Every finding on record at The Care Center of Dequincy

Based on record review and interviews, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#41) out 1 resident investigated for ADLs. Findings: Review of the facility's policy titled, Bathing a Resident, with a reported annual review date of November 2025 read in part: policy: residents will be assisted with bathing as needed. Resident baths will be scheduled per resident preference as possible or at least 3 times weekly. Review of Resident #41's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but not limited to, chronic diastolic (congestive) heart failure, anxiety disorder, unspecified, morbid (severe) obesity due to excess calories, bipolar disorder, unspecified and muscle weakness (generalized). Review of Resident #41's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/18/2025 revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. Further review of Section GG: revealed Resident #41 was dependent for shower/bathe. Review of Resident #41's care plan read in part, resident needs assist with ADLs. Interventions included.bathing/showering: The resident is totally dependent. Review of the CNA's (Certified Nursing Assistant) electronic bathing Monday, Wednesday and Friday task charting from 01/11/2026 to 02/09/2026 for Resident #41 revealed there was no documented bath for resident on 01/12/2026, 01/14/2026, 01/19/2026, 01/23/2026, 01/26/2026, 01/28/2026, 01/30/2026, 02/02/2026 and 02/04/2026. On 02/09/2026 at 10:25 a.m., an interview was conducted with Resident #41. She reported she had difficulty with getting a bath on her scheduled days. She stated her bath was not always given when she was supposed to get it. On 02/10/2026 at 12:35 p.m., an interview was conduct with S3CNA (Certified Nursing Assistant), shower aide. She reported Resident #41, required a bed bath and she provided the bath on Wednesdays, unless the floor CNA had already done the bath. She stated the CNAs on the unit provided the bed baths on Mondays and Fridays. S3CNA stated when she provided a bath/shower for the residents she would document the bath/shower in the residents' record. On 02/10/2026 at 12:46 p.m., an interview was conducted with S4CNA, she reported she was responsible for the care of Resident #41. S4CNA reported the shower aide was responsible for bathing/showering of all the residents. S4CNA stated if she gave a bed bath to Resident #41, she would only document it in the medical record if it was the residents scheduled bath day. On 02/10/2026 at 1:10 p.m., a record review and interview was conducted with S2CNA (Certified Nursing Assistant Supervisor). S2CNA reviewed Resident #41's ADL documentation from January 11, 2026 to February 09, 2026 and confirmed the resident did not have a shower/bath at least every Monday, Wednesday and Friday as scheduled.

Based on interviews and record reviews, the provider failed to administer medications as ordered by the physician for 1 (#42) out of 5 residents investigated for medication regimen review.Findings: On 02/10/2026, a review of Resident #42's electronic medical record revealed he admitted to the facility on [DATE] with diagnoses including hypertensive heart disease. Review of Resident #42's medications orders revealed the following: Norvasc oral tabs (Tablet) 5 mg (milligram). Give 1 tablet by mouth at bedtime related to hypertensive heart disease. Hold for B/P (Blood pressure) < (less than) 100/60. Metoprolol Tartrate 25 mg. Give 1 tab by mouth two times a day. Hold for B/P <100/60 or pulse <60. Review of Resident #42's electronic Medication Administration Record (EMAR) for January 2026 and February 2026 revealed his Norvasc 5 mg tablet scheduled for 2100 (9:00 p.m.) was not given and documented by S5LPN as a 4 which indicated vitals outside of parameters for administration on the following dates, with his blood pressure reading as follows: 01/04/2026.118/7601/12/2026. 137/7901/17/2026.144/7901/18/2026.136/8101/22/2026. 151/8601/26/2026.124/7001/27/2026. 146/8201/30/2026.129/8602/01/2026.182/8902/04/2026.118/8002/09/2026.119/84On 02/10/2026 at 4:40 p.m., a telephone interview was conducted with S5LPN (Licensed Practical Nurse). She stated that Resident #42 was prescribed blood pressure medications, Norvasc and Metoprolol, and on his orders perimeters were given. If Resident #42's pulse or blood pressure falls within those perimeters she would hold his medication as ordered. She confirmed that his blood pressure readings were within the stated perimeters for the medication to be administered, but due to his pulse being out of perimeters she held Norvasc and Metoprolol. On 02/10/2026 at 4:45 p.m., an interview and record review was conducted with S1DON (Director of Nursing). She confirmed Resident #42's Norvasc order stated that it should be held if his blood pressure <100/60. She acknowledged that according to the orders, and review of Resident #42's blood pressure readings that his Norvasc should have been administered on the above stated dates.

Based on record review and interview, the facility failed to electronically transmit a completed Minimum Data Set (MDS) Quarterly Assessment to the CMS (Center for Medicare and Medicaid Services) system within 14 days after completion for 1 ( #56) out of 1 resident investigated for resident assessment submission activities. Findings:On 02/10/2026 a review of Resident #56's electronic Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 01/02/2026, revealed Section Z0500B - date assessment complete was 01/16/2026. On 02/10/2026 a review of the facility's CMS Submission Report from 02/05/2026 revealed in part: Resident #56.Assessment Date 01/02/2026. Record submitted late: the submission date is more than 14 days after Z0500B on this assessment.On 02/10/2026 at 4:15 p.m., an interview and record review was conducted with S1DON (Director of Nursing). She confirmed Resident #56's Quarterly MDS with ARD of 01/02/2026, was completed on 01/16/2026 and was not transmitted within the required timeframe of 14 days after completion.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse for 2 (#3 and #8) of 2 (#3 and #8) sampled residents investigated for abuse. The facility failed to protect: 1. Resident #8 from physical abuse by Resident #3 2. Resident #3 from physical abuse by Resident #63 This deficient practice resulted in physical harm for Resident #8 on 11/17/2024 at 4:22 p.m. when Resident #3 hit him multiple times. On 11/17/2024 at 4:22 p.m. when Resident #3 hit him multiple times, Resident #8 sustained skin tears to his left forearm and left lower leg. Findings: Review of the facility's undated policy titled Abuse Prevention and Investigation revealed, in part, the following: It is the policy of this facility to provide protections .that prohibit and prevent abuse. Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching . 1. Resident #8 Review of Resident #8's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia with Behavior Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Severe Major Depressive Disorder with Psychotic Features, Schizoaffective Disorder, and Cognitive Communication Deficit. Review of Resident #8's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 12, indicating moderate cognitive impairment. Resident #8 had verbal behavioral symptoms directed toward others. Review of Resident #8's current comprehensive care plan revealed, in part, the resident has a behavior problem related to diagnosis of schizoaffective disorder initiated 09/01/2024, and the resident has the potential to be physically aggressive due to poor impulse control initiated on 09/29/2024. Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #8 dated 11/17/2024. Review of the facility's incident report dated 11/17/2024 at 4:36 p.m. revealed, in part, the following: Incident Type: Physical Aggression Received Person Preparing Report: S9RN Incident Description: Resident #8 backed chair into Resident #3 while waiting to go outside to go smoke. Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to Resident #8's left forearm. Residents separated. Immediate Action Taken: Residents were separated and placed on 1:1 monitoring Injuries Observed at the Time of Incident: Skin tear to left lower leg, and skin tear to left forearm Review of Resident #8's Nurse's Notes revealed, in part, the following: 11/17/2024 at 04:44 p.m. written by S9RN: Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to left forearm. Skin tear to left forearm treated at this time. Review of Resident #8's Order Summary Report revealed, in part, the following: 11/17/2024 Telephone order: Cleanse skin tear to left lower leg with normal saline, apply antibiotic ointment and a dressing once daily until resolved. 11/17/2024 Telephone order: Cleanse skin tear to left forearm with normal saline, apply antibiotic ointment and a dressing once daily until resolved. On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed the Incident of Physical Aggression Received reported on 11/17/2024 at 4:36 p.m. was an incident of resident to resident abuse. 2. Resident #3 Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Mild Cognitive Impairment, Generalized Anxiety Disorder, Major Depressive Disorder, Unspecified Intracranial Injury, Bipolar Disorder, and Schizoaffective Disorder. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 14, indicating intact cognition. Review of Resident #3's current Comprehensive Care Plan revealed, in part, the resident has the potential to be physically aggressive due to anger and poor impulse control initiated on 09/12/2024. Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #3 dated 09/12/2024. Review of the facility's Incident Report dated 09/12/2024 at 6:46 p.m. revealed, in part, the following: Incident Type: Physical Aggression Received Person Preparing Report: S8LPN Incident Description: Resident #3 and Resident #63 were both going outside to smoke. Resident #3 backed his wheelchair into Resident #63 three times. Resident #63 hit Resident #3 in the face 3 times with his closed fist. The nursing aide separated the residents. Resident #3 stated he backed up on Resident #63 three times. Resident #3 stated he was hit three times in the face by Resident #63. Immediate Action Taken: Resident #3 was sent to the emergency room for psychiatric evaluation Injuries: No injuries observed at the time of the incident. Review of the facility's investigation record for the incident which occurred on 09/12/2024 revealed, in part: 1. An Incident Communication form dated 09/12/2024 revealed, in part, Resident #63 then hit Resident #3 in the face. 2. An undated, handwritten note prepared by Resident #63, revealed in part, .after he turned to me I punched him in the face. On 01/29/2025 at 1:45 p.m., an interview was conducted with S1ADM. He confirmed the Incident of Physical Aggression Received reported on 09/12/2024 at 6:46 p.m. was an incident of resident to resident abuse.

Based on review of the facility's Quality Assurance and Performance Improvement (QAPI) Program and interview, the facility failed to take actions aimed at performance improvement and after implementing those actions, measure its success and track performance. This was evidenced by lack of evidence of: 1. Measuring or tracking success of actions implemented; and 2. collection and analysis of data; This deficient practice had the potential to affect a census of 61 residents. Findings: On 01/29/2025, a review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI) Program, with a review date of 01/2025, revealed the following in part: Each facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. 2. c. Develop and implement appropriate plans of action to correct identified quality deficiencies. On 01/29/2025 at 2:30 p.m., a review of the QAPI program and an interview was conducted with S2DON (Director of Nursing). There was no documented evidence that the actions implemented were measured or performance of the action plans were tracked from July 01, 2024 through January 12, 2025. There was also no evidence of data collection and analysis. S2DON confirmed there was no documented evidence of data collection, analysis of data, monitoring, or performance tracking being conducted from July 01, 2024 to January 12, 2025.

Based on record reviews and interviews, the facility failed to ensure alleged violations of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (Resident #3, Resident #8 ) of 2 (Resident #3, Resident #8) residents reviewed for Abuse. Findings: Review of the facility's policy titled Abuse Prevention and Investigation revealed, in part, the following: It is the policy of this facility to provide protections .that prohibit and prevent abuse. Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching . The facility will report all alleged violations to the Administrator, state agency .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The Administrator will follow up . to report the results of the investigation when final within 5 working days of the incident as required by state agencies. Resident #3 Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Mild Cognitive Impairment, Generalized Anxiety Disorder, Major Depressive Disorder, Unspecified Intracranial Injury, Bipolar Disorder, and Schizoaffective Disorder. Review of Resident #3's most recent Quarterly MDS assessment dated [DATE] revealed a BIMS Score of 14, indicating intact cognition. Review of Resident #3's current Comprehensive Care Plan revealed, in part, the resident has the potential to be physically aggressive due to anger and poor impulse control initiated on 09/12/2024. Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #3 dated 09/12/2024. The facility denied reporting any Critical Incident Reports to the Statewide Incident Management System during the last six months. Review of the facility's Incident Report dated 09/12/2024 at 6:46 p.m. revealed, in part, the following: Incident Type: Physical Aggression Received Person Preparing Report: S8LPN Incident Description: Resident #3 and Resident #63 were both going outside to smoke. Resident #3 backed his wheelchair into Resident #63 three times. Resident #63 hit Resident #3 in the face 3 times with his closed fist. The nursing aide separated the residents. Resident #3 stated he backed up on Resident #63 three times. Resident #3 stated he was hit three times in the face by Resident #63. Immediate Action Taken: Resident #3 was sent to the emergency room for psychiatric evaluation Injuries: No injuries observed at the time of the incident Review of the facility's investigation record for the incident which occurred on 09/12/2024 revealed, in part: 1. An Incident Communication form dated 09/12/2024 revealed, in part, Resident #63 then hit Resident #3 in the face. 2. An undated, handwritten note prepared by Resident #63, revealed in part, .after he turned to me I punched him in the face On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed no Critical Incident Reports have been created during the last six months. He confirmed the Incident of Physical Aggression Received reported on 09/12/2024 at 6:46 p.m. was an incident of resident to resident abuse. He confirmed the incident of abuse was not reported immediately, or within 2 hours after the allegation was made to the State Survey Agency, but should have been. Resident #8 Review of Resident #8's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia with Behavior Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Severe Major Depressive Disorder with Psychotic Features, Schizoaffective Disorder, and Cognitive Communication Deficit Review of Resident #8's most recent Quarterly MDS assessment dated [DATE] revealed a BIMS Score of 12, indicating moderate cognitive impairment. Review of Resident #8's current Comprehensive Care Plan revealed, in part, the resident has a behavior problem related to schizoaffective disorder initiated 09/01/2024, and the resident has the potential to be physically aggressive due to poor impulse control initiated on 09/29/2024. Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #8 dated 11/17/2024. Review of the facility's Incident Report dated 11/17/2024 at 4:36 p.m. revealed, in part, the following: Incident Type: Physical Aggression Received Person Preparing Report: S9RN Incident Description: Resident #8 backed chair into Resident #3 while waiting to go outside to go smoke. Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to left forearm. Residents separated. Immediate Action Taken: Residents were separated and placed on 1:1 monitoring Injuries Observed at the Time of Incident: Resident #8 had a skin tear to left lower leg and left forearm Review of Resident #8's Nurse's Notes revealed, in part, the following: 11/17/2024 at 4:44 p.m. written by S9RN: Resident #8 was struck multiple times by another resident resulting in a skin tear to left forearm. On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed no Critical Incident Reports have been created during the last six months. He confirmed the Incident of Physical Aggression Received reported on 11/17/2024 at 4:36 p.m. was an incident of resident to resident abuse. He confirmed the incident of abuse was not reported immediately, or within 2 hours after the allegation was made to the State Survey Agency, but should have been.

Based on record review and interviews, the facility failed to initiate an investigation of an alleged violation of abuse for 1 (Resident #8) of 2 (Resident #3, Resident #8) sampled residents. Findings: Review of the facility's undated policy titled Abuse Prevention and Investigation revealed, in part, the following: It is the policy of this facility to provide protections .that prohibit and prevent abuse. Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching . An immediate investigation is warranted when suspicion of abuse or reports of abuse occur. Investigations include identifying and interviewing all involved persons, determining if abuse occurred, determining the extent and cause of the abuse, and providing complete and thorough documentation of the investigation. Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #8 dated 11/17/2024. Review of Resident #8's Nurse's Notes revealed, in part, the following: 11/17/2024 at 4:44 p.m. written by S9RN: Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to left forearm. Skin tear to left forearm treated at this time. On 01/28/2025 at 10:08 a.m. S1ADM stated he was responsible for investigation of all incidents. S1ADM stated he was responsible for creating Critical Incident Reports. S1ADM was asked to provide a copy of the incident report involving Resident #8 which occurred on 11/17/2024. On 01/28/2025 at 10:37 a.m. S1ADM was asked to also provide documentation of the investigation of the 11/17/2024 incident. On 01/28/2025 at 10:41 a.m. S2DON provided copy of incident report. No documentation of investigation was provided. Review of the facility's incident report dated 11/17/2024 at 4:36 p.m. revealed, in part, the following: Incident Type: Physical Aggression Received Person Preparing Report: S9RN Incident Description: Resident #8 backed chair into Resident #3 while waiting to go outside to go smoke. Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to Resident #8's left forearm. Residents separated. Immediate Action Taken: Residents were separated and placed on 1:1 monitoring Injuries Observed at the Time of Incident: Skin tear to left lower leg, and skin tear to left forearm On 01/28/2025 at 12:33 p.m. S1ADM stated he had no documentation of investigation of the incident involving Resident #8 which occurred on 11/17/2024. On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed the Incident of Physical Aggression Received reported on 11/17/2024 at 4:36 p.m. was an incident of resident to resident abuse. S1ADM confirmed an investigation of the abuse was not conducted or documented, but should have been.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure schedule IV controlled medications were stored in a locked, permanently affixed compartment and/or a single unit package drug distribution system for 1 (Room A) of 1 medication storage room reviewed. Findings: On 01/27/2025, a review of the facility's policy titled, Medications - Controlled Substances with a last review date of 01/2025, read in part, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use or controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposer. The policy also indicated how controlled medications are to be stored: Patient-specific controlled substances (e.g. narcotic/epidural infusions, tablets, etc.) are stored under double lock until administered to the patient. On 01/27/2025 at 12:54 p.m., an observation was conducted of medication storage in Room A with S2DON (Director of Nursing). Upon entering into Room A, a black refrigerator was noted and was unlocked. S2DON stated medications were stored in the black refrigerator. A black safe box was noted inside the refrigerator and was unlocked. Medications observed inside of the unlocked black safe box were: 1. Valium suppository 10 mg (milligram) PR (per rectum) - Quantity was 2 2. diazePAM Rectal Gel 10 mg PR - Quantity was 3 An interview was conducted with S2DON at this time. S2DON confirmed the black medication refrigerator and black safe box were unlocked. S2DON further confirmed the medications stored in the black safe box were schedule IV controlled medications that should have been double locked and were not.

Based on observation, record review and interview, the facility failed to ensure that the recipes for pureed foods were followed by the S6DC (Dietary Cook) failing to follow the recipes when preparing pureed foods. This deficient practice had the potential to affect the six residents in the facility who received a pureed diet. Findings: On 01/28/2025, a review of the facility's policy titled, Use of Recipes with no revision date, read in part, .Policy: Recipes are to be used when preparing menu items. Procedure: #3) Cooks are expected to use and follow the recipes provided. On 01/27/2025 at 10:20 a.m., an observation was conducted of S6DC as she prepared pureed white beans with ham. S6DC placed an undetermined amount of white beans with ham using a large scoop with no marked measurements. S3DM (Dietary Manager) stopped S6DC from beginning the puree process and poured the white beans with ham back in the original large pot. S3DM then measured out 7 servings of white beans with ham using a 6oz (ounce) spoodle into the blender. S6DC then began the puree process adding 4 scoops of powdered food thickener. S6DC transferred the puree white beans with ham to a pan on the steam table and washed the blender. S6DC then began the puree process for cornbread muffins. S6DC placed 7 cornbread muffins into the blender, added an 8oz carton of thickened milk and pureed until smooth. S6DC was observed preparing both items without using a recipe. S6DC subsequently interviewed. S6DC confirmed she does not follow recipes; stated she just adds water, juice, milk, or thickener as needed. On 01/27/2025 at 12:45 a.m., an interview was conducted with the S3DM. S3DM confirmed that the dietary staff had not been following recipes when preparing puree foods since the rotation of the menu's and could not recall when that was. She provided the recipes for this day's noon meal and stated; I'm not going to lie, I just printed these and made this binder. S3DM confirmed the dietary staff should be following recipes when preparing puree foods.

Based on record reviews, observations, and interviews, the facility failed to ensure the resident was treated with respect and dignity as evidenced by the facility failing to keep a resident's urine collection bag covered and private for 1 (Resident #113) out of 1 resident (#113) investigated for dignity. Findings: Review of Resident #113's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, acute kidney failure and retention of urine. Review of Resident #113's most recent admission Minimum Data Set (MDS) dated [DATE], revealed in part, Section H: Bladder and Bowel checked for indwelling catheter. Review of Resident #113's comprehensive care plan revealed in part, the resident has (foley) catheter with an intervention that read in part, catheter: the resident has 16 FR (French), 10 CC (cubic centimeter) foley. Position catheter bag and tubing below the level of the bladder and away from entrance room door. On 01/27/2025 at 9:30 a.m., an observation was made of Resident #113 from the hallway as his room door was open, he was resting in bed and his urine collection bag was observed hanging on the left side, at the foot of his bed without a privacy bag or covering. The urine collection bag was visible from the hallway. On 01/27/2025 at 9:45 a.m., an interview and observation was conducted with S7CNASup (Certified Nursing Assistant Supervisor). An observation was made of Resident #113 from the hallway with S7CNASup as his room door was open, he was resting in bed and his urine collection bag was observed hanging on the left side, at the foot of his bed without a privacy bag or covering. The urine collection bag was visible from the hallway. S7CNASup confirmed the resident's urinary collection bag was visible from the hallway, and did not have a privacy bag over it. S7CNASup further confirmed there should have been a privacy bag over the urine collection bag to ensure the resident's dignity. On 01/27/2025 at 2:04 p.m., an interview with S2DON (Director of Nursing) who confirmed that when a resident's urinary collection bag was visible from the hallway it should of had a privacy bag it to maintain the resident's dignity.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the discharge status for 1 (Resident # 60) out of 31 sampled residents. Findings: Review of Resident #60's discharge transfer summary on 11/29/2024 revealed he was transferred to another nursing home. Review of Resident #60's Discharge MDS assessment, with an ARD (Assessment Reference Date) of 11/29/2024 revealed: Section A .Discharge assessment, return not anticipated, planned A2105. Discharge Status. Code 04. Short-Term General Hospital. On 01/29/2025 at 12:21 p.m., an interview and record review was conducted with S4MDS. She confirmed Resident #60 was discharged from the facility on 11/29/2024 to another nursing home. She reviewed the Discharge MDS, and confirmed the discharge status indicated he was discharged to a short term general hospital, which was coded inaccurately.

Based on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 2 (Resident #34, Resident #58) out of 5 (Resident #11, Resident #17, Resident #19, Resident # 34, Resident #58) residents reviewed for respiratory care, with the potential to effect 23 residents receiving oxygen therapy. Findings: The facility did not provide a policy for storing of oxygen/nebulizer equipment by survey exit. Resident #34 Review of Resident #34's EMR (Electronic Medical Record) revealed the resident was admitted to facility on 01/02/2024 with diagnosis not limited to Dyspnea, COPD (Chronic Obstructive Pulmonary Disease) and CHF (Congestive Heart Failure). Review of the physician's orders for Resident #34 revealed an order dated 09/03/2024 - apply O2 (oxygen) 2-4 liters (L) via N/C (nasal cannula) PRN (as needed) to keep oxygen saturation above 90% (percent). On 01/27/2025 at 9:53 a.m., an observation of Resident #34's O2 concentrator was done. The oxygen storage bag with a date of 01/27/2025 was on floor, with oxygen tubing running through the bag. On 01/27/2025 at 1:53 p.m., during an observation and interview with S5LPN (Licensed Practical Nurse), she observed and confirmed the oxygen storage bag was on the floor. She confirmed the oxygen tubing storage bag should not be on the floor. Resident #58 Review of Resident #58's EMR revealed the resident was admitted to facility on 09/24/2024 with diagnosis not limited to Acute and Chronic Respiratory Failure with Hypoxia, COPD and Pneumonia. Review of the physician's orders for Resident #58 revealed an order dated 10/09/2024 - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) give 1 vial inhale orally every 6 hours as needed for wheezing and 09/24/2024 - Pulmicort Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation) give 1 blister inhale orally two times a day On 01/27/2025 at 10:00 a.m., an observation of Resident #58's nebulizer machine and nebulizer tubing in a storage bag were on the floor at the head of the resident's bed. On 01/27/2025 at 11:13 a.m., an interview was conducted with Resident #58. Resident #58 stated that his respiratory equipment should be clean and did not understand why it was stored on the floor and not on a shelf. On 01/27/2025 at 1:48 p.m., an observation and interview with S5LPN of Resident #58's nebulizer machine and nebulizer tubing. She confirmed the nebulizer machine and nebulizer tubing were on the floor and should not be stored on the floor.

Based on record reviews and interviews, the facility failed to obtain the most recent recertification of terminal illness and most recent POC (plan of care) for 1 (Resident #26) out of 1 resident (#26) sampled residents reviewed for hospice. Review of Resident #26's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, personal history of colon polyps and vascular dementia. Review of Resident #26's Quarterly MDS (Minimum Data Set) dated 01/07/2025 revealed in part, Section O: Special Treatments, Procedures, and Programs checked for Hospice Care. Review of Resident #26's physician's orders revealed an order entry with a start date of 10/07/2024 read in part, Admit to contracted hospice under the care of physician with Terminal dx (diagnosis) of senile degeneration of brain. Review of Resident #26's hospice documents in the contracted hospice binder revealed, in part, the most recent certification of terminal illness by the contracted hospice agency's physician was signed on 10/27/2024 for the certification period dated 10/07/2024 to 01/04/2025. Review of Resident #26's hospice documents in the contracted hospice binder revealed, in part, the most recent POC by the contracted hospice agency's physician was signed on 10/27/2024 for the period dated 10/07/2024 to 01/04/2025. On 01/29/2025 at 9:34 a.m. a record review and interview was conducted with S2DON (Director of Nursing). Review of Resident #26's hospice documents in the contracted hospice binder was conducted with S2DON who confirmed the most recent certification of terminal illness and POC was for the period dated 10/07/2024 to 01/04/2025. She confirmed there was not an updated recertification of terminal illness and POC in Resident #26's contracted hospice binder and should have been.

Based on observations, record review and interviews, the facility failed to ensure its medication error rate was not 5 percent or greater, as evidenced by a calculated medication error rate of 72 percent. Findings: Review of a facility document titled, Medications - Administering, read in part: Policy Statement - medications shall administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders. Resident #10 Resident #10 was admitted to the facility on [DATE] with diagnoses in part: Epilepsy, Hemiplegia, Unspecified Psychosis, Alcohol Abuse, Major Depressive Disorder and Hypertension. Review of Resident #10's January 2024 physician's orders revealed in part: Escitalopram 10 mg (milligrams) orally (po) daily Bupropion HCL XL 300 mg po daily Divalproex Sod ER 500 mg po twice a day (BID) Depakote EC 125 mg po BID Lisinopril-HCTZ (Hydrochlorothiazide) 20-12.5 mg po daily Lisinopril 20 mg po every night at bed time (QHS) Vitamin D3 1,000 unit's po daily Review of Resident #10's eMAR (Electronic Medication Administration Record) revealed the following medications were scheduled for administered at 8:00 a.m. on 01/23/2024: Lisinopril-HCTZ 20-12.5 mg po daily Depakote Na DR 500mg po BID Escitalopram 10mg po daily Vitamin D3 25 mcg (1,000 units) po daily Depakote 125 mg po BID Wellbutrin XL 300 mg po daily Review of Resident #10's administration record for January 2024 revealed: 10:02 a.m.,01/23/2024 (scheduled: 8:00 a.m., 01/23/2024; Lisinopril-HCTZ 20-12.5 mg tablet) Pre Admin (administration) Blood Pressure - Generic 162/70 //01/23/2024 10:02 a.m. Resident #36 Resident #36 was admitted to the facility on [DATE] with diagnoses in part: Limited activity d/t disability, Muscle Weakness, Atrial Fibrillation, Major Depressive Disorder, Tremors, Bipolar Disorder, Fibromyalgia, Congenital Scoliosis, Schizophrenia, and Anxiety. Review of Resident #36's physician orders dated January 2024 read in part: Eliquis 2.5 mg po BID Keppra 500mg po BID K+ CL ER (Potassium Chloride extended release) 20 MEQ (Milli equivalent) po daily Digoxin 0.125 mg po daily Review of Resident #36's administration record for January 2024 revealed: 10:12 a.m.,01/22/2024 10:12 a.m., (scheduled: 8:00 a.m., 01/22/2024; Digoxin 0.125 mg) Pre Admin pulse: 60 //01/22/2024 10:12 a.m. Resident #70: Resident #70 was admitted to the facility on [DATE] with diagnoses in part: Alzheimer's disease, Hypothyroidism, and Type 2 diabetes mellitus. Review of Resident #70's physician orders for January 2024 read in part: Levothyroxine 50 mcg one tab before breakfast daily. Review of Resident #70's eMAR (Electronic Medication Administration Record) revealed the following medication was administered at 8:25 a.m., on 01/09/2024: Levothyroxine 50 mcg one tab before breakfast daily due at 6:00 a.m. Resident #43 Resident #43 was admitted to the facility on 03//06/2023 with diagnoses in part: Epilepsy, Tremors, Tachycardia and Alcohol use. Review of Resident #66's physician orders dated January 2024 read in part: Vitamin D3 400 units give 2 tabs po daily Keppra ER 750 mg give 2 tabs daily Review of Resident #43's January 2024 eMAR (Electronic Medication Administration Record) revealed the following medication were scheduled for administered at 8:00 a.m.: Vitamin D3 400 units give 2 tabs po daily Keppra ER 750 mg give 2 tabs daily Resident #59 Resident #59 was admitted to the facility on [DATE] with diagnoses in part: Major Depressive Disorder, Diabetes Mellitus type 2, Heart Failure, Epilepsy, Bradycardia and Hypertension. Review of Resident #59's physician orders dated January 2024 read in part: Metformin 1000mg BID po Metoprolol Tar 25mg BID po Fluoxetine 20mg po Daily Eliquis 5mg po BID Levetiracetam 100mg/ml 5 ml BID po Potassium/Phosphorous supplement powder 2 packets in 6 ounces H2O (water) QID (four times a day) Review of Resident #59's eMAR (Electronic Medication Administration Record) revealed the following medication were scheduled to be administered at 8:00 a.m.: Metformin 1000mg BID po Metoprolol Tar 25mg BID po Fluoxetine 20mg po Daily Eliquis 5mg po BID Levetiracetam 100mg/ml 5 ml (milliliters) BID po Potassium/Phosphorous supplement powder 2 packets in 6 ounces H2O (water) QID (four times a day) On 01/22/2024 at 9:55 a.m., an observation of medication pass and interview was conducted with S7LPN. S7LPN confirmed she was still trying to pass her 8:00 a.m. medications to residents, and still had several resident that needed their 8:00 a.m. medications. S7LPN confirmed she was aware that medications should be given within one hour before to one hour after scheduled administration times and she was late giving 8:00 a.m. medications to Resident's #36 and Resident #59. On 01/23/2024 at 9:10 a.m., an observation of medication pass and interview was conducted with S6LPN. S6LPN confirmed she had not finished with her 8:00 a.m. medication administration, having several more medications to give to residents. S6LPN confirmed she was aware that medication should be given within one hour before to one hour after scheduled administration times and she was late giving her 8:00 a.m. medications to Resident #43. On 01/23/2024 at 9:40 a.m., an observation of medication pass and interview with S5LPN. S5LPN stated that she was late with finishing her medication administration to residents for 8:00 a.m. She confirmed medication that was due at 8:00 a.m., should be given one hour before to one hour after the scheduled time. She confirmed the medication given to Resident #10 were considered late because it was greater than one hour of administration time of 8:00 a.m. On 01/24/2024 at 10:45 a.m., an interview was conducted with S1DON, she confirmed scheduled medications should be given within one hour before to one hour after scheduled administration time.

Based on observations and interviews, the facility failed to ensure medications were stored properly for routine medications, medication refrigerator temperature logs were up to date, disposal of expired medications and schedule II-V medications being maintained in separately locked, permanently affixed compartments. The deficiency had the potential to affect a census of 65. Findings: Review of the facility's policy titled, Medication - Controlled Substances read in part: 2. Storage and Security: b. areas without automated dispensing systems utilize a substantially-constructed storage unit with two locks and a paper system for 24 hour recording of controlled substance use. Review of the facility's policy titled, Medications - Storage read in part: Policy statement: the facility shall store all drugs and biologicals in a safe secure and orderly manner. 4. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. A policy for refrigerator temperature log was not provided to surveyor by time of exit from survey. On 01/23/2024 at 9:35 a.m., an observation of Hall A medication cart, in the hallway, the medication cart was observed not locked at main key lock. On 01/23/2024 at 9:40 a.m., an interview was conducted with S5LPN, she confirmed she had forgot to lock medication cart before she had walked away from the cart. S5LPN stated the cart should be locked before stepping away from the cart. On 01/24/2024 at 10:05 a.m., a review of the facility medication storage room with S6LPN was conducted. Review of the temperature log book revealed January 2024 with no temperature documented on 01/15/2024, 01/16/2024, 01/19/2024, 01/20/2024 and 01/21/2024. Further review of the temperature logs from October 2023 to December 2023 revealed November 2023 temperature log did not have a temperature logged on 11/26/2023, 11/27/23 and 11/28/2023. December 2023 temperature log did not have a temperature logged on 12/01/2023 and 12/03/2023. S6LPN confirmed the temperature logs were not completed for November 2023, December 2023, and January 2024. On 01/24/2024 at 10:35 a.m., an interview was conducted with S6LPN, who confirmed the following medications were found in the resident storage bin and were expired with the following dates of expiration: Resident #6 - a) Medroxyprogesterone injectable 150mg per ml with an expiration date of 08/17/2023 b) Sertraline 100mg issued 12/27/2022 with an expiration date 12/27/2023 (#6 pills) c) Divalproex DR 125mg capsule issued 12/01/2022 with an expiration date 11/26/2023 (#10 pills) Resident #12 - Fluticasone Propionate 50mcg/spray nasal inhaler issued 01/24/2022 and expiration date 01/09/2023 Resident #20 - a) Atrovent HFA 17mcg/inhalation issued 01/09/2023 and expiration date 01/04/2024 b) Atrovent HFA 17mcg/inhalation issued not available and expiration date 11/03/2023 c) Atrovent HFA 17mcg/inhalation issued 07/17/2023 and expiration date 01/08/2024 Resident #47 - Xulane patch 150/35mcg/day with an expiration date of 10/23/2023 S6LPN stated medications are checked for expiration regularly by a nurse. On 01/24/2024 at 10:45 a.m., an interview was conducted with S1DON, she confirmed the medication storage room is checked for expired medication, usually on a weekly basis and medications are placed in the cubicle in the medication storage room to be destroyed or discarded by the DON. S1DON stated the controlled medications are kept in a drawer in her desk, with a key lock. She stated that she is the only person with a key to drawer. She stated the controlled medication, for disposal, are not kept under double lock and key at all times. S1DON also confirmed the medication cart should be locked when the nurse is present at the cart; and the medication refrigerator temperature should be documented daily on the temperature log.

Based on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records observed during a medication pass. The facility had a total census of 65 residents. Findings: On 01/23/2024 at 8:40 a.m., while walking down Hall B, a medication cart was observed against the wall with a computer on top of the cart. Upon getting to medication cart, the electronic medical record was open with a list of resident's names visible. On 01/23/2024 at 8:45 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed the computer was not locked by privacy screen and a list of resident names was visible on the computer. She stated the nurse should have initiated the privacy screen before walking away from the computer. On 01/23/2024 at 9:10 a.m., an interview was conducted with S6LPN. She confirmed she forgot to use the privacy screen when she walked away from her computer earlier to give a resident medication. She stated the computer should be placed on privacy screen before walking away. On 01/24/2024 at 10:45 a.m., during an interview with S1DON (Director of Nursing), she confirmed the computer privacy screen should be initiated prior to leaving the computer unattended.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status of 1 (#1) out of 33 sampled residents, by failing to ensure that the resident's fall status was coded. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part: Parkinson's Disease, Abnormal Posture, Acute Diastolic Congestive Heart Failure, Unspecified Dementia with Other Behavioral Disturbances and History of Falling. A review of Resident #1's clinical record revealed a progress note written on 10/10/2023 that read in part . Resident found lying on the floor. A review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE], read in part: Section J1800: Falls since admit/reentry/prior assessment: any falls - No. In section J1900A: Falls since admit/reentry/prior assessment: no injury was left blank. On 01/24/2024 at 11:16 a.m., a review of Resident #1's clinical record and interview was conducted with S4LPNMDS (Licensed Practical Nurse, Minimum Data Set). She confirmed Resident #1 had a fall on 10/10/2023. S4LPNMDS reviewed the Quarterly MDS assessment with an Assessment Reference Date (ARD) of 12/13/2023. She confirmed Section J1800 for falls since admit/reentry/prior assessment was coded as no and J1900A had No injury left blank. She stated J1800 should have been coded as Yes to reflect Resident #1 had 1 fall with no injury since prior assessment.

Based on observation, interviews, and record reviews, the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards for 1 (#20) of 1 residents investigated for respiratory care out of a total of 33 sampled residents, by failing to ensure that the resident's oxygen tubing was labeled stored in a sanitary manner when not in use. Findings: A review of the facility's policy titled Oxygen Administration read in part: Purpose. The purpose of this procedure is to provide guidelines for oxygen administration and storage of oxygen cylinders. 18. Tubing, cannulas and mask should be dated and replaced weekly unless otherwise ordered. Resident #20 was admitted to the facility on [DATE] with diagnoses including: Shortness of breath, Chronic Obstructive Pulmonary Disease and Asthma. A review of the physician's orders revealed an order written on 07/08/2022 for O2 (oxygen) per (delivered by) NC (nasal cannula) at 2 l/min (liters per minute) prn (as needed) SOB (shortness of breath). On 01/22/2024 at 10:05 a.m., Resident #20 was receiving oxygen per NC at 2 liters. An observation of the oxygen tubing revealed the tubing and humidifier were not labeled with a date. On 01/22/2024 at 11:18 a.m., a second observation of Resident #20's oxygen tubing revealed the tubing still did not contain a date of initiation. On 01/23/2024 at 8:30 a.m., an observation was made of Resident #20 lying in bed with eyes closed. Further observation revealed an oxygen concentrator to the left side of the bed with NC and oxygen tubing rolled-up and under concentrator handle, with no storage bag in use. On 01/23/2024 at 8:53 a.m., an observation of the oxygen concentrator with S3LPN was conducted. S3LPN confirmed oxygen tubing and humidifier had no date or labeling and was resting under the handle of the oxygen concentrator, with no storage bag in use. She stated the oxygen tubing should have been labeled with the date and stored in a bag when not in use. On 01/23/2024 at 10:06 a.m., an interview was conducted with S2ADON. S2ADON confirmed oxygen tubing should be dated and stored in a bag when the tubing was not in use.

Based on observations, interviews, and record review, the facility failed to provide appropriate, treatment and care to prevent urinary tract infections for residents who had indwelling urinary catheters for 2 (#6, #7) out of 7 sampled residents as evidenced by: 1. Failing to follow the physician orders for changing the suprapubic catheter q (every) month for Resident #6 and; 2. Failing to ensure a split gauze dressing was applied to the resident's suprapubic catheter; failing to ensure the catheter drainage bag was not on the floor; and failing to replace a soiled catheter stabilization device for Resident #7. Findings: Review of the facility's policy titled Indwelling Urinary Catheters read in part .8. Monthly changing of indwelling urinary catheters is often the accepted standard in a long term care setting .11. Bag contact with the floor must be avoided. Resident #6 Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Palsy, Neuromuscular Dysfunction of Bladder. Review of the resident's care plan revealed the resident was at risk for infections due to indwelling catheter (suprapubic). The care plan included an intervention for change q month on the 23rd and PRN (as needed) leakage/occlusion/dislodgement. Review of the resident's physician's orders dated 12/09/2022 revealed in part: suprapubic catheter 22 french r/t (related to) neurogenic bladder change q month on the 23rd and PRN leakage/ occlusion/dislodgement. On 10/23/2023 at 10:30 a.m., an observation and interview was conducted with Resident #6. The resident stated she just had a bath. She looked clean and was dressed appropriately. Her suprapubic catheter was observed with a moderate amount of sediment in the tubing and in the bag. The suprapubic catheter was secured to her thigh. There was no date, time or initials of when it was changed. When the resident was asked about the catheter, she stated it had been over a month since her catheter was changed. 10/23/2023 at 11:23 a.m., an interview was conducted with S3TN (treatment nurse). She stated she was unsure when the last time the suprapubic catheter was changed due to the bag having no date on it. S3TN reviewed the resident's TAR (treatment administration record) and stated there was no evidence of when the suprapubic catheter was changed. Resident #7 Resident #7 was admitted to the facility on [DATE] with diagnoses including Limitation of Activities Due to Disability, Other Neuromuscular Dysfunction of Bladder, and Urinary Tract Infection. Review of Resident #7's October 2023 Physician's Orders revealed an order dated 07/14/2023 that read: Suprapubic Catheter Site - Clean with wound cleanser, pat dry, and apply split gauze daily. Review of Resident #7's plan of care revealed an intervention for catheter care every shift. On 10/23/2023 at 4:00 p.m., an observation was made of Resident #7 in his room. The resident was lying in bed on his back with his left leg partially exposed. A catheter stabilization device was observed on his left leg. The white adhesive portion of the device had brown and tan stains, and there was no clamp on device to stabilize the catheter tubing. The drainage bag was on the floor. Resident #7 stated that he did not place the drainage bag on the floor and could not change his position on his own. On 10/23/2023 at 4:08 p.m., an observation of Resident #7 and interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN stated the resident has a suprapubic catheter. She proceeded to remove the resident's blanket and exposed the resident's catheter site. There was no split gauze on the site. S4LPN also observed the resident's catheter stabilization device and confirmed it was dirty, had no clamp to stabilize the catheter, and should have been replaced. S4LPN stated there was no split gauze on the catheter insertion site, and there should have been. S4LPN also confirmed that the catheter drainage bag should not have been on the floor. On 10/23/2023 at 4:50 p.m., S6CNA (Certified Nursing Assistant ) stated Resident #7 hadn't had a split gauze dressing on his catheter insertion site since she began her shift at 6:00 a.m. On 10/23/2023 at 4:56 p.m., an interview was conducted with S5ADONIP (Assistant Director of Nursing/Infection Preventionist). She stated that she usually cleaned and applied the resident's split gauze dressing, but any floor nurse could have applied the split gauze. She confirmed Resident #7 should have had split gauze on his catheter insertion site per the physician orders; the catheter stabilization device should have been changed; and the catheter drainage bag should not have been on the floor.

Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#1) of 7 sampled residents. This was evidenced when facility failed to follow the physician's orders for fall mat to the right side of the bed, between the bed and the bathroom for Resident #1. Findings: Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cognitive Communication Deficit, Dysphagia, ESRD (End Stage Renal Disease), Major Depressive Disorder, Sepsis, Heart Failure, Atelectasis, and Type 2 DM (Diabetes Mellitus). Review of the resident's care plan revealed the resident was at risk for falls due to history of falling on 05/12/2023, 10/04/2023, and 10/15/2023. The care plan included an intervention for fall mat to right side of bed between bed and bathroom. Review of the resident's physician's orders revealed in part: Fall mat to the right side of bed between the bed and the bathroom. On 10/23/2023 at 11:00 a.m., an observation was made of Resident #1 lying in bed in his room. No fall mat was observed in his room on the right side of the bed between the bed and bathroom. On 10/23/2023 at 2:00 p.m., another observation was conducted of Resident #1's room. No fall mat was observed in his room on the right side of the bed between the bed and bathroom. On 10/23/2023 at 2:15 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse). She reviewed the resident's chart and confirmed orders for a fall mat. She observed the resident's room and confirmed no fall mat and should have been there per physician orders.

Based on interviews and record reviews; the facility failed to protect the resident's right to be free from physical and psychosocial abuse from other residents for 3 (#1, #2, and #3) out of 5 (#1-#5) sampled residents. The facility failed to protect Resident #1, Resident #2 and Resident #3 from being bit by Resident #5. This deficient practice resulted in: 1. Physical and psychosocial harm for Resident #2, on 01/20/2023 at 11:47 a.m., when Resident #5 bit her on the right ankle causing redness and discomfort. Resident #2 voiced being fearful of Resident #5 and being bit by him again. 2. Physical and psychosocial harm for Resident #3, on 02/21/2023 at 1:45 p.m., when Resident #5 bit her on the hand that caused a skin tear. Resident #3 required preventive antibiotics and a TDAP (Tetanus, Diphtheria, and Whooping Cough) vaccine. Resident #3 was observed tearful and upset following the incident. Resident #3's son had to report to facility to assist in comforting her after the incident. 3. Physical harm for Resident #1, on 12/17/2022 at 3:30 p.m., when Resident #5 bit her on her right forearm causing several bite marks with 2 puncture sites. Findings: A review of the facility's Abuse Prevention and Investigation Policy statement read in part: Residents have the right to be free from .physical abuse. Residents will not be subjected to abuse by anyone. Resident #5 Review of Resident #5's clinical record revealed an admitted [DATE] with diagnoses of Severe Intellectual Disabilities, Fetal Alcohol Syndrome, Bipolar, and Impulse Disorder. Review of Resident #5's MDS (Minimum Data Set) dated 11/27/2022 revealed a BIMS (Brief Interview for Mental Status) score of 00 which indicated he was rarely understood. Review of Resident #5's care plan revealed he was care planned for behaviors that included socially inappropriate/disruptive behavior and child-like behaviors (grabbing, biting, playing, running, jumping). Interventions included talk in calm voice, remove from public when behavior unacceptable, monitor behaviors, elicit input from family, medications for behaviors and diversional activities. Interventions for physically aggressive behaviors listed the following: 12/17/22 bit peer- placed on 1:1 (supervision) with staff at this time; 1/20/23 bit peer- redirected, staff to observe for adverse behaviors and redirect; and 2/21/23 bit peer- placed on 1:1. Resident #2 Review of Resident #2's clinical record revealed an admitted [DATE] with diagnoses of Encephalopathy, Seizures, Essential Tremor, Anoxic Brain Injury, Adjustment Disorder with Mixed Anxiety and Depression, Viral Hepatitis, and Stimulant Abuse. Resident #2's MDS Quarterly assessment dated [DATE] revealed she had a BIMS score of 14, indicating she was cognitively intact. Resident #2's care plan revealed she was independent in her locomotion, transferred with no assistive devices utilized, and monitored for skin integrity related to bite from peer (Resident #5) on 01/20/2023. A review of Resident #2's investigation report dated 01/20/2023 at 11:47 a.m. completed by S1ADM revealed in part, Resident #2 was sitting on the couch in the front lobby when Resident #5 was moving back and forth in front of her. Resident #5 was noted to be playing childlike, clapping his hands and moving to and from his wheelchair. Resident #5 looks at Resident #2 and puts his face down on her leg. Resident #2 stated Ouch, he is biting me. S5LPN was in the lobby at the time, but had her back to residents. The treatment nurse assessed Resident #2 and provided an ice pack and bandage to a reddened area on her right ankle. Resident #5 was removed from the lobby and placed on 1:1 supervision for 24 hours and to have extra supervision when in the front lobby. A review of Resident #2's nursing progress note dated 01/20/2023 at 11:47 a.m. written by S5LPN, revealed that the resident was seated on one the couches in the main lobby area when another resident (Resident #5) rolled up to her in his wheelchair and bit her right lower leg. She was assessed for a slight bite mark to lower extremity with no broken skin. On 03/14/2023 at 11:55 a.m., an interview was conducted with Resident #2. She recalled the biting incident involving Resident #5. She stated she was just sitting on the couch and he came up to her and bit her on her ankle. She stated she has did not want Resident #5 near her because she was fearful of him biting her again. On 03/14/2023 at 11:40 a.m., an interview was conducted with S6SpeechTherapist. She stated she had witnessed the biting incident between Resident #2 and Resident #5. She stated Resident #2 had finished eating her lunch and sat down on the couch in the front lobby area. Once Resident #5 finished his lunch, he wheeled himself in his wheelchair to the front lobby area. When he passed by Resident #2, he bent over and bit her on her foot. During an interview on 03/14/2023 at 12:40 p.m. S5LPN, confirmed she was in the front lobby when Resident #5 bit Resident #2 on her ankle. She verbalized that she was at her medication cart and had her back turned to the residents. She heard Resident #2 holler ouch, he (Resident #5) is biting me and went over to check on her. She stated the Resident #2 had red area to her ankle. On 03/14/2023 at 12:15 p.m., an interview conducted with S3 Treatment Nurse confirmed she had assessed Resident #2 for injuries after Resident #5 bit her on the ankle. Resident #2 had a small reddened area to her right ankle and was provided an ice pack for discomfort. During an interview on 03/15/2023 at 3:00 p.m. with S1ADM and S2DON, they confirmed that on 01/20/2023, Resident #2 was bit on her ankle by Resident #5. They acknowledged that Resident #2 had a reddened area to her ankle with no skin breakage, and was provided an ice pack for pain. They stated that Resident #5 was placed on 1:1 supervision for 24 hours after he bit Resident #2's ankle on 01/20/2023. Resident #3 A review of Resident #3's clinical record revealed an admitted [DATE] with diagnosis of Anxiety, Depression, Hypertension, Dementia, Osteoporosis, Bilateral Hearing Loss, and Cataracts. Resident #3's MDS Quarterly assessment dated for 02/09/2023 revealed she had a BIMS score of 3, indicating she was severely cognitively impaired. Resident #3's care plan revealed she required supervision with locomotion and transfers with use of rolling walker. Further review revealed she was monitored for skin integrity related to a bite from peer (Resident #5) on 02/21/2023, including administration of preventive antibiotics, daily wound care until resolution on 03/02/2023. A review of Resident #3's investigation report dated 02/21/2023 at 2:00 p.m. completed by S1ADM revealed in part, Resident #5 was in the front lobby with other residents and sat down next to Resident #3. Resident #5 put his head on Resident #3's shoulder and then tried to put his head in her lap where her hand was placed. Resident #5 then bit Resident #3 on the hand. A review of Resident #3's nursing progress notes dated 02/21/2023 at 1:45 p.m. written by S4LPN revealed multiple staff heard Resident #3. Resident was sitting on the couch and Resident #5 bit her on right wrist causing a skin tear of 1.2 cm (centimeters) x 0.8 cm. Resident was tearful. Resident #3's son was notified and was asked to come spend time with mother and calm her. Resident #3's physician was notified and ordered TDAP vaccine and Keflex 250 milligrams (an antibiotic used to treat infections) three times daily for 7 days for preventative infection from bite wound. A review of Resident #3's physician's orders for 02/21/2022 listed an order for Keflex 250 mg by mouth three times a day for 7 days for prevention from infection from bite wound; and TDAP booster give 0.5 ml (milliliters) IM (intramuscular) for 1 dose. A review of Resident #3's electronic medication administration record for 02/2023 to 03/2023 revealed Resident was administered Keflex 250 mg three times daily for 7 days and received an intramuscular injection to the right deltoid (arm muscle) of TDAP booster 0.5 ml on 02/22/2023. Daily wound care for the skin tear was provided from 02/21/2023 until resolution on 03/02/2023. On 03/15/2023 at 9:30 a.m., a telephone interview was conducted with Resident #3's son. He voiced the facility called to inform him of Resident #5 biting his mother on the hand that caused a skin tear. His mother was crying and upset. He stated he came to the facility to sit and talk with her to comfort her. He verbalized that he was concerned that his mother may be bitten again by Resident #5 and that she would be fearful of Resident #5 if she didn't have dementia and could recall the incident. On 03/15/2023 at 11:00 a.m., during an interview with S4LPN, she confirmed Resident #3 was sitting on the couch in main lobby area. Resident #5 sat next to her and put his head on her shoulder, then immediately put his head on her lap and bit her on the hand. It happened in just a few seconds of him sitting down next to her. Resident #3 was visibly upset and crying. Resident #3's son was called and said he would come to the facility to see about his mother and help calm her down. She stated Resident #3 had a skin tear on her right hand that required treatment. During an interview on 03/15/2023 at 3:00 p.m. with S1ADM and S2DON, they confirmed that on 02/21/2023 Resident #5 bit Resident #2 on her hand. They acknowledged she sustained a skin tear requiring treatment, was placed on preventive antibiotic treatment for 7 days and received a TDAP vaccine. S2DON confirmed that Resident #2's son was notified of his mother being visibly upset and came to the facility to help calm her. She voiced he stayed for an hour with his mother. They reported that Resident #5 was placed on 1:1 supervision within arm's length of staff at all times after he bit Resident #3's hand on 02/21/2023. They stated that Resident #5 has remained on 1:1 supervsion since he bit Resident #3's hand. Resident #1 Review of Resident #1's clinical record revealed an admitted on 09/09/2020 with diagnoses of Schizoaffective disorder, Bipolar, PVD (Peripheral Vascular Disease), Osteoporosis, Anoxic Brain Damage, Depression, Seizures, and Impulse disorder. Review of Resident #1's MDS (Minimum Data Set) Quarterly Assessment, dated 11/27/2022, revealed she had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. Resident #'s 1 care plan revealed she required total assistance from staff for transfers, but was able to perform locomotion with her wheelchair independently. Further review, revealed she was monitored for skin integrity related to bite from peer (Resident #5) on 12/17/2022, including daily wound care until resolution on 12/27/2022. A review of an incident reported dated 12/17/2022 at 3:30 p.m. and completed by S1ADM, revealed Resident #1 reported another resident (Resident #5) had bit her on her arm and then told nurse not to worry about it. Resident #5 was playing with Resident #1's wheelchair, and rubbing his head and face on her back and arm. Staff encouraged Resident #1 to not let Resident #5 do those things due to him not being able to understand or communicate. Residents were in the front lobby area for 45 minutes before Resident #5 moved away. Resident #1 looked at her arm and told the nurse Resident #5 had bitten her but it was no big deal. A review of Resident #1's nursing progress notes dated 12/17/2022 at 3:30 pm written by S4LPN revealed that Resident #1 reported that Resident #5 had bit her arm. Look, he bit me, but it's no big deal She had several bites to right forearm with 2 puncture sites. Resident #1 was discharged from the facility on 02/14/2023 and was unavailable for an interview. On 03/14/2023 at 12:15 p.m., during an interview conducted with S3 Treatment Nurse, she confirmed she treated Resident #1's right forearm for a bite mark with a puncture site. She stated she cleaned area, applied triple antibiotic ointment daily until wound resolved on 12/27/2022. On 03/15/2023 at 11:00 a.m., an interview was conducted with S4LPN. She confirmed she was working on 12/17/2022 when Resident #5 bit Resident #1. Resident #5 was playing with Resident #1's arms and hands. She instructed Resident #1 not to let him play with her. Resident #1 voiced later to her that Resident #5 had bitten her on the arm. During an interview on 03/15/2023 at 3:00 p.m. with S1ADM and S2DON, they confirmed that on 12/17/2022 Resident #5 had bitten Resident #1. Resident #5 had been rubbing his face on her arm and back. Resident #1 was told numerous times not to let him do that to her. Resident #1 showed her arm to the nurse and told her Resident #5 had bitten her. S2DON acknowledged Resident #1 had a bite mark with skin puncture to her right forearm.They stated that Resident #5 was placed on 1:1 supervision for 24 hours after he bit Resident #1's arm on 12/17/2022.