourself but not to actually hold resident's hands down. They educated on reassurance, re-approaching, using another staff to try as well for interventions. She said that was the end of their investigation. She stated they did education on reporting and types of abuse. The Administrator stated that the month of August was focused on education on abuse, reporting, who to report to, and those who are at high risk for abuse. The Administrator stated they had to go through with the CNAs who their Supervisor was and that it wasn't Staff C, it was the ADON and before that it was the DON. On 10/3/23 at 11:49 p.m., Staff E stated that Staff A had come to her with concerns and Staff A made a report on what she witnessed. She said she had to ask Staff B to leave the room. She said that Resident #8 was yelling and Staff B didn't handle it well. Staff E thought that Staff B put his hand over her mouth, or something like that and he scared Resident #8. Staff A stated that she wanted to let Staff E know because Staff A had reported it and nothing had been done, and asked if Staff E would help her handle this. Staff E stated that they then went into the Nurse's Office and called the Administrator. Staff E thought it was around 5:00 in the morning. She stated that Staff B was not working that night. Staff E wrote out a statement with exactly how Staff A had worded it to Staff E. She stated that it was an allegation that Staff A had reported at an earlier date to a nurse and then she wrote a statement out and put it in the Administrator's mailbox. Staff E talked to the Administrator about it and the Administrator said she had not received the statement. Staff E stated Staff A's statement was that Staff B took Resident #8's arm and kind of put it in her chest and then rubbed her hands in her face. Staff E stated it was almost like he was making fun of Resident #8. Staff E stated that Staff A did not say who the other nurse was that she reported this incident to. Staff E stated the only other night nurse was Staff F, RN. Staff E stated that she physically, herself never saw any actual abuse. Staff E stated that Staff B's temperament upon hire showed lack of education and that Staff B's ability to understand Alzheimer's disease and dementia was limited. She stated that Staff B was a new CNA right out of school and seemed to really have no grasp that the residents with dementia actually didn't know what they were doing. Staff E said that Staff B would get frustrated and walk outside and she had told him before to go outside because he seemed stressed out. Staff B stated there was an incident before that involved Staff B and it was unfounded. Staff E stated there was a lot of education after that incident on dementia training. A handwritten note provided by Staff F written to the DON and the Administrator and dated 7/3/23 at 4:03 a.m., documented the following: An incident between Staff B and Resident #9 was witnessed by herself (Staff F) at 4:03 a.m., on 7/3/23 in the dining room. There were 3 other residents in the dining room as well as Resident #9. Staff F was standing at the medication cart and saw the commotion initiated between the 2. The light was off on the southwest side of the dining room. Resident #9 went to turn on the light switch by the fire alarm. In the dark it looked like she was going to pull the alarm, and Staff F asked her not to, so Resident #9 turned on the light. Staff B asked Resident #9 why did you turn that on, and she said he's (one of the other residents) was in the dark. The resident was asleep and had chosen to be there. Resident #9 began to holler at Staff B. Staff B answered her and then Resident #9 said 'I am going to hit you'. Staff B replied 'no you are not'. Resident #9 raised her hands toward his face which Staff B raised his hands grasping her wrists. Resident #9 was hollering, and Staff F told them to stop. They separated and Resident #9 was encouraged to go to her room, which she did. Staff F did speak with Staff B about needing not to respond to her outbursts. A review of the July's schedule revealed that Staff B worked the following nights shifts (10 p.m. to 6 a.m.): a. On 7/2/23. b. On 7/4/23. c. On 7/5/23. d. On 7/6/23. e. On 7/7/23. f. On 7/10/23. g. On 7/11/23. h. On 7/12/23. i. On 7/13/23. A Facility Abuse Policy updated on 10/2022 directed the following: a. Purpose: To ensure all residents are protected from the threat of abuse and all allegations of abuse are properly investigated. b. Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. Employee Screening: The facility shall screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. The facility will not employ or otherwise engage individuals who: (i) Have been found

Based on clinical record review, staff interview and policy review, the facility failed to develop a Comprehensive Person Centered Care Plan for 1 of 17 residents reviewed (Resident #25). The facility reported a census of 50 residents. Findings Include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #25 admitted to the facility on [DATE] and readmitted on [DATE]. The MDS identified the resident with diagnosis that included chronic obstructive pulmonary disease, dysphagia, dementia, major depressive disorder, delusional disorder, ulcerative colitis, ischemic heart disease, anemia, peripheral vascular disease, diabetes mellitus, cognitive communication deficit and generalized anxiety disorder. Resident #25's MDS revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severely impaired cognition. The resident required extensive assistance of 2 staff for bed mobility, total dependence of 2 staff for transfers and toileting and supervision with set-up for eating. Resident #25 received insulin, antipsychotic, antianxiety, antidepressant, antibiotic, and diuretic daily in the 7 day observation period. The Care Plan dated 11/20/17 with target dates of 2/18/23 revealed focus areas for resident #25 that included: a. An activities of daily living deficit related to amputation and chronic pain. b. History of falls. c. History of urinary tract infections and neuropathy. d. Potential for impaired cognitive functioning and communication related to dementia. e. Depression and anxiety, need for antidepressant and antianxiety medications. f. The potential for nutritional problem. g. Potential for impaired skin integrity. The Care Plan lacked information that pertained to the resident's diabetes mellitus and need for insulin. Review of December 2022 Medication Administration Record (MAR) for Resident #25 revealed the resident received Humalog (Lispro) insulin 10 units subcutaneously daily. Lantus insulin 35 units subcutaneously at bedtime and Humalog (Lispro) insulin sliding scale subcutaneously two times a day as follows: a. Blood Sugar of 151-200 = 4 units b. Blood Sugar of 201-250 = 6 units c. Blood Sugar of 251-300 = 8 units d. Blood Sugar of 301- 350 = 10 units e. Blood Sugar of 351-400 = 12 units f. Blood Sugar of 401- 450 = 14 units In an interview on 12/8/22 at 11:05 AM, the Director of Nursing stated she expected for each resident have all their needs addressed on the Care Plan and that it is updated as needed and appropriate. In the facility provided policy titled Care Plans - Comprehensive, it stated the comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. It further stated each resident's comprehensive care plan is designed to incorporate identified problem areas and risk factors associated with the identified problems and reflect treatment goals, timetables and objectives in measurable outcomes.

Based on observation, record review, resident interview, staff interviews, and policy review the facility failed to implement new interventions on Care Plans (Resident #5 and #15) and to ensure resident participation in Quarterly Interdisciplinary Team Meeting for Care Planning (Resident #32) for 3 of 17 residents reviewed. The facility reported a census of 50. Findings Include: 1. Minimum Data Set (MDS) Assessment for Resident #15 dated 11/27/22 included diagnoses of non-Alzheimer's dementia, pneumonia, shortness of breath, Parkinson's disease and encephalopathy. The MDS listed the Resident's Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating is cognition moderately impaired. The Progress Notes for Resident #15, dated 12/2/2022 by the Director of Nursing (DON) stated resident is alert and she has oxygen on at two liters nasal cannula, oxygen saturation is initially 93% then with some deep breathing up to 97%, lung sounds are clear, she complained of feeling very tired and reports some shortness of breath with exertion, this is somewhat of her baseline. The residents record informed of return from the hospital on 11/23/22 diagnosis of pneumonia. The Medication Administration Record (MAR) for Resident #15 documented oxygen may be applied at two Liters, nasal cannula to keep oxygen blood saturation above 90 percent, every four hours as needed due to pneumonia, shortness of breath and low oxygen start date 11/28/2022. Review of Resident #15 record in the hard chart revealed a Care Plan Meeting Note dated 11/30/22 documented summary noted recent pneumonia, two emergency room visits, order changes related to pneumonia. Observation on 12/05/22 at 11:51 AM Resident #15 in her room recliner stated I need air oxygen was not on, Staff A, Licensed Practical Nurse (LPN) summoned and assisted with getting nasal cannula on resident. Resident stated I am not sure why the oxygen was not on. Interview on 12/07/22 at 2:02 PM with the DON, included review of the Care Plan that did not include the resident's oxygen needs. The DON acknowledged the new order for oxygen related to pneumonia. The DON also acknowledged the Care Plan Meeting followed hospitalization for the resident Care Plan review and updates, and the oxygen order should be included on the resident's Care Plan . 2. The MDS Assessment for Resident # 32 dated 9/24/22, included diagnoses of heart failure, anemia, macular degeneration, osteoarthritis and pain. The MDS listed the Resident's BIMS score of 15 indicated is cognitively intact. The Progress Notes for Resident # 32 dated 9/20/2022 at 11:06 titled Social Services documented family is involved in care however Resident #32 makes her own decisions. In an Interview on 2/06/22 7:49 AM Resident #32 stated she had not been to any meetings for Care Planning, voiced, would like to attend care plan meetings. Interview on 12/07/22 at 2:02 PM, the DON voiced formal Care Plan Meetings have gone on the wayside since COVID, relayed we don't have a place for formal Care Plan Meetings. The DON reported she signed the residents' name on the Care Conference Summary Sheets. 44972 3. The MDS assessment dated [DATE], recorded Resident #5 admitted to the facility on [DATE] and readmitted on [DATE]. Res #5's MDS revealed a BIMS of 7 out of 15, indicating severe cognitive impairment and diagnosis including chronic obstructive pulmonary disease, dependent personality disorder, type II diabetes mellitus, major depressive disorder, kidney failure, acute cystitis with hematuria, anemia, anxiety disorder and post-traumatic stress disorder. The MDS coded Resident #5 as requiring total dependence of two staff for toileting and frequently incontinent of bowel and bladder. Progress Notes indicated the following relating to the resident's urinary tract infections (UTI): a. On 8/19/22 at 7:46 PM, it was noted the resident was not acting herself, was unable to verbalize her needs but when asked if she wanted to go to the emergency room (ER) she replied she did if she needed to. Resident #5's skin was pale, warm and dry and her vital signs stable, her lungs were clear to auscultation and her bowel sounds were present in all 4 quadrants. b. On 8/19/22 at 7:56 PM, an order was received to send the resident to the ER for evaluation and treatment. c. On 8/19/22 at 8:40 PM, Emergency Medical Service arrived and transported resident to the local ER. d. On 8/20/22 at 1:24 AM, the hospital notified the facility Resident #5 was admitted to the medical floor with a diagnosis of acute cystitis and pneumonia. Resident was being treated with intravenous (IV) antibiotics and fluids for dehydration. e. On 8/22/22 at 11:20 AM, the hospital notified the facility the resident would be returning to the facility via ambulance. She was treated for a urinary tract infection (UTI) with IV Levaquin and would be transitioned to oral antibiotics upon her return. f. On 8/22/22 at 12:10 PM, Resident #5 returned to facility via ambulance. She was alert to name, room and place but otherwise slow to respond. Her vital signs were stable. She denied any symptoms of a UTI. g. On 10/6/22 at 8:38 PM, an order was received for a urinalysis (UA) with culture and sensitivity related to resident having dark colored and foul smelling urine. Resident #5 denied painful urination, however was incontinent and displayed frequent urination. h. On 10/7/22 at 9:24 AM, a urine sample was obtained and sent to lab. Resident denied dysuria, remained incontinent and her urine continued to have a foul odor. Fluid were encouraged. i. On 10/10/22 at 9:49 AM, the UA results were reviewed and an order was obtained to start Macrobid 500 mg twice daily for 5 days for diagnosis of UTI. j. On 10/10/22 at 11:42 AM, the resident started an antibiotic for UTI. Her temperature was 98.0. Her urine continued to have a strong foul odor. She denied any pain or frequency with urination. The Care Plan dated 8/13/13 with most recent update on 12/6/22 and target dates of 3/1/23 revealed focus areas related to the resident's need for assistance with her activities of daily living, her need for antidepressant medications, nutrition related to diabetes mellitus and obesity, motivation, chronic pain, and the potential for impaired skin integrity. The Care Plan dated 8/13/13 with most recent update on 12/6/22 and target dates of 3/1/23 failed to address Resident #5's actual or potential for UTI's after a hospitalization for a UTI in August 2022 and another UTI on October 2022. In an observation on 12/7/22 at 8:36 AM, Staff, B, Certified Nursing Assistant (CNA) and Staff C, CNA completed incontinence care for Resident #5. Resident was lying on her bed on her back with a hospital gown on and an incontinence brief. Staff performed cares using wet wipes. They cleansed the groins and mons pubis area then each labia and down the middle using one swipe one wipe method from front to back then dried the areas in the same manner. She was then assisted to her right side and her left buttock and hip were cleansed and then her rectal area using one swipe one wipe method wiping area from front to back. Area was then dried in the same manner. The staff then assisted the resident onto her left side and cleansed her right buttock and hip and then dried the area. A new incontinence brief was applied and resident was covered up and made comfortable upon completion. Resident tolerated the care well. Staff were noted to perform good hand hygiene, before, during and after and they used good infection control measures throughout the procedure. In an interview on 12/8/22 at 11:05 AM, the Director of Nursing (DON), stated she expected each resident have all their needs addressed on the Care Plan and that it gets updated as needed and appropriate. In the facility provided undated policy titled Care Plans - Comprehensive, it stated assessments of residents are ongoing and Care Plans are revised as information about the resident and the resident's condition change. It also stated the Care Planning/Interdisciplinary Team is responsible for the review and updating of Care Plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly.

Based on facility record review, staff interview and policy review, the facility failed to have the minimum required members at the Quarterly Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities are necessary. The facility identified a census of 50 residents. Finding Include: Per review of the Federal Regulation the required members at all QAA meetings are as follows: a. The Director of Nursing (DON). b. The Medical Director or his/her designee. c. At least three other members of the facility's staff, at least one of who must be the Nursing Home Administrator, owner, board member or other individual in a leadership role. d. The Infection Preventionist (IP). Review of facility QAA sign in sheets revealed the required Team Members were not present at all quarterly meetings: a. On 1/25/22 - missing the IP. b. On 5/6/22 - missing the DON. c. On 7/19/22 - missing the IP. d. On 10/25/22 - missing the Medical Director and IP. In an interview on 12/8/22 at 11:15 AM, the Administrator stated the expectation was that all required Team Members attend the Quarterly QAA meetings. Review of the facility Quality Assurance Performance Improvement (QAPI) Plan and Policy dated 2017 and updated annually, revealed the QAPI committee would consist of the Administrator, DON, Administrative Assistant, Maintenance Director, Dietary Supervisor, Medical Director, Infection Preventionist, and Pharmacy Consultant (as able to participate).

Based on review of resident Care Plans, clinical records, and staff interviews, the facility failed to update Care Plans for two of thirteen residents reviewed ( Resident #8 & #11) for significant changes and for skin integrity. The facility reported a census of 49 residents. Findings Include: 1. A Minimum Data Set (MDS) dated [DATE], revealed the Resident #8's Brief Interview for Mental Status (BIMS) documented as a 5 out 15 indicating cognition impaired. The resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan for Resident #8 revealed the resident at risk for skin impairment but failed to show a Care Plan entry for the resident's swelling or [CONDITION(S)]. An observation on 7/29/21 at 10:30 AM, revealed the resident to have swelling in her lower legs, the resident did not have any knee high stockings on. Both legs appeared to be very swollen. A follow-up observation on 8/03/21 at 1:20 PM, observation also showed the resident failed to have them the stockings on. Both legs appeared to be very swollen. An interview with the Administrator on 8/05/21 at 10:26 AM, revealed she believed the knee high stockings should be documented on the Care Plan. An interview with the Director of Nursing (DON) on 8/05/21 at 10:29 AM, revealed she believed the knee high stockings would not have necessarily been on the Care Plan. She reported the facility just received the Electronic Medical Administration Record (EMAR) back in the early spring and the staff are still learning the software. 2. The MDS assessment dated [DATE] for Resident #11, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident required extensive assistance of one staff for personal hygiene, extensive assistance of two staff for bed mobility, and total dependence on two staff for transfer and toilet use. A BIMS score of 15 indicated no cognitive impairment for decision-making. During an interview on 7/29/21 at 10:55 AM, Resident #11 stated wears a depends (incontinence pad), does not always know when she has to go to the bathroom and staff help her with cares. During an observation on 8/03/21 at 3:15 PM, Staff A, Certified Nursing Assistant (CNA) and Staff C, CNA provided incontinent cares for Resident #11 due to incontinent of bladder and bowel. Review of Resident #11's Care Plan, date initiated 11/20/17 and target date 8/17/21, documented: resident is aware when she needs to go to the bathroom and will ask for assist with this. She needs extensive assist of 2 to help her get on and off the toilet and then also for her personal care. She may use the bedpan as needed (prn) and uses the bed side commode also. Staff may use timer to help her remember when she went to the bathroom last and/or clip board to record time. This is a guide for resident to help alleviate behaviors and anxiety. During an interview on 8/04/21 at 12:55 PM, Staff A, CNA, stated worked with Resident #11 daily and the resident is always incontinent of bowel and bladder and cares are provided for resident by staff. Staff A, CNA, stated resident does not use toilet, bedside commode, or bedpan and has been this way for months. During an interview 8/04/21 at 4:15 PM, the Director of Nursing stated expected Care Plans to be updated when a change in resident care needs occurs.

Based on observations, clinical record review, family and staff interviews, the facility failed to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census reported a census of 49 residents. Findings Include: A Minimum Data Set (MDS) dated [DATE], the resident's Brief Interview for Mental Status (BIMS) is a 5 out 15, indicating cognition impaired. The resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 7/29/21 at 10:30 AM, revealed the resident to have swelling in her lower legs, the resident did not have any knee high stockings on. A follow-up observation on 8/03/21 at 1:20 PM, observation also showed the resident without the knee high stockings on. An interview on 8/3/21 at 1:20 PM, Resident #8's family member reported the resident utilized the knee high stockings and it didn't appear staff put them on the resident today. The family member looked around the room for the stockings and found them in a plastic bag in the night stand between the bed and the chair. The family member reported the resident's stockings missing before and she purchased more for her. An interview on 8/4/21 8:19 AM, the Administrator reported the resident sometimes refused her stockings or took them off. Later, the Administrator reported the reason the knee high stocking order did not show up on the MAR/TAR is because it was ordered under other and reported it should be fixed and ordered correctly to show up in the MAR/TAR.

Based on observations, facility policy review and staff interviews, the facility failed to keep foods items dated, check for outdated items in the Activity Room cupboards, maintain clean kitchenware, keep scoops out of drink powders, and provide a sanitary dining environment for residents. The facility reported a census of 49 residents at the time of the survey. Findings Included: 1. During an initial kitchen visit on 7/29/21 at 9:02 AM, a frying pan noted with black debris on the inside of pan. Three containers had scoops insides with handles touching the powder for: regular hot chocolate, a sugar free hot chocolate and a thick-it powder. In the freezer of the kitchen, a bag of sausage links opened and not dated. A tour of the Activity Room Kitchenette on 7/29/21 revealed three open mountain dew bottles with no dates when opened or names on them in the refrigerator. During a follow-up kitchen tour on 8/3/21, three containers had scoops inside with the handles touching the powder for: two thick its, and a sugar free hot chocolate. One of the thick-it containers did not have a date on it. A food Service policy dated for 2018 showed all food in the refrigerator or freezer will be covered, labeled, and dated. Food items and snacks kept on the nursing units must be maintained with resident's name on the item, have a use date on the item, and any beverages must be dated when opened and discarded after 24 hours. A follow-up Activity Room Kitchenette tour on 8/4/21 revealed the three open mountain dew bottles with no dates or names on them still in the refrigerator. An interview with Dietary Supervisor on 8/5/21 at 9:15 AM revealed, she cooked with the medium size frying pan only on occasion for grilled cheese sandwiches or when someone orders an egg for supper. She reported she knew a new one should be ordered. The Dietary Supervisor reported the kitchenette in the Activity Room is taken care of by the Activity Director. An observation on 8/5/21 at 9:15 AM revealed the Dietary Supervisor disposing of the medium frying pan into the trash. 2. During a dining observation on 7/29/21 at 11:24 AM, Staff E, Dietary Aide had her mask below her nose while she served residents. The dietary aide touched her mask with gloved hands and served a resident their lunch plate. The Dietary Aide gave a plate with food to Resident #28. Staff E then touched her mask while retrieving another lunch plate with food, and then handed a different resident the lunch plate. A COVID 19 response plan for Personal Protection Equipment (PPE) dated 5/4/21 revealed staff are to wear masks at all times when in resident areas regardless of COVID 19 or vaccination status. Staff should make sure not to touch the outer surface of the mask during cares.