Every finding on record at The Lingenfelter Center

Based on observation, clinical record review, staff interviews, and review of facility documentation and policy, the facility failed to ensure that privacy was maintained during medication administration for 3 residents (#203, #200, and #206) out of 11 sampled residents. The universe was 87. This deficient practice could result in unauthorized access to residents' private medical records.Findings include:-Resident #203Resident #203 was admitted on [DATE] with diagnosis including vascular dementia with anxiety, type 2 diabetes mellitus, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. An observation conducted of medication administration with Registered Nurse (RN, Staff #70) on July 8, 2026, at 11:10 a.m During medication administration the RN prepared medications for Resident #203. The RN stepped away from the medication cart and went into medication storage room; however, the computer screen was not closed or locked, and displayed Resident #203's name, date of birth and medications. Staff #70 came back to screen at approximately 11:14 a.m. and utilized the computer, then minimized the screen and went to check blood sugar for Resident #203 in his room.-Resident #200Resident #200 was admitted on [DATE], with diagnosis including unspecified dementia with anxiety, post-traumatic stress disorder, type 2 diabetes mellitus, and sleep apnea.A review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 01, indicating severe cognitive impairment. An observation was made on July 8, 2026, at 1:29 p.m., during medication administration with Registered Nurse (RN, Staff #70) who prepared medications for Resident #200. Staff #70 then stepped away from the medication cart at approximately 1:34 p.m., and went to Resident #200 in the dining area to administer his medications; however, the computer screen was not closed or locked, and displayed Resident #200's name, date of birth and medications. Resident #200 refused to take his medications and at approximately 1:35 p.m., Staff #70 then went to wash her hands with the computer screen still open and which displayed Resident #200 medical information.-Resident #206Resident #206 was admitted on [DATE], with diagnosis including Alzheimer's disease, acute kidney failure, seizure, dementia, hypertension, and type 2 diabetes.A review of the MDS assessment dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment.An observation was made on July 8, 2026, at 1:36 p.m., with Registered Nurse (RN, Staff #70) who prepared medications for Resident #206. Staff #70 was observed crushing the Resident's medications and mixing in chocolate pudding. At approximately 1:38 p.m., Staff #70 administered the medications to Resident #206 in the dining area; however, the computer screen was not closed or locked, and displayed Resident #206's name, date of birth and medications.An interview was conducted on July 8, 2026, at 3:04 p.m., with the RN (Staff #70), who stated that she is a PRN (as needed) nurse and worked in the facility for a year. The RN stated that she provided medication administration and wound treatment to residents. The RN further stated that the facility expectation during medication administration, was to ensure that computer screens were locked, when away from the medication cart, because other residents could read patient's personal information, demography and medication documentation. The RN stated that she recalled leaving the computer screen on once or twice on July 8, 2026, for residents #200 and #206 during the medication administration. The RN further stated that risk if the computer screen was left unlocked would be a HIPAA (Health Insurance Portability and Accountability Act) violation and other people could read the patient's personal information.An interview was conducted on July 9, 2026, at 8:26 a.m., with a Licensed Practical Nurse (LPN) Staff #21, who stated that she provides wound treatment and medication administration to residents. The LPN stated that during medication administration, she would verify the resident's order, prepare medication, lock the computer screen and medication cart, and then go to the resident's room to administer the medications. The LPN stated that the facility had taken measures to protect resident information by instructing staff to close the computer screen and cover all documents before stepping away from the computer during the medication administration. The LPN further stated that the risk if a computer screen was left unlocked, would be a HIPAA violation and other residents would be able to read patient's medical information, demography, and code status.An interview was conducted on July 9, 2026, at 2:13 p.m. with the Director of Nursing (DON) Staff #76 who stated that the facility process during medication administration would be to protect resident information by covering documents with the resident's name. The DON stated that computer screens should be locked when providing medications to a resident, to prevent a breach of private information. The DON stated that staff were educated on minimizing and locking computer screens during medication administration.A review of the policy titled, Resident Rights, reviewed on June 1, 2020, revealed that the resident has the right of privacy and confidentiality. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.A review of the policy titled, Charting and documentation, reviewed on June 1, 2026, revealed that the information in the clinical record is confidential and may only be released in accordance with state law and the facility law.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure one of six sampled residents (#210) received a timely, monitoring, and treatment following a fall. The deficient practice delayed recognition of the resident's injury and delayed medical treatment resulting in prolonged pain, hospitalization and surgical hip repair of a right hip fracture. Findings include:Resident #210 was admitted on [DATE] with diagnoses including dementia, osteoporosis, paranoid schizophrenia, cognitive communication deficit, epilepsy, history of falling, and generalized muscle weakness.The fall risk assessment dated [DATE] revealed a score of 6.0, indicating a low fall risk. The MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 2, indicating severe cognitive impairment. Further, the assessment included that Resident #210 was independent for walking 10, 50, and 150 feet; and, did not use any assistive devices.The care plan revised on September 4, 2025, revealed the resident had a potential injury from falls, was high risk for falls, had difficulty ambulating, and was unsafe and unreliable to ask or wait for help. Interventions included assistance with ambulation, using a wheelchair as needed, observing, recording, and correcting all unsafe conditions, putting hip pads on the resident when she is out of bed due to falling history and recent fracture of the left hip and the left knee.The nursing progress note dated September 15, 2025 at 4am documented that the resident was wandering during the shift and was redirected as needed.Review of incident report involving Resident #210 dated September 15, 2025, revealed that the resident was noted to have had a fall in the hallway to the ground while she was being led to the dinner meal on September 15, 2025 at 5:40 p.m. The report indicated that the fall was witnessed by staff, and no injuries were observed post incident. Predisposing physiological factors included gait imbalance, impaired memory, recent change in medications/new medications, confusion, and incontinence. Predisposing situation factors included active exit seeking, wandering, and improper footwear. There was no evidence on the report regarding the immediate action that was taken, or pain level at the time of the incident. The report also indicated that the insurance case manager was notified two days after the fall occurred on September 17, 2025, and the Power of Attorney was notified on September 16, 2025, one day after the incident. There was no evidence the witnessed fall was reported to the licensed nurse at the time of the incident. Consequently, there was no evidence the resident received an immediate nursing assessment, evaluation, physician notification, or post-fall monitoring from 5:40 p.m. util 11:52 p.m.A medication administration note dated September 15, 2025 at 11:52 p.m. revealed that Resident #210 had pain score of 8 and was given narcotic medication for right leg pain. A medication administration note dated September 16, 2025 at 12:46 a.m. revealed the follow up pain score was a 6 and the pain medication was deemed ineffective due to the resident's pain being minimally relieved.The nursing progress note dated September 16, 2025, at 12:51 a.m. documented that the Certified Nursing Assistant (CNA) reported the resident had been resistant to care that evening and refused to transfer or stand, which was a change from the resident's usual baseline.A same nursing progress note dated September 16, 2025 at 12:51 a.m. revealed that at approximately 11:40 p.m., Resident #210 was yelling in her room; and that, the nurse found the resident lying in bed with a grimacing facial expression, crying out ow, and grabbing her right leg. The documentation also included that the resident's right leg appeared mildly externally rotated and shorter than the left leg, with no visible abnormality of the hip; and that, the resident cried out when the right hip was lightly palpated. There was no bruising or skin discoloration noted. According to the documentation, the resident reported a pain level of 8 and received as-needed pain medication; and, the physician was notified, and orders and consent were obtained to transfer the resident to the hospital. Further, the documentation noted that the resident was transferred to the hospital on September 16, 2025, at approximately 12:25 p.m.The nursing progress note dated September 16, 2025 at 2:47 a.m. revealed a report was received that the resident had a fracture to the right hip and the resident would be admitted . The discharge MDS assessment dated [DATE] revealed that the resident had an unplanned discharge to an acute hospital with return to the facility anticipated.The nursing progress note dated September 16, 2025 at 10:48 a.m. documented that during the morning report the nurse on shift was notified by a CNA that the resident #210 had been assisted up from the ground in the hallway on September 15, 2025 at approximately 5:40 p.m. The documentation further indicated that while another CNA was leading the resident to dinner, the resident #210 lost balance and fell onto her right side in the hallway. According to the documentation, the resident was then assisted into a wheelchair by CNA's and provided dinner. However, there was no evidence of any such incident or the CNA reporting any incident to any staff prior to the morning of September 16, 2025. There was also no documentation of interventions put in place post fall. Review of Human Resources Personnel Action Notice for CNA (staff #121) dated September 16, 2025 revealed that the CNA's last scheduled working day was September 15, 2025 and was terminated September 16, 2025 due to being unsuccessful at maintaining compliance with facility policies and procedures on September 15, 2025 when she failed to properly utilize facility equipment while performing her job duty, failed to utilize proper techniques while performing her job duties and failed to properly notify. The response section revealed that the CNA indicated it was the end of the day and she was feeling overwhelmed and stressed; and that she rushed through the situation instead of following protocol.Hospital records revealed the resident sustained an acute displaced intertrochanteric fracture of the right hip requiring hospitalization and surgical repair.Review of a social services progress note dated September 19, 2025 revealed that the resident was re-admitted to the facility on [DATE] and the resident was anticipated to stay long term. During an interview conducted on July 7, 2026 at 11:55 a.m., CNA (staff #59) stated that after a fall occurs, she cannot leave a resident alone or help the resident until the nurse arrives to assess.An interview was conducted on July 9, 2026 at 12:44 p.m., with another CNA (staff #42) who stated that over the course of six months Resident #210 went from ambulating to breaking her hip. He stated that a staff member was walking her down the hall and the resident stumbled and fell. However, he said that he was not present during the incident. The CNA further stated that after the fall the resident was very dependent, required total care, and had a pretty slow decline.In an interview conducted with a Licensed Practical Nurse (LPN/staff #56) on July 9, 2026 at 12:52 p.m., the LPN (staff #56) stated that when a staff member is with a resident during a fall, the staff member gets the nurse, the nurse conducts neurological and physical checks, checking the resident's extremities, seeing if a leg is shorter than the other, seeing if the resident is showing any signs of pain upon palpation, and determines if the resident needs to be sent to the hospital/ER for a higher level of care. Regarding Resident #210, the LPN stated that Resident #210 had suffered a hip fracture, had failed to thrive, never walked again, and had a steady decline. During an interview conducted on July 9, 2026 at 2:41 p.m. with a Registered Nurse (RN/staff #27), who stated that during night shift on September 15, 2025, Resident #210 was in more pain than her baseline so she assessed the resident and gave her as needed pain medication. The RN also stated that the resident was assessed for vital signs, pain, and skin condition. The RN explained that the resident's leg was assessed based on how she was holding her body. The RN further stated that Resident #210 did go to the hospital that night. The RN also stated she did not know what happened to Resident #210 because the night shift staff did not get report of anything happening to Resident #210 from the CNAs (staff #121 and staff #122).During an interview conducted on July 9, 2026 at 4:26 p.m. with the Director of Nursing (DON/staff #76) and the Administrator (staff #1), the DON stated that initial fall risk assessments are conducted upon admission by asking the residents representative questions about any falls in the last thirty days and the last three to six months, if they have an increased risk of falling, it is included in the care plan. The DON stated that the primary difference between a witnessed and an unwitnessed fall is that an unwitnessed fall always requires neurological checks. The DON further stated that if a staff member witnesses a fall but does not follow facility procedures, corrective action may include progressive discipline and reeducation, as appropriate. The DON also stated that failing to report a fall to the nurse immediately could worsen the resident's injuries, increase pain, and delay necessary treatment. The Administrator (staff #1) stated that if a resident had a fall in the facility, staff investigates the fall, and revises the care plan with necessary interventions to attempt to prevent another fall. Immediately after a resident has had a fall, a nurse must assess the resident by taking vitals, conducting a brief skin assessment, assess for injuries, ensure the resident's safety, and determine if it is safe for the resident to be moved to their room for a more thorough skin assessment. Staff #1 also stated that staff would notify the physician, responsible party, case manager, and pharmacy consultant for any medication adjustments. Staff #1 further stated that care plan revisions are conducted within a few hours after the fall after the residents' needs are taken care of such as dressing wounds and if needed, being transported to another facility for further care. The DON stated that the only difference between unwitnessed and witnessed falls is that unwitnessed falls have a neurological check no matter what the situation is. The DON also stated that depending on the situation, if a staff member witnesses a fall and does not follow the facilities process, that corrective actions are put in place with progressive discipline and reeducation is conducted, if warranted. The DON further stated that the risks of a fall occurring and staff not reporting it to the nurse immediately include aggravating injuries with potential to injure the resident further and create increased pain for the resident. The Administrator stated that on September 15, 2025 the witnessed fall incident report was not as comprehensive due to the incident not being reported in a timely manner after it occurred. The Administrator also stated that the night nurse on September 15, 2025 had done an assessment on the resident and sent the resident to the hospital and when staff entered the facility on September 16, 2025 they did an investigation after being told by the hospital that the resident had sustained a hip fracture. The Administrator further stated that on September 16, 2025, a CNA (staff #121) reported that she had been leading Resident #210 down the hallway and the resident had fallen on the floor behind the CNA (staff #121) and that CNA (staff #121) and CNA (staff #122) then transferred the resident into a wheelchair and took her to dinner instead of notifying the nurse of the fall, to assess the resident prior to transferring. The Administrator further stated that CNA (staff #121) had been leading the resident incorrectly without a gate belt, that CNA (staff #122) had thought that the resident had been assessed by a nurse already, and staff's actions did not meet the facilities standards. The Administrator also stated that CNA (staff #121) was terminated due to not adhering to policies and procedures and that CNA (staff #122) was not terminated for helping CNA (staff #121) due to thinking that the nurse had already assessed the resident. The facilities policy titled, Post Fall Protocols and Reporting Incidents, revealed that if a fall is witnessed or a resident is found on the ground, the direct care staff member is to notify the nurse on duty, never move or pick up a resident without the nurse present, once the nurse has responded, gather equipment to obtain vital signs, once the nurse has completed an assessment and the staff member has been instructed, lift the resident from the floor, if the fall was unwitnessed or there is a head injury, neuro checks will be completed for 72 hours.The facilities policy titled, Falls and Fall Risk Management, revealed that staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The policy further revealed that if interventions have been successful in preventing falls, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has been resolved.

Based on observation, clinical record review, interviews, facility documentation and policy, the facility failed to ensure necessary blood sugar medications were administered according to provider orders for one resident (#200) out of five sampled residents. The universe was 87. This deficient practice could put residents at the risk for not receiving medications as per the parameter.Finding include: Resident #200 was admitted on [DATE], with diagnosis including unspecified dementia with anxiety, post-traumatic stress disorder, type 2 diabetes mellitus (DM), and sleep apnea.A review of the care plan dated [DATE], revealed that the resident was at risk of fluctuating blood sugar related to DM. The interventions included checking blood sugar (BS) and administering insulin as per order or protocol.A physician order dated [DATE], was written for Humalog solution 100 UNIT/ML (Insulin Lispro), to inject subcutaneously before meals and at bedtime for diabetes as per sliding scale: if blood sugar is 200 - 250= 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451 - 500 = 12 units, and to call provider if blood sugar is less than 70 and greater than 400.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment. The assessment further revealed that the resident had a diagnosis of DM and was receiving insulin.A review of the blood sugars, as noted on the vitals section of the electronic health record, on [DATE], at 11:01 a.m., revealed a blood sugar of 382 mg/dl (milligrams per deciliter) which was struck out by Registered Nurse (RN, Staff #70) on [DATE], at 12:42 p.m., with a rationale noted as 'deceased . An observation was made on [DATE], at 11:01 a.m. Registered Nurse (RN, Staff #70) was preparing medications for Resident #200 and stated that resident is on sliding scale insulin and that the amount of insulin administered depends on the BS level. The RN was observed going to the resident's room at approximately 11:03 a.m. with an insulin pen of around 100 units, sterile lancet, and glucometer. The RN was then observed taking the resident's blood sugar which was observed to be 382, per the glucometer reading. The RN then notified the resident that he would receive 6 units of insulin. The RN was then observed dialing an insulin pen to 6 units and administering the 6 units to the resident.However, a Medication Administration Record (MAR), dated [DATE], at 11 a.m., revealed that the blood sugar for Resident #200 was 282 and that 4 units of insulin had been administered.An interview was conducted on [DATE], at 3:04 p.m., with the RN (Staff #70), who stated that she is a PRN (as needed) nurse and worked in the facility for a year. The RN stated that she provided medication administration, wound treatment, and conducted vitals for the residents. The RN stated that when taking BS, she would first review the order, then take the resident's blood sugar, then review the medication order again to determine the insulin units to be given to the resident. The RN then reviewed the medication order for Resident #200 and stated that resident had an order dated [DATE], which was written for Humalog solution 100 UNIT/ML (Insulin Lispro), and noted to inject insulin subcutaneously before meals and at bedtime for diabetes as per sliding scale: if blood sugar is 200 - 250= 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451 - 500 = 12 units, and to call the provider if blood sugar is less than 70 and greater than 400. The RN then stated that Resident #200 BS was 382 on [DATE], at approximately 11 a.m. and that he was given 6 units instead of 8 units. The RN further stated that risk of administering residents insulin out of parameters could result in the residents feeling lethargic.An interview was conducted on [DATE], at 8:26 a.m., with a Licensed Practical Nurse (LPN) Staff #21, who stated that she provided wound treatment, vitals, and medication administration to residents. The LPN stated that for medication administration she would review the resident's order to identify which resident had diabetes. The LPN then stated that she would then take the resident's BS and review the order again to determine the amount of insulin units to be given to the resident. The LPN then stated that the risk if insulin were given out of parameters would include the resident being lethargic, sweating, and potentially hypoglycemic.An interview was conducted on [DATE], at 2:13 p.m. with the Director of Nursing (DON) Staff #76. The DON stated that the facility process for giving insulin to residents included checking the resident's blood sugar and that sliding scale insulin was given based on the provider orders and would be documented in the Medication Administration Record (MAR). The DON stated that values in the MAR would have to be struke- out and re-input if values were to be changed at any point in time. DON stated that the risk, if insulin was given out parameter, could include not enough insulin given that the BS level would not go down enough to reach therapeutic levels and if too much insulin were given that it would exceed therapeutic levels. The DON reviewed the medication orders for Resident #200 and stated that resident had an order dated [DATE], written for Humalog solution 100 UNIT/ML (Insulin Lispro), and to inject the insulin subcutaneously before meals and at bedtime for diabetes as per sliding scale: if the blood sugar was 200 - 250= 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451 - 500 = 12 units, and to call provider if blood sugar is less than 70 and greater than 400. The DON then reviewed the MAR for Resident #200 and stated that on [DATE], at 11:00 a.m., BS was noted as 282 with 4 units documented as administered; however, the observation on the date and time noted was that BS was 382 at 11 a.m. on [DATE], and that 6 units of insulin were observed to have been administered. The DON then reviewed the progress notes for Resident #200 and stated that the note did not show as struck out in MAR. The DON pulled up the resident vitals noting the BS and stated on [DATE], at 11:00 am a BS of 382 was struck out with a rationale noted as deceased . The DON stated that RN (staff #70) should have reported the medication error to the DON but she had not. DON further stated that there is no reason, without an order, to administer anything counter to the original order. The DON stated that the risk of inaccurate documentation included incorrect treatment from physicians, problematic charting for nurses following the resident to ensure that the resident received the appropriate care. The DON further stated that if medications were given out of parameter then the provider and family were notified and the staff would fill out the medication error report form. The DON then reviewed the clinical record for Resident #200 and stated that there is no evidence in the resident's clinical record that the provider was notified of insulin given out of parameter.A review of the policy titled, Medication Administration, reviewed on [DATE], revealed that all medications must be administered in accordance with the physician's orders including any and all-time frames. The policy further revealed that orders will be checked for administrations and parameters and will be administered accordingly.A review of the policy titled, Following Physician Orders, reviewed on [DATE], revealed that the order will be verified by the nurse.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights for two of three sampled residents (#3, #5) to be free from physical abuse by another resident. The deficient practice could lead to additional resident-to-resident altercations, creating an unsafe environment. The sample was 3. The universe was 3.Findings include:A facility-reported 5-day investigation, submitted to the State Agency on April 3, 2026, revealed that a resident-to-resident altercation occurred on March 31, 2026, at approximately 7:11 PM, involving Resident #3 and Resident #5. The report included an interview conducted with Resident #3 on March 31, 2026, at 7:26 PM revealed that he had been pushed from behind, told Resident #5 to leave him alone, and was then struck in the face. The report included an interview with the alleged aggressor, Resident #5 on March 31, 2026, at 7:32 PM which revealed that Resident #3 approached him, and Resident #5 pushed him and struck him in the neck to push him back. The report also included a signed witness statement dated March 31, 2026, by Certified Nursing Assistant (CNA/Staff #33) revealing that the CNA observed Resident #5 standing in front of Resident #3 with hands raised. Resident #3 was observed with blood on the bridge of his nose, and Resident #5 was wiping blood from his hand onto his pants. The CNA reported that Resident #3 stated Resident #5 hit him in the nose. The also report included that the CNA was able to get in between the two residents to separate them. A skin assessment dated [DATE], revealed that Resident #3 sustained two abrasions to the bridge of the nose, measuring 0.25 cm. Resident #5 had no injuries. A psychiatric consultation dated April 1, 2026 included in the report, revealed that Resident #5 was identified as the aggressor and had punched his peer. The consultation for Resident #3 revealed the incident was described as somewhat traumatic.Regarding Resident #3:Resident #3 was admitted on [DATE], with diagnoses that included dementia, with behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, agitation; and Alzheimer's disease.An annual MDS (minimum data set) assessment dated [DATE], revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment. The assessment also revealed that the resident exhibited physical and verbal behavioral symptoms directed towards others, rejection of care and wandering behaviors, 1 to 3 days of the assessment reference date.A Neurologic Focused Evaluation dated March 11, 2026, revealed that the resident has disorganized thinking, requires cues and is oriented to person and place. The evaluation included that the resident has mild impairment with some confusion, is coherent, speech is clear and usually makes self-understood, and usually understands others.A Neurologic Focused Evaluation, dated March 14, 2026 revealed the resident was experiencing signs of short-term memory loss, with severe cognitive impairment, and no unwanted behaviors witnessed.An incident follow-up note dated March 16, 2026 revealed that the resident continued to propel self around hall.Behavior progress notes dated March 23, 28, and 29, 2026, documented anxiety, delusions, and escalating behaviors. There was no evidence in the clinical record that the provider was notified of these behaviors.A care plan initiated on March 31, 2026, revealed that Resident #3 was reported to have been involved in a resident-to-resident altercation. Interventions included a psych consult, nursing staff to monitor and assess for signs/symptoms of a decline in psychosocial well-being.A skin assessment dated [DATE], revealed that Resident #3 received two small wounds, measured at 0.25 cm each.An incident note dated March 31, 2026, revealed that a CNA (certified nursing assistant) came around the corner and saw two residents facing each other, and observed Resident #3's nose bleeding.A psychiatric consultation dated April 1, 2026, revealed Resident #3 had been seen following a Resident-to-Resident altercation, where he stated it was somewhat of a traumatic experience. The consultation also revealed that Resident #3 was observed with a skin tear to the nose. -Regarding Resident #5:Resident #5 was admitted on [DATE], with diagnoses that included Alzheimer's disease, dementia with mood disturbance, psychotic disturbance, other behavioral disturbance, and post-traumatic stress disorderAn MDS assessment dated [DATE], revealed a BIMS score of 00, which indicated severe cognitive impairment. The assessment also revealed that the resident exhibited physical and verbal behavioral symptoms directed towards others, and rejection of care, 1 to 3 days of the 7 before the completion of the assessment reference date. The assessment also revealed that Resident #5 exhibited behavioral symptoms not directed towards others, and wandering behaviors 4 to 6 days before the assessment reference date. A behavior progress note dated March 20, 2026 revealed that the resident had repetitive behaviors, was restless, and began to get impatient with attempts to redirect.Behavior progress note dated March 22, 2026 and March 23, 2026, documented that the resident was exhibiting anxiety, delusional statements, pacing, was making repetitive statements to staff, and that redirection had been effective for a short period of time. There was no evidence the provider was notified of the behaviors.A behavior progress note dated March 26, 2026 and March 30, 2026, revealed that the resident wanders the hall, and was easily directed by staff.A care plan initiated on March 31, 2026, revealed that Resident #5 was reported to have been involved in a resident-to-resident altercation. Interventions included a psych consult, and nursing staff to monitor/assess for signs/symptoms of a decline in psychosocial well-being.A skin assessment dated [DATE], revealed that Resident #5 had no injuries.A behavior note dated March 31, 2026, at 4:10 PM (approximately 3 hours prior to the incident), revealed the resident was combative with staff, including pushing, hitting, and pinching, and was not easily redirected. However, there was no evidence that the provider was notified regarding the behaviors.An incident progress note on March 31, 2026, at 7:10 PM, revealed that a CNA came around the corner and saw two residents facing each other, and observed the other resident's nose bleeding.A psychiatric consultation dated April 1, 2026, revealed Resident #5 had been seen following a Resident-to-Resident altercation in which he was the aggressor. The consultation also revealed that Resident #5 was walking down the hall when he encountered a peer, who turned around to tell Resident #5 to stop, and Resident #5 punched the peer in the nose.A phone interview was attempted with the CNA who separated the two residents (Staff #33) on April 8, 2026, at 1:13 PM; however, it was unsuccessful. A phone interview was attempted with the CNA who was assigned to the unit (Staff #12) on April 8, 2026, at 1:16 PM; however, it was unsuccessful, with no return response. A phone interview was attempted with the LPN (licensed practical nurse) who was assigned to the unit (Staff #43) on April 8, 2026, at 1:18 PM; however, it was unsuccessful. An interview was conducted on April 8, 2026, at 1:55 PM with a CNA (Staff #3), who stated that the facility provided abuse training and that incidents of abuse, such as punching or hitting, would need to be reported immediately to the nurse of the unit, the DON (director of nursing), and the Administrator. The CNA stated that they were made aware of the incident between Resident #3 and #5 due to the room change, but had not been on shift during the incident. An interview was conducted on April 8, 2026, at 2:06 PM, with an RN (registered nurse/Staff #52) who stated that the facility provided abuse training and that incidents of abuse, such as punching or hitting, would need to be reported immediately to her supervisor, the DON, and the Administrator. The RN stated that she did not witness the incident, but was informed of what transpired between Resident #3 and Resident #5. She further stated that should a resident-to-resident altercation occur on her shift, she would ensure the residents are safe and separated, have staff sit with both residents individually, while notifications to the DON and the administrator are made. Then she would assess the residents for any injuries, treat any injuries, assist with the investigation by providing statements, and then assist with moving the residents to separate units to prevent further contact. A joint interview was conducted on April 8, 2026, at 2:21 PM, with the DON (Staff #73) and the Administrator (Staff #62). The DON stated that staff receive abuse training on the different types of abuse, who to report it to, and anticipating behaviors of residents to prevent altercations. The DON stated that she was notified regarding the resident-to-resident altercation between Resident #3 and #5, and that there had not been any witnesses. The DON stated that Resident #3 was observed with an abrasion on the bridge of his nose and stated that he had been 'sucker punched.' and that Resident #5 was not observed with any injuries. The DON stated that review of the video footage revealed that Residents #3 and Resident #5 had a tuffle, described as an interaction in the hallway where Resident #5 had his hands up, but had been uncertain if there was physical contact and due to not having a clear view of the altercation and the inconsistencies of additional interviews with the residents, the facility was unable to verify or refute that abuse occurred. The video footage was still available and was reviewed with both the DON and the Administrator, and the video was unclear related to physical contact between the residents; however, the wheelchair of Resident #3 was observed rocking back and forth in what appeared to be an uncontrolled fashion, but the video contained no evidence that physical contact was made to the face due to the back of Resident #5 facing the camera. A facility policy titled, Resident Rights Policies and Procedures, last edited in November of 2021, defined resident abuse as the willful infliction of injury; It also included abuse types such as verbal abuse, sexual abuse, physical abuse. The policy defined physical abuse as the intentional infliction of physical pain or injury to the resident, or the resident is inappropriately restrained.

Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#4) was free from physical abuse by another resident (#2). The deficient practice could result in residents suffering from injuries. Findings include: Regarding resident #4 -Resident #4 was admitted on [DATE] with diagnoses that included unspecified dementia, rash and other nonspecific skin eruption, insomnia, hypothyroidism, unspecified complications of genitourinary prosthetic device and bradycardia. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. The resident ' s MDS also revealed physical behavioral symptoms directed towards others that included, but was not limited to, hitting, kicking and pushing. Review of the resident ' s behavioral care plan dated September 12, 2024 revealed a problem of the resident being protective of his personal space. Review of resident #4 ' s standard care plan dated December 23, 2024 revealed a problem of the resident exhibiting negative physical behaviors as evidenced by hitting, kicking, spitting, pinching or biting towards others. A progress note dated May 5, 2025 at 16:24 by a Registered Nurse (RN/Staff #112) revealed that the resident had poor awareness of proximity to staff and other residents. The note further stated that the resident would get ' very close ' to staff and other residents and needs frequent redirection. A progress note dated May 11, 2025 at 11:50 by RN/Staff #112 revealed that resident #4 was in the dining room and entered another resident ' s (resident #2) personal space. Resident #2 balled up his right fist and swung towards resident #4 and grazed his left cheek. The residents were separated and redirected from one another. Regarding resident #2 Resident #2 was admitted on [DATE] with diagnoses that included unspecified dementia, seborrheic dermatitis, vascular dementia moderate with psychotic disturbance, anxiety disorder, unspecified mood disorder and unspecified psychosis. A quarterly MDS assessment dated [DATE] revealed that the resident had a BIMS score of 00 indicating the resident had severe cognitive impairment. Further review revealed the resident had inattention and disorganized thinking that was continuously present. The resident ' s MDS also revealed physical behavioral symptoms directed towards others that included, but was not limited to, hitting, kicking and pushing. Review of resident #4 ' s standard care plan dated November 23, 2022 revealed a problem of the resident exhibiting negative physical behaviors as evidenced by hitting, kicking, spitting, pinching or biting towards others. As well as verbal outbursts during meals and activities that disturbs others. Review of the resident ' s behavioral care plan dated December 5, 2024 revealed a problem of the resident needing supervision and redirection due to his wandering/pacing and territorial to space. A progress note dated May 11, 2025 at 11:50 by RN/Staff #112 revealed that resident #2 entered another resident ' s (resident #4) personal space. Resident #2 balled up his right fist and swung towards resident #4 and grazed his left cheek. The residents were separated and redirected from one another. An interview with a Certified Nursing Assistant (CNA/staff #64) was conducted on May 15, 2025 at 10:02 a.m. Staff #64 stated she was the one who intervened after the physical altercation. The CNA detailed that she did not see what transpired prior to the altercation but saw resident #2 attempting to take away a bedside table from resident #4. She further stated that she saw resident #2 punch resident #4 in the face and intervened with the nurse to avoid resident #4 from striking resident #2 in retaliation. The CNA recounted that the resident did make contact with the other resident and as a result resident #4 had a red mark on his face. Staff #64 stated that there were no prior altercations between the two residents. The CNA also stated that the facility has training and education for staff on abuse. Finally, the CNA stated that the facility process is to report any alleged abuse immediately which she did and reported to the nurse who then reported it to the Administrator and Director of Nursing (DON). An interview with a RN (staff #112) was conducted on May 15, 2025 at 10:10 a.m. Staff #112 stated that the two residents were very territorial, specifically resident #2 who is path driven and does things in a certain manner. The RN further detailed that Sunday morning the two gentleman ' s paths crossed and the two residents were on either side of a bedside table arguing over its placement. The RN stated that resident #2 balled up his right fist and hit resident #4 ' s left cheek. In return resident #4 balled up his fist as well but staff intervened before another punch was thrown. Staff #112 stated that she noticed slight pinkness to resident #4 ' s cheek where contact was made and there were no further injuries noted. The RN stated that she assessed resident #2 ' s right hand and his mental status and notified the altercation to the DON. She further stated that she documented the altercation in the facility ' s electronic health record. The RN stated that after the altercation the residents returned to their normal demeanors and there were no prior aggressive behaviors between the two. The RN stated that facility policy is to immediately separate the residents, assess those involved and report it as soon as possible. Staff #64 concluded by stating that the facility provides training on abuse via an annual inservice, at monthly all staff meetings and an online educational platform. An interview was conducted on May 15, 2025 at 11:04 a.m., with the Administrator (staff #73) who serves as the facilities investigator. The administrator stated that she was notified of the alleged abuse by the DON who was notified by the nurse on duty. Staff #73 detailed what was reported to her , she stated that resident #2 had been wandering in the dining area and resident #4 had come out of his room to the dining room. She further stated that resident #4 sat in a recliner that was in resident #2 ' s path that he had been pacing. The administrator stated that resident #4 grabbed a beside table and when he turned he was in resident #2 ' s path. Resident #2 then grabbed onto the table and the two were moving it back and forth between one another. Staff #73 then stated that it was reported to her that resident #2 then grazed resident #4 ' s face with a closed fist. The administrator stated that staff reported there was a connection. The administrator stated that resident #4 was immediately separated and transferred to another unit and there was an order for 1:1 monitoring with resident #2 in addition to updating both resident ' s care plans. The administrator stated that she notified all appropriate parties including the local police department during the course of her investigation. Review of facility policy signed into effect on June 1, 2020 by the administrator titled, Abuse Prevention Program, states that the facility is committed to protecting its residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to its residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure two residents (#3 and #4) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse. Findings include: -Resident # 3 (alleged perpetrator) was admitted to the facility on [DATE] which include diagnoses of Hypertension, Diabetes Mellitus, Non-Alzheimer's Dementia, and Post Traumatic Stress Disorder (PTSD). Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has confusion-poor decision making related to cognitive impairment, limited mental function and disease process. The interventions include reorient to situations as needed, anticipate needs, observe for signs and symptoms of disease, administer medications as ordered, observe for side effects and effectiveness, and note changes and notify medical doctor as needed. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has unsafe wandering. The interventions include monitor for any needed interventions such as alarms; monitor closely, 30 minutes safety checks as needed; notify for increased restlessness; anticipate needs such as thirst, hunger, and need to toilet; monitor for patterns and redirect to safe areas. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident exhibits negative physical behavior manifested by hitting, kicking, spitting, pinching or biting towards others-strikes/hits/pinches/attempts to bite/scratch staff when they assist with activities of daily living or administer medications. The interventions include remove person from situation if begins to show signs of agitation in public place, remind calmly about the necessity to refrain from physical acting out. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident require supervision and redirection from staff related to behaviors such as delusional thoughts, paranoia, verbal and physical aggression, accusatory statements, wandering, rejection of cares, agitation, and anxiousness. Review of plan of care document titled, Standard Care Plans, dated October 30, 2024 at 23:30, resident #3 was in a resident to resident altercation, resident #3 was the aggressor. The interventions included one on one conversation, reapproach, watching television, assess for injuries, and psych consult. Review of record, Medication Administration Record (MAR) dated October 31, 2024 at 01:35 revealed resident was administered Haldol and Ativan for signs and symptoms of clinical distress related to anxiety-pacing, unprovoked physical aggression-punching, short tempered and irritable, paranoia and delusions of believing resident is at home and others are intruders. Review of records from progress note titled physician's order note dated October 31, 2024 at 02:57 revealed resident-resident altercation, psych eval. Review of records from progress note titled Incident Note dated October 31, 2024 at 04:12 revealed 2 staff members heard curtains opening and several loud thuds, staff went down hall and entered room to find resident #3 pacing in circles in the middle of the room saying he did not approve of anybody else to stay in his house. Resident stated hit roommate and threw roommate out of bed. Residents separated. No injury noted to resident #3. Review of records from progress note titled Incident Follow Up dated October 31, 2024 at 10:24 revealed the provider was notified about a resident to resident incident on 10/30/2024 at 2330. Review of records from progress note titled Incident Follow Up dated October 31, 2024 at 10:32 revealed case manager informed about October 30, 2024 at 23:30 incident. Review of resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5.0 indicating severely impaired, has difficulty focusing attention, has disorganized or incoherent thinking behavior, has physical behavioral symptoms directed towards others, and exhibited rejection of care and wandering behavior. Resident uses a walker for mobility. Resident is mostly independent with functional abilities which include walking 10 feet on uneven surfaces and bending/stoop from standing position to pick up a small object, such as a spoon, from the floor. Resident is taking Antipsychotic, Antianxiety, and Antidepressant medications. -Resident #4 (alleged victim) was admitted to the facility on [DATE] which include diagnoses of Heart Failure, Hypertension, and Non-Alzheimer's Dementia. A review of MDS admission assessment dated [DATE] revealed a BIMS score of 1.0 indicating severe impairment. Resident has difficulty focusing attention continuously. Resident exhibits physical and verbal behavioral symptoms directed towards others. Resident exhibits behaviors such as rejection of care and wandering. Resident mostly requires supervision or touching assistance with activities of daily living. Resident is taking Antipsychotic, Antidepressant, Anticoagulant, and Diuretic medications. A review of MDS quarterly assessment dated [DATE] revealed an entry date of November 3, 2023 and a BIMS score of 3.0 indicating severe impairment. Resident exhibits physical behavioral symptoms directed towards others, rejection of care and wandering. Review of records titled Standard Care Plan dated November 3, 2023 revealed resident has confusion-poor decision making related to cognitive impairment, and disease process. Review of records titled Standard Care Plan dated November 15, 2023 revealed resident has impaired verbal communication manifested by difficult expressing thoughts. Review of records titled Standard Care Plan dated November 15, 2023 revealed resident has hearing loss, and vision impairment. Review of records titled Standard Care Plan dated November 15, 2023 revealed resident has verbal behaviors making loud verbal outburst, will yell out/curse at others when uncomfortable in current situation. Review of records from progress note Communication with Family dated October 31, 2024 at 01:48 revealed resident's family member was notified about an incident earlier and skin tear to right elbow and resident to move to another location within the facility. Review of records from progress note Physician's Order Note dated October 31, 2024 at 02:58 revealed regarding resident to resident altercation: 1.17 by 5 cm (centimeter) bruise to mid-back, LOTA (leave open to air). Review of records Incident Note in progress note dated October 31, 2024 at 04:19 revealed 2 staff members heard curtains opening and several loud thuds, staff went down hall and entered room to find resident #4 (alleged victim) on ground next to bed on his right side. Residents separated and resident #4 assessed for any injury with skin tear to right elbow and bruising to mid back. Resident #4 stated the roommate just started hitting and dragged him onto the floor. Resident #4 was assisted up onto bed for treatment to right elbow and to get dressed. Review of records titled Standard Care Plan dated October 31, 2024 revealed resident was in a resident to resident altercation. Resident #4 was not the aggressor. The intervention includes psych eval. Review of records, Clinical Census, dated October 31, 2024 revealed resident #4 was moved to another location within the facility. Review of records titled, N Adv-Skin Check-V 13, effective date 10/31/2024 04:22 revealed skin issues note skin tear to right elbow. Bruising to mid back. Review of records dated November 14, 2024 revealed resident #3 and resident #4 were roommates since October 29, 2024. An interview was conducted on November 13, 2024 at 2:40 pm with a certified nursing assistant (CNA)/resident care coordinator (RCC)/Staff #45. Staff #45 stated that her role consist of helping train CNAs to ensure they do everything for the resident. They are a CNA training facility, and after attending their training class, their students can work on their unit as helping hand while in training. Staff #45 stated that one of their halls is dedicated for male residents only. Regarding new resident admission, Staff #45 stated that they go with a nurse and start a new resident body survey to assess if they have any marks or wounds, and then the nurse documents their skin assessment and also takes the resident's vital signs. In addition, for new residents, their director of nursing (DON) will give them an admit packet to review any intervention relating to their new resident. For instance, do they need a wheelchair, turning or changing position schedule, are they fall risk, or are they coming with a wound. Staff #45 stated that when some of their residents have verbal outburst, they talk to them, they take them to their courtyard, to the bathroom, or they give them snack, provide activity to help deescalate the behavior or they help redirect them to calm them down. Staff #45 stated that they have monthly in-services to go over abuse, and different behaviors. Staff #45 stated that regarding resident #3, resident is [NAME] new to them and resident forgets due to sundown. And, in their all male resident hall, they have two CNAs and one nurse scheduled for day and night shifts. An interview was conducted on November 13, 2024 at 3:03 pm with a licensed practical nurse (LPN)/Quality Assurance Nurse (QA)/Staff #90. Staff #90 stated that for their new admitted resident, the floor nurse will do skin assessment, they go over the new orders, vaccines, and tuberculosis. The skin assessment is done to check for bruises, rashes, or open areas. Their newly admitted residents are on a 72-hours every 30 -minute safety check. The flowsheet for their safety check is in the resident's' room. Furthermore, regarding altercation between residents, they do investigation, their floor nurse immediately separate the residents, they assess for injuries and do evaluation. If they are roommates, one will stay in another room and will eventually be moved to another room or hall after family notification. On November 13, 2024 at 3:15 pm, resident #3 sleeping in bed and was unable to interview. An interview was conducted on November 13, 2024 at 4:26 pm with a CNA/Staff #123. Staff #123 stated that they are provided a care plan to review what their residents' needs are. They grab a care plan sheet every morning which has the following information: names of their residents, type of fluids, floor pad, 2-hour turning, and toileting, etc. The care plan sheet is printed out by their RCC. Staff #123 stated that regarding resident #4, the resident care plan is every 2-hour toileting and turning, resident has a bed pad alarm for fall risk precaution, resident can talk and walk, cooperative, and had an altercation with another resident in the other hall. Staff #123 stated that the other resident hit resident #4 and resident #4 was moved to their hall to be away from the resident who hit resident #4. Regarding resident to resident altercation their intervention is to separate them right away, and report to the nurse. An interview was conducted on November 13, 2024 at 4:39 pm with resident #4. Resident was sitting in the dining area, and observed a scab on their right outer elbow. Resident #4 stated that he scratched it and that no one had hurt her. An interview was conducted on November 13, 2024 at 4:42 pm with a registered nurse (RN)/Staff #125. Staff #125 works in the mixed female and male hall. Staff #125 stated that when there is a resident to resident altercation, they separate them. Regarding resident care, their CNAs carry a pocket care plan, which is updated daily and they get it at the beginning of their shift. The RCC calls for any updates or changes regarding their residents so the RCC can make changes and update the pocket care plan. Regarding resident #4, Staff #125 stated that the resident was moved because there was concern about their roommate at the other hall, and the concern happened during night shift, and staff #125 is not familiar with the event. In addition, staff #125 stated that if they notice any tension from the residents, they separate them, they redirect them, and they provide reassurance. Some of their residents have an every 15-minute check typically due to a fall. They also check them on a regular basis when their passing medications, when walking in the hall, and they do a every 30-minute check start with their new admission for the first 48 hours. On November 14, 2024 at 09:06 am, resident #3 was unable to be interviewed. Resident sleeping. An interview was conducted on November 14, 2024 at 09:15 am with a CNA/Staff #60. Staff #60 stated that she heard about resident #3 incident, which the resident hit the other resident, and that happened in the middle of the night couple weeks ago. Regarding staffing, staff #60 stated that for 22 residents, there is an average of two CNAs and one nurse and sometimes they also have the helping hand staff scheduled. An interview was conducted on November 14, 2024 at 10:25 am with the administrator/Staff #31 and present during the interview was the DON/Staff #32. The administrator stated that regarding their abuse policy, their staff reports it directly to the administrator or the DON. Their staff separates the residents, they get their statement from staff and their residents, report the abuse incident, and finish their investigation. The administrator stated that they were informed about the potential resident to resident altercation, their investigation started, their staff were in a one on one with the resident, they performed skin assessment, one resident was moved to another unit, they informed their psych provider, ombudsman, the department, their physician, and their case manager. The administrator stated that regarding resident #3, they did not find any apparent injury and resident #3 made a statement that someone was in their house. And, regarding resident #4, the administrator stated that their nurse indicated that the resident was found on the floor, had a skin tear on the elbow, and an abrasion on their back. The administrator added that resident #4 regularly sit in a recliner, and a week or 2 prior to the incident, resident #4 had slid off the bed in regards to potential abrasion on his back. On November 15, 2024 at 09:49 am, LPN/Staff #129 returned a call for an interview. Staff #129 stated that they work 12-hours night shift and they remembered the incident with resident #3. Staff #129 stated that around 11:30 pm at night, they were up in the desk with one CNA and the other CNA was out on lunch, they were making their vital signs paper for the next day, and staff #129 was not sure what the other CNA was doing, and staff #129 heard a loud noise, curtains divider had been closed previous and heard the sound of the curtain opening so they went down the hallway. They found resident #3 pacing in the room, and the other resident/roommate was on the ground. Resident #3 was talking to themselves and the other resident just on the ground. Resident #3 was assessed with no injury and the other resident 's elbow had a big new skin tear on their right forearm/elbow that was bleeding like it was fresh. They separated the residents, they called the on-call supervisor, they took resident #3 to the dining room and they treated the roommate's skin tear by cleansing their skin tear and assessing for any other injuries. Regarding their training, Staff #129 stated that they have monthly in services, they have the crisis to care training bi yearly or yearly, and a training hand and hand for de-escalation and redirection. Review of facility's policy titled, Abuse Prevention Program, has no issued date and no review or revised date revealed it is the policy of this facility for our residents to have the right to be free from abuse. Review of facility's policy titled, Resident Rights, has no issued date and no review or revised date revealed the facility policy is will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure two residents (#3 and #4) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse. Findings include: -Resident # 3 (alleged perpetrator) was admitted to the facility on [DATE] which include diagnoses of Hypertension, Diabetes Mellitus, Non-Alzheimer's Dementia, and Post Traumatic Stress Disorder (PTSD). Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has confusion-poor decision making related to cognitive impairment, limited mental function and disease process. The interventions include reorient to situations as needed, anticipate needs, observe for signs and symptoms of disease, administer medications as ordered, observe for side effects and effectiveness, and note changes and notify medical doctor as needed. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident has unsafe wandering. The interventions include monitor for any needed interventions such as alarms; monitor closely, 30 minutes safety checks as needed; notify for increased restlessness; anticipate needs such as thirst, hunger, and need to toilet; monitor for patterns and redirect to safe areas. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident exhibits negative physical behavior manifested by hitting, kicking, spitting, pinching or biting towards others-strikes/hits/pinches/attempts to bite/scratch staff when they assist with activities of daily living or administer medications. The interventions include remove person from situation if begins to show signs of agitation in public place, remind calmly about the necessity to refrain from physical acting out. Review of plan of care document titled, Standard Care Plans, dated October 29, 2024 revealed resident require supervision and redirection from staff related to behaviors such as delusional thoughts, paranoia, verbal and physical aggression, accusatory statements, wandering, rejection of cares, agitation, and anxiousness. Review of plan of care document titled, Standard Care Plans, dated October 30, 2024 at 23:30, resident #3 was in a resident to resident altercation, resident #3 was the aggressor. The interventions included one on one conversation, reapproach, watching television, assess for injuries, and psych consult. Review of record, Medication Administration Record (MAR) dated October 31, 2024 at 01:35 revealed resident was administered Haldol and Ativan for signs and symptoms of clinical distress related to anxiety-pacing, unprovoked physical aggression-punching, short tempered and irritable, paranoia and delusions of believing resident is at home and others are intruders. Review of records from progress note titled physician's order note dated October 31, 2024 at 02:57 revealed resident-resident altercation, psych eval. Review of records from progress note titled Incident Note dated October 31, 2024 at 04:12 revealed 2 staff members heard curtains opening and several loud thuds, staff went down hall and entered room to find resident #3 pacing in circles in the middle of the room saying he did not approve of anybody else to stay in his house. Resident stated hit roommate and threw roommate out of bed. Residents separated. No injury noted to resident #3. Review of records from progress note titled Incident Follow Up dated October 31, 2024 at 10:24 revealed the provider was notified about a resident to resident incident on 10/30/2024 at 2330. Review of records from progress note titled Incident Follow Up dated October 31, 2024 at 10:32 revealed case manager informed about October 30, 2024 at 23:30 incident. Review of resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5.0 indicating severely impaired, has difficulty focusing attention, has disorganized or incoherent thinking behavior, has physical behavioral symptoms directed towards others, and exhibited rejection of care and wandering behavior. Resident uses a walker for mobility. Resident is mostly independent with functional abilities which include walking 10 feet on uneven surfaces and bending/stoop from standing position to pick up a small object, such as a spoon, from the floor. Resident is taking Antipsychotic, Antianxiety, and Antidepressant medications. -Resident #4 (alleged victim) was admitted to the facility on [DATE] which include diagnoses of Heart Failure, Hypertension, and Non-Alzheimer's Dementia. A review of MDS admission assessment dated [DATE] revealed a BIMS score of 1.0 indicating severe impairment. Resident has difficulty focusing attention continuously. Resident exhibits physical and verbal behavioral symptoms directed towards others. Resident exhibits behaviors such as rejection of care and wandering. Resident mostly requires supervision or touching assistance with activities of daily living. Resident is taking Antipsychotic, Antidepressant, Anticoagulant, and Diuretic medications. A review of MDS quarterly assessment dated [DATE] revealed an entry date of November 3, 2023 and a BIMS score of 3.0 indicating severe impairment. Resident exhibits physical behavioral symptoms directed towards others, rejection of care and wandering. Review of records titled Standard Care Plan dated November 3, 2023 revealed resident has confusion-poor decision making related to cognitive impairment, and disease process. Review of records titled Standard Care Plan dated November 15, 2023 revealed resident has impaired verbal communication manifested by difficult expressing thoughts. Review of records titled Standard Care Plan dated November 15, 2023 revealed resident has hearing loss, and vision impairment. Review of records titled Standard Care Plan dated November 15, 2023 revealed resident has verbal behaviors making loud verbal outburst, will yell out/curse at others when uncomfortable in current situation. Review of records from progress note Communication with Family dated October 31, 2024 at 01:48 revealed resident's family member was notified about an incident earlier and skin tear to right elbow and resident to move to another location within the facility. Review of records from progress note Physician's Order Note dated October 31, 2024 at 02:58 revealed regarding resident to resident altercation: 1.17 by 5 cm (centimeter) bruise to mid-back, LOTA (leave open to air). Review of records Incident Note in progress note dated October 31, 2024 at 04:19 revealed 2 staff members heard curtains opening and several loud thuds, staff went down hall and entered room to find resident #4 (alleged victim) on ground next to bed on his right side. Residents separated and resident #4 assessed for any injury with skin tear to right elbow and bruising to mid back. Resident #4 stated the roommate just started hitting and dragged him onto the floor. Resident #4 was assisted up onto bed for treatment to right elbow and to get dressed. Review of records titled Standard Care Plan dated October 31, 2024 revealed resident was in a resident to resident altercation. Resident #4 was not the aggressor. The intervention includes psych eval. Review of records, Clinical Census, dated October 31, 2024 revealed resident #4 was moved to another location within the facility. Review of records titled, N Adv-Skin Check-V 13, effective date 10/31/2024 04:22 revealed skin issues note skin tear to right elbow. Bruising to mid back. Review of records dated November 14, 2024 revealed resident #3 and resident #4 were roommates since October 29, 2024. An interview was conducted on November 13, 2024 at 2:40 pm with a certified nursing assistant (CNA)/resident care coordinator (RCC)/Staff #45. Staff #45 stated that her role consist of helping train CNAs to ensure they do everything for the resident. They are a CNA training facility, and after attending their training class, their students can work on their unit as helping hand while in training. Staff #45 stated that one of their halls is dedicated for male residents only. Regarding new resident admission, Staff #45 stated that they go with a nurse and start a new resident body survey to assess if they have any marks or wounds, and then the nurse documents their skin assessment and also takes the resident's vital signs. In addition, for new residents, their director of nursing (DON) will give them an admit packet to review any intervention relating to their new resident. For instance, do they need a wheelchair, turning or changing position schedule, are they fall risk, or are they coming with a wound. Staff #45 stated that when some of their residents have verbal outburst, they talk to them, they take them to their courtyard, to the bathroom, or they give them snack, provide activity to help deescalate the behavior or they help redirect them to calm them down. Staff #45 stated that they have monthly in-services to go over abuse, and different behaviors. Staff #45 stated that regarding resident #3, resident is [NAME] new to them and resident forgets due to sundown. And, in their all male resident hall, they have two CNAs and one nurse scheduled for day and night shifts. An interview was conducted on November 13, 2024 at 3:03 pm with a licensed practical nurse (LPN)/Quality Assurance Nurse (QA)/Staff #90. Staff #90 stated that for their new admitted resident, the floor nurse will do skin assessment, they go over the new orders, vaccines, and tuberculosis. The skin assessment is done to check for bruises, rashes, or open areas. Their newly admitted residents are on a 72-hours every 30 -minute safety check. The flowsheet for their safety check is in the resident's' room. Furthermore, regarding altercation between residents, they do investigation, their floor nurse immediately separate the residents, they assess for injuries and do evaluation. If they are roommates, one will stay in another room and will eventually be moved to another room or hall after family notification. On November 13, 2024 at 3:15 pm, resident #3 sleeping in bed and was unable to interview. An interview was conducted on November 13, 2024 at 4:26 pm with a CNA/Staff #123. Staff #123 stated that they are provided a care plan to review what their residents' needs are. They grab a care plan sheet every morning which has the following information: names of their residents, type of fluids, floor pad, 2-hour turning, and toileting, etc. The care plan sheet is printed out by their RCC. Staff #123 stated that regarding resident #4, the resident care plan is every 2-hour toileting and turning, resident has a bed pad alarm for fall risk precaution, resident can talk and walk, cooperative, and had an altercation with another resident in the other hall. Staff #123 stated that the other resident hit resident #4 and resident #4 was moved to their hall to be away from the resident who hit resident #4. Regarding resident to resident altercation their intervention is to separate them right away, and report to the nurse. An interview was conducted on November 13, 2024 at 4:39 pm with resident #4. Resident was sitting in the dining area, and observed a scab on their right outer elbow. Resident #4 stated that he scratched it and that no one had hurt her. An interview was conducted on November 13, 2024 at 4:42 pm with a registered nurse (RN)/Staff #125. Staff #125 works in the mixed female and male hall. Staff #125 stated that when there is a resident to resident altercation, they separate them. Regarding resident care, their CNAs carry a pocket care plan, which is updated daily and they get it at the beginning of their shift. The RCC calls for any updates or changes regarding their residents so the RCC can make changes and update the pocket care plan. Regarding resident #4, Staff #125 stated that the resident was moved because there was concern about their roommate at the other hall, and the concern happened during night shift, and staff #125 is not familiar with the event. In addition, staff #125 stated that if they notice any tension from the residents, they separate them, they redirect them, and they provide reassurance. Some of their residents have an every 15-minute check typically due to a fall. They also check them on a regular basis when their passing medications, when walking in the hall, and they do a every 30-minute check start with their new admission for the first 48 hours. On November 14, 2024 at 09:06 am, resident #3 was unable to be interviewed. Resident sleeping. An interview was conducted on November 14, 2024 at 09:15 am with a CNA/Staff #60. Staff #60 stated that she heard about resident #3 incident, which the resident hit the other resident, and that happened in the middle of the night couple weeks ago. Regarding staffing, staff #60 stated that for 22 residents, there is an average of two CNAs and one nurse and sometimes they also have the helping hand staff scheduled. An interview was conducted on November 14, 2024 at 10:25 am with the administrator/Staff #31 and present during the interview was the DON/Staff #32. The administrator stated that regarding their abuse policy, their staff reports it directly to the administrator or the DON. Their staff separates the residents, they get their statement from staff and their residents, report the abuse incident, and finish their investigation. The administrator stated that they were informed about the potential resident to resident altercation, their investigation started, their staff were in a one on one with the resident, they performed skin assessment, one resident was moved to another unit, they informed their psych provider, ombudsman, the department, their physician, and their case manager. The administrator stated that regarding resident #3, they did not find any apparent injury and resident #3 made a statement that someone was in their house. And, regarding resident #4, the administrator stated that their nurse indicated that the resident was found on the floor, had a skin tear on the elbow, and an abrasion on their back. The administrator added that resident #4 regularly sit in a recliner, and a week or 2 prior to the incident, resident #4 had slid off the bed in regards to potential abrasion on his back. On November 15, 2024 at 09:49 am, LPN/Staff #129 returned a call for an interview. Staff #129 stated that they work 12-hours night shift and they remembered the incident with resident #3. Staff #129 stated that around 11:30 pm at night, they were up in the desk with one CNA and the other CNA was out on lunch, they were making their vital signs paper for the next day, and staff #129 was not sure what the other CNA was doing, and staff #129 heard a loud noise, curtains divider had been closed previous and heard the sound of the curtain opening so they went down the hallway. They found resident #3 pacing in the room, and the other resident/roommate was on the ground. Resident #3 was talking to themselves and the other resident just on the ground. Resident #3 was assessed with no injury and the other resident 's elbow had a big new skin tear on their right forearm/elbow that was bleeding like it was fresh. They separated the residents, they called the on-call supervisor, they took resident #3 to the dining room and they treated the roommate's skin tear by cleansing their skin tear and assessing for any other injuries. Regarding their training, Staff #129 stated that they have monthly in services, they have the crisis to care training bi yearly or yearly, and a training hand and hand for de-escalation and redirection. Review of facility's policy titled, Abuse Prevention Program, has no issued date and no review or revised date revealed it is the policy of this facility for our residents to have the right to be free from abuse. Review of facility's policy titled, Resident Rights, has no issued date and no review or revised date revealed the facility policy is will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure all of the correct information was on the daily staff posting. Findings include: Review of the daily staff posting dated April 14, 2024 revealed the date, census, total number of licensed staff, the total number of non-licensed staff, total hours for licensed staff and total hours for non-licensed staff, but did not reveal the actual hours worked for each category of licensed and non-licensed staff. The daily staff posting dated January 1, 2024 was not provided by the facility. An interview was conducted on June 6, 2024 at 8:28 a.m. with the Resident Care Coordinator (staff #4), who stated that she is responsible for updating the daily staff posting and posting it daily and requires the date, first and last name of staff scheduled to work. She stated that the purpose of the daily staff posting is to make staff aware of their schedule. She reviewed the daily staff posting dated April 14, 2024 and acknowledged that the postings did not include the actual hours worked for the licensed and unlicensed staff. She stated that she was not aware that actual hours needed to be on the daily staff posting and payroll is responsible for keeping track of actual hours worked. She also stated that she did not have the daily staff posting dated January 1, 2024. During an interview conducted on June 6, 2024 at 1:45 p.m. with the Administrator (staff #103), she stated that the pathway for the daily staff posting has been reviewed with Resident Care Coordinator (staff #4), and the daily staff posting regulation will be reviewed with her as well. She stated that the purpose of the daily staff posting is so the residents and visitors are aware of the ratios of staff in the building. The facility policy, Posting Nurse Staffing Information stated that the information recorded on the form shall include the actual time worked during that shift for each category and type of nursing staff.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that resident (#69) to resident (#25) abuse did not occur with two residents. The deficient practice could result in residents being physically and emotionally injured. Findings include: Resident #69 was admitted to the facility on [DATE] with diagnoses that included dementia in other diseases classified elsewhere, severe, with behavioral, mood, and psychotic disturbance. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 7 indicating the resident had a severe cognitive impairment. A progress note dated December 2, 2023 revealed that the resident wandered about the unit approaching others' personal space and attempted to push residents who were in their wheelchairs and Geri chairs around. A progress note dated December 4, 2023 revealed that the resident was observed rapidly pacing around the unit. She was moving furniture and other residents. She appeared to be talking to people who weren't there. The care plan dated December 20, 2023 revealed that the resident engages in unsafe wandering related to a decline in cognitive status, poor decisions, puts her at risk of falling during elopement attempts or upsetting other residents. Interventions included to monitor for any needed interventions such as alarms, etc. Monitor closely, and 30-minute safety checks as needed. Monitor the resident's patterns and redirect her to safe areas. Progress notes dated December 21, 2023 revealed that the resident wanders aimlessly or non-goal directed. Wandering behavior is likely to affect the safety or well-being of self and others. Wandering behavior is likely to affect the privacy of others. Progress note dated December 29, 2023 revealed that the resident entered another resident's room and the other resident started to yell at her to leave her room. Progress note dated January 8, 2024 revealed that the resident was wandering in the dining room and talking out loud. Another resident pulled resident #69 down and the two residents began yelling loudly and grabbing each others arms. The two residents were separated. Resident #69 did not have any injuries. A behavior care plan note dated January 8, 2024 revealed that the resident was a victim in a resident to resident altercation. Provide the resident with a psych consultation for increased behaviors. -Resident #25 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with anxiety, major depressive disorder, and a delusional disorder. The care plan dated November 8, 2022 revealed that the resident exhibits negative physical behavior manifested by: hitting, kicking, spitting, pinching or biting towards others. She strikes out, hits, pinches, and attempts to bite/scratch staff when they assist with activities of daily living (ADLs) or administer medications. Interventions included to provide a calm, non-rushed environment and to provide individualized attention and time with a goal to be free of physical altercations with injury involving other residents. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 1 indicating the resident had a severe cognitive impairment. The behavioral care plan dated January 11, 2024 states that the resident requires frequent supervision and redirection from staff as she frequently enters other residents' space, makes loud inappropriate comments, and becomes physically aggressive with staff including hitting, punching, grabbing, kicking, and scratching during redirection and cares. I have frequent outbursts of unprovoked crying. I have also been involved in a resident altercation where I was the aggressor. She becomes physically aggressive when others enter her personal space. Interventions included to monitor the resident via 15-minute safety checks and will be redirected if noted to be entering others personal space or becoming verbally/physically aggressive. Progress note dated December 25, 2023 reveals that the resident is observed to have increased behaviors during meal times. The resident yells loudly and constantly at staff and other residents, swearing and name calling. Progress note dated December 29, 2023 revealed that the resident became combative with a certified nursing assistant (CNA) during care. She cussed and slapped at the CNA. Progress note dated January 1, 2024 revealed that the resident was redirected from yelling at other residents three times. Progress note dated January 6, 2024 revealed that the resident was grabbing and pinching staff while being provided care. Review of the progress note dated January 8, 2024 revealed that while resident #25 was sitting in the dining room, she was showing signs of increased anxiety. Another resident was walking close to her and both residents began yelling loudly, while grabbing onto each other. The two residents were separated. Resident #25 had a 2.5 cm long superficial scratch to her upper left arm. Review of the 5-day written investigation dated January 12, 2024 per review of the camera system, resident #25 was sitting in her wheelchair when she was approached from behind by resident #69, who appeared to lean around the wheelchair. Resident #25 grabbed resident #69's arm and pulled her down towards herself. The staff intervened and skin checks were completed on both residents. Resident #25 had a small scratch to her upper left arm. There were three staff statements included in the investigation and all three staff stated that the two residents were grabbing and holding onto each other and yelling. An interview was conducted on June 6, 2024 at 1:45 p.m. with the Administrator (staff #103), who stated that resident #69 was trying to push resident #25's wheelchair. Resident #69 bent down and resident #26 pulled resident #69 down. She stated that she watched the video of the incident and the staff intervened immediately and separated the residents. She agreed that this was resident to resident abuse, but thought that her staff interceded quickly. The facility policy, Abuse Prohibition stated that it is the policy of this facility to screen and train employees to provide for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, exploitation, neglect, mistreatment, and misappropriation of property.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident's (#70) clinical record included the required information for discharge. The deficient practice could result in residents not having a safe and effective transition of care. Findings include: Resident #70 was admitted on [DATE] with diagnosis including recurrent major depressive disorder, pneumonia, dementia with mood disturbance, agitation and psychotic disturbance, anemia, wandering, insomnia and hypertension. A review of the electronic health record for resident #70 revealed two short-term unplanned hospital discharges, one on November 7, 2023 and the other on February 12, 2024. A review of the quarterly MDS (minimum data set) dated March 15, 2024 revealed a BIMS (brief interview of mental status) score of 3, suggesting severe cognitive impairment. A review of the progress notes revealed that notifications for both of the aforenoted hospital discharges transpired timely. A progress noted dated November 7, 2023 revealed a communication entry noting that the nurse had call the resident's doctor and notify him of what had happened, vital signs, and signs/ symptoms the resident was experiencing. A review of the physician orders revealed an order on February 12, 2024 noting that the resident is to be sent to 'KRMC' ([NAME] Regional Medical Center). However, there was no evidence of a physician order evident for the hospitalization on [DATE]. An interview was conducted on May 5, 2024 at 12:15 P.M. with staff #1 , CNA (certified nursing assistants). Staff #1 stated that generally CNA's ready the resident for discharge and the nurses conduct the notifications, to include notifying the doctor and obtaining the necessary orders. Staff #1 stated that there is a guide available that breaks down the steps to make sure nothing is missed. An interview was conducted on June 6, 2024 at 12:23 PM with staff #101, LPN (licensed practical nurse). Staff #101 stated that an order is required any time that a resident is transferred out of the facility and that this would include hospitalization s. Staff #101 further stated that notification of family, case manager and doctor also needed to transpire and that the notifications are generally done by the charge nurse. Staff #101 stated that the facility has a resource binder on each hall that contains a step by step process on what need to happen for a hospitalization to include who is responsible for what step of the process. She stated that if it's an emergent situation, that the order might not immediately be noted in the record but should within a few days of the transfer to the hospital. An interview was conducted on June 6, 2024 at 12:42 P.M. with staff #19, DON (director of nursing). Staff #19 stated that the facility was unable to find the physician order for the hospital transfer on November 7, 2023. She stated that the expectation would be that an order is in place for each hospital transfer. She stated that the nursing staff have a guide in place that tells the staff the steps that they have to take for a discharge to the emergency department or hospital. Staff #19 stated that the risk could include potential liability for the nurse and the facility. A review for the facility policy entitled Transfer and discharge date d December 2, 2021 revealed that if a transfer is necessary for the resident's welfare or that their needs can't be met in the facility, or due to an improvement in the resident's health where they no longer need the services of the facility or the resident has failed to pay after reasonable and appropriate notice, then the physician will provide documentation in the clinical record.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#76) care planned interventions were reassessed for effectiveness and revised as needed. The deficient practice could result in a care plan that does not meet the resident's needs. Findings include: Resident #76 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, malignant neoplasm of left bronchus, metabolic encephalopathy, dementia, major depressive disorder, and insomnia. A care plan dated December 26, 2023 indicated that resident has an order for psychotropic medications and exhibits behavior of psychosis and difficulty sleeping related to depression. Interventions include to administer medication per physician orders, medication use to be evaluated every 4 months and tapered to the lowest effective dose, notify nurse if increase in lethargy or change in behaviors or cognitive function. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 00 indicating that resident had severe cognitive impairment. The MDS also indicated that resident exhibited physical behavioral symptoms directed towards others 4-6 days during the assessment period. Additionally, he exhibited verbal behavioral symptoms directed towards other 1-3 days during the assessment period. The resident also exhibited other behavioral symptoms not directed towards others 1-3 days during the assessment period. The assessment also indicated that resident exhibited rejection of care 4-6 days during the assessment period. The resident also exhibited behavior of wandering which occurred 4-6 days during the assessment period. A behavior note dated May 15, 2024, timestamped 4:37 (a.m.) documented that resident was up wandering all throughout shift in and out of others rooms. The note indicated that resident was turning on lights and talking loudly, and waking others. Resident was redirected several times throughout shift. Review of a communication note dated May 15, 2024 documented that provider was consulted regarding resident not sleeping, going in others' rooms, turning on lights, and talking loudly. The note stated that provider will come in to see resident. A physician visit note dated May 16, 2024 documented that provider came in to see resident and that new orders were received. A physician's order note dated May 16, 2024 documented that resident prescription was increased to Seroquel 50 mg at hour of sleep. The note indicated to keep the resident awake during day shift at much as possible. Review of a skilled evaluation note dated May 16, 2024 and May 18, 2024 through May 21, 2024 stated that resident sleeps intermittently and wanders at night. A behavior note dated May 22, 2024, timestamped 4:47 (a.m.) documented that resident was up wandering and rummaging about room. The note stated that when resident was approached he became physically and verbally aggressive. Review of a neurologic focused evaluation note dated May 23, 2024 and skilled evaluation note from May 26, 2024 through May 29, 2024 documented that resident sleeps intermittently and wanders at night. A skilled evaluation note dated May 31, 2024, a long-term care evaluation note dated June 2, 2024 and a neurologic focused evaluation note dated June 4, 2024 indicated that resident sleeps intermittently and resident wanders at night. During dining observation of residents conducted on June 3, 2024 at 12:42 p.m., resident #76 was not observed in the dining room. Staff indicated to the administrator (staff #103) that resident did not want to leave the room since he was tired and did not want to eat. Further review of the resident's clinical record did not indicate that the resident's intermittent sleep pattern was addressed despite numerous instances/documentation's that resident was sleeping intermittently. Additionally, there was no evidence that provider was notified of this continued behavior since resident's medication was adjusted and provider was last notified of behavior on May 15, 2024. An interview with a Licensed Practical Nurse (LPN/staff #101) was conducted on June 6, 2024 at 9:30 a.m. Staff #101 stated that typically if they see residents are having sleep issues, they talk with the doctor. Normally, they refer to psych doctor and prescribed Melatonin or Ativan if they have increased anxiety. Staff #101 noted that it is a nursing job to recognize if a resident is experiencing insomnia and relay that information to the provider. The LPN stated that if a resident is uncomfortable due to lack of sleep, they can become agitated. This would be documented in PCC (Point Click Care) and that it was communicated to the doctor. Staff #101 noted that each specific behavior as it pertains to the resident is in the care plan. The LPN said that nursing staff can add or discontinue items on care plan. Staff #101 said that for insomnia, care plan would state if doctor had prescribed a medication. Staff #101 stated non-pharmacological approaches would be noted in behavior note in PCC, might include taking a walk, putting on music. Staff #101 stated that if there is an increased pattern a psych eval is initiated to determine if medications need to be changed or increased. During an interview with the Director of Nursing (DON/staff #19) conducted on June 6, 2024 at 1:41 p.m., staff #19 noted that care planning for issues ensures that behaviors are monitored and that interventions are in place to help residents. The DON stated that care plans are important so that the different caregivers know how to care and meet the needs of the resident. Staff #19 said that the impact of not addressing issues is that it could cause discomfort to resident and caregivers will not know how to re-direct behavior or if there is an increase in behavior. Staff #19 stated that with regards to resident #76, she acknowledged that the care plan should have been more updated. The facility policy titled Comprehensive Care Plan signed June 1, 2020 indicated that assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. The policy noted that an individualized comprehensive care plan that includes measurable objectives and time tables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Review of the facility policy titled Behavior Monitoring Policy and Procedure signed June 1, 2020 indicated that nurses will document behavior information, interventions, and resident responses as needed. Should behavior have a significant change the nurse will notify the attending physician for orders for psych consult as determined needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management. The policy further noted that the care plan will be updated to include known triggers to behavior and interventions.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure that ordered fluid restrictions were followed for one resident (#21) on dialysis. The deficient practice could result in the potential for complications and fluid overload for residents. Findings include: Resident # 21 was admitted on [DATE] with diagnosis that included congestive heart failure and dependence on renal dialysis. A review of the MDS (minimum data set) dated revealed a BIMS (brief interview of mental status) score of 5, suggesting severe cognitive impairment. The MDS further noted that the resident was noted to be on dialysis. A review of the physician orders revealed that the resident was on 950 cc (cubic centimeter) fluid restriction every day and night for end stage renal disease. A review of the progress notes, revealed no documentation that CNA's (certified nursing assistants) had notified nursing staff of fluid intake beyond the ordered amount. A review of the facility POC (plan of care) revealed that the following daily fluid intake levels: May 8, 2024 revealed 1080 cc of fluids, May 10, 2024 revealed 1440 cc of fluids, May 12, 2024 revealed 1680 cc of fluids and May27, 2024 revealed 1560 cc of fluids. However, per physician orders, fluid intake should have been limited to 950 cc. There was no evidence of physician notification in the electronic health record that the resident's fluid intake was outside of ordered parameters on the previous dates identified. An interview was conducted on June 6, 2024 at 12:18 P.M. with staff #98 , CNA (certified nursing assistant). Staff #98 stated that if there is an order in place for fluid restrictions then it has to be followed, but further stated that she thought there was some flexibility if the resident is on comfort care. She stated that if the resident had reached the maximum fluid allowed, per physician order, and he wanted more, she would give him more but would notify the nurse. An interview was conducted on June 6, 2024 at 12:23 P.M. with staff #101, LPN (licensed practical nurse-[NAME]). Staff #101 stated that if a resident is on fluid restrictions, even if they are on comfort care, fluid restrictions must be adhered to. Staff #101 reviewed the residents POC and stated that the fluid intake noted on several days on the POC did not meet expectations. She stated that the risk to the resident could include fluid overload or potentially heart failure. An interview was conducted on June 6, 2024 at 12:42 P.M. with staff #19 , DON (director of nursing). Staff #19 stated that with a dialysis resident who is on ordered fluid restrictions that input and output are monitored and that fluid restrictions are adhered to as much as possible. Staff #19 reviewed the resident's electronic health record and stated that on several days the resident had gone over the prescribed fluid restrictions. Staff #19 further reviewed the record for physician notification, but stated she saw no evidence that the physician had been notified. Staff #19 stated that the risk to the resident could include fluid volume overload and heart. A review of the physician policy entitled Following Physician Orders dated June 1, 2020 revealed that it is the policy of the facility that physician orders be carried out as ordered and if an order is not completely carried out as ordered then the facility will notify the prescribing physician.

Based on documentation, staff interviews, and facility policy and procedures, the facility failed to designate a qualified individual to provide recreational activities. The deficient practice could result in appropriate activities not being identified and assessed for the residents. Findings include: Review of the employee record revealed that staff #95 was: -employed by the facility on October 27, 2020 as an Activities Assistant. -employed by the facility on May 5, 2021, as the Director of Activities. -employed by the facility on May 15, 2023 as the Director of Life Enrichment. The employee record did not reveal a certification as an activities professional , or two years of prior experience in recreational activities prior to staff #95 being employed as the Director of Activities on May 5, 2021. Review of staff #95's resume revealed that staff #95: -received a high school diploma. -did not have prior experience in recreational activities. -did not have certification as an activities professional. An interview was conducted on June 5, 2024 at 8:30 a.m. with the Human Resource Director (HR/staff #130), who stated that the Director of Life Enrichment had not completed the certification for activities specialist. During an interview conducted on June 6, 2024 at 1:45 p.m. with the Administrator (staff #103), she stated that the Director of Life Enrichment (staff #95) requires certification and she is very close to finishing the training. Staff #103 was aware that staff #95 should have been certified as an activities specialist. The job description for the Director of Life Enrichment included the following education, experience, and training: -a high school diploma or its equivalent. -satisfactory completion of a training course for Life Enrichment Director approved by the Department of Health and Human Services or a qualified therapeutic recreation specialist or an activities professional certified by a recognized accrediting body or a qualified occupational therapist or occupational therapy assistant. -two years of experience in a social or recreational program approved by the Department of Health and Human Services within the last five years, one of which was full time in a resident activities program in a health care setting.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure provide respiratory care for one resident (#6) is in accordance with physician's order. The deficient practice could result in hypoxia. Findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses that included Epilepsy, dementia in other diseases classified elsewhere, severe with psychotic disturbance, mood disturbance, and anxiety. Review of the orders revealed an order dated March 24, 2022 to administer 2 liters of oxygen via (cannula/mask) continuously per original order every day and night shift The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. During the initial interview with resident #6 conducted on June 3, 2024 in the afternoon the resident was observed lying in bed with the cannula placed under the nostrils. The concentrator was set at 1.5 liters (L). On June 6, 11:04 a.m., the resident was observed sitting in the dining room to the left of the nurse's station. The resident was wearing the cannula and the concentrator was set at 1.5L. A licensed practical nurse (LPN/staff #47) looked at the concentrator and stated that it was set just past 1.5L. and was supposed to be at 2L. She checked the order and changed it to the correct amount, which was 2L. During an interview with the Director of Nursing (DON/staff #19), she stated that a physician's order is needed to administer oxygen and the order should specify the amount/liters needed. She also stated that the facility has a standing order for 2L of oxygen if a resident is having trouble breathing. She stated that there is a risk of under oxygenation if staff don't follow the order and resident #6 is incapable of changing her O2 level. The facility policy, Oxygen Administration dated June 1, 2020 states that It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. Reassess oxygen flowmeter for correct liter flow.

Based on clinical record review, staff interviews, the facility assessment, and review of policy and procedure, the facility failed to ensure that the necessary behavioral health care and services were provided to one resident (#76). The deficient practice could result in residents not receiving the necessary behavioral health care and services. Findings include: Resident #76 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, malignant neoplasm of left bronchus, metabolic encephalopathy, dementia, major depressive disorder, and insomnia. A care plan dated December 26, 2023 indicated that resident has an order for psychotropic medications and exhibits behavior of psychosis and difficulty sleeping related to depression. Interventions include to administer medication per physician orders, medication use to be evaluated every 4 months and tapered to the lowest effective dose, notify nurse if increase in lethargy or change in behaviors or cognitive function. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 00 indicating that resident had severe cognitive impairment. The MDS also indicated that resident exhibited physical behavioral symptoms directed towards others 4-6 days during the assessment period. Additionally, he exhibited verbal behavioral symptoms directed towards other 1-3 days during the assessment period. The resident also exhibited other behavioral symptoms not directed towards others 1-3 days during the assessment period. The assessment also indicated that resident exhibited rejection of care 4-6 days during the assessment period. The resident also exhibited behavior of wandering which occurred 4-6 days during the assessment period. A behavior note dated May 15, 2024, timestamped 4:37 (a.m.) documented that resident was up wandering all throughout shift in and out of others rooms. The note indicated that resident was turning on lights and talking loudly, and waking others. Resident was redirected several times throughout shift. Review of a communication note dated May 15, 2024 documented that provider was consulted regarding resident not sleeping, going in others' rooms, turning on lights, and talking loudly. The note stated that provider will come in to see resident. A physician visit note dated May 16, 2024 documented that provider came in to see resident and that new orders were received. Another physician's order note dated May 16, 2024 documented that resident prescription was increased to Seroquel 50 mg at hour of sleep. The note indicated to keep the resident awake during day shift at much as possible. Review of a skilled evaluation note dated May 16, 2024 and May 18, 2024 through May 21, 2024 stated that resident sleeps intermittently and wanders at night. A behavior note dated May 22, 2024, timestamped 4:47 (a.m.) documented that resident was up wandering and rummaging about room. The note stated that when resident was approached he became physically and verbally aggressive. Review of a neurologic focused evaluation note dated May 23, 2024 and skilled evaluation note from May 26, 2024 through May 29, 2024 documented that resident sleeps intermittently and wanders at night. A skilled evaluation note dated May 31, 2024, a long-term care evaluation note dated June 2, 2024 and a neurologic focused evaluation note dated June 4, 2024 indicated that resident sleeps intermittently and resident wanders at night. During dining observation of residents conducted on June 3, 2024 at 12:42 p.m., it was observed that resident #76 was not in the dining room. Staff indicated to the administrator (staff #103) that resident did not want to leave the room since he was tired. Resident did not want to eat. A neurologic focused evaluation note dated June 4, 2024 indicated that resident sleeps intermittently. Additionally, the note stated that resident wanders at night. Further review of the resident's clinical record did not indicate that the resident's intermittent sleep pattern was addressed despite numerous instances/documentations that resident was sleeping intermittently. Additionally, there was no evidence that provider was notified of this continued behavior since resident's medication was adjusted and provider was last notified of behavior on May 15, 2024. An interview with a Licensed Practical Nurse (LPN/staff #101) was conducted on June 6, 2024 at 9:30 a.m. Staff #101 stated that typically if they see residents are having sleep issues, they talk with the doctor. Normally, they refer to psych doctor and prescribed melatonin or Ativan if they have increased anxiety. Staff #101 noted that it is a nursing job to recognize if a resident is experiencing insomnia and relay that information to the provider. The LPN stated that if a resident is uncomfortable due to lack of sleep, they can become agitated. This would be documented in PCC (Point Click Care) and that it was communicated to the doctor. Staff #101 stated that non-pharmacological approaches would be noted in behavior note in PCC, that might include taking a walk, putting on music. During an interview with the Director of Nursing (DON/staff #19) conducted on June 6, 2024 at 1:41 p.m., staff #19 noted that her expectation is that if staff identifies a resident has a known history of insomnia who is sleeping intermittently and wandering at night is that the staff would offer activities at night and redirect. Additionally, staff #19 stated that she expects staff to notify the provider and get a psych eval. The DON noted that is it important to address this issue since it can disrupt the resident's daily living, disrupt other residents, and impact the comfort of the resident and fell ow residents. Review of the facility policy titled Behavior Monitoring Policy and Procedure signed June 1, 2020 indicated that nurses will document behavior information, interventions, and resident responses as needed. Should behavior have a significant change the nurse will notify the attending physician for orders for psych consult as determined needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management. The policy further noted that the care plan will be updated to include known triggers to behavior and interventions.

Based on observation, staff interview, facility policy and procedure review, the facility failed to ensure that four medications were disposed of in accordance with professional standards of practice. The deficient practice could result in medications not being disposed properly. The sample was 25 medication administrations observed. Findings include: During the medication pass observation with a licensed practical nurse (LPN/staff #47) conducted on [DATE] at 7:10 a.m., the LPN attempted to administer 5 medications to a resident. The resident ended up spitting out the Aspirin and Docusate Sodium back into the medicine cup. The LPN then went back to the nurse's station and threw the medicine cup containing the two medicine in the trash can. In another medication administration observation with staff #47 conducted on [DATE] at 7:17 a.m., the LPN dropped one of the two Depakote (anticonvulsant) 125 mg (milligram) capsule on to the top of the medication cart. She then picked up the dropped capsule off the top of the medication cart and disposed of it with the other capsule in the trash can in the nurse's station. An interview was conducted with a LPN (staff #47) on [DATE] at 7:17 a.m., staff #47 stated that she had to waste the first set (blister pack) of Depakote since one of the capsule fell on the medication cart. During an interview with a Licensed Practical Nurse (LPN/staff #93) conducted on [DATE] at 8:42 a.m., staff #93 stated that non-narcotic drugs are wasted by throwing in the trash or sharps container. If not, MedSafe is used at the end of the Med Pass (Medication Pass) to get rid of medications that was refused by resident or fell to the floor or medication cart counter. An interview was conducted with a LPN (staff #101) on [DATE] at 9:30 a.m. Staff #101 stated that they have a gray box in the conference room and that is where they dispose of medication. The LPN said that typically mediation disposal is done by two nurses. Usually the DON and the QA (Quality Assurance) nurse will take the unused/expired meds and dispose of them. Staff #101 said that if during Med Pass, medication is observed that needs to be disposed of, they call supervisor and will call pharmacy to get updated meds. The LPN said that if a resident refused meds, try a second approach. If the resident does not take the meds on the re-approach, then dispose of it in the sharp container or sand stuff if the meds are crushed and then throw it in the garbage. If meds are intact, throw in sharps container only. Staff #101 said never throw full pills in the garbage since you never know who could take it. During an interview with the Director of Nursing (DON/staff #19) conducted on [DATE] at 1:41 p.m., staff #19 stated that her expectation is that staff use MedSafe bin if they have expired meds or have to dispose medication. The DON said that if the medication needing to be disposed/destructed is a narcotic, then two nurses have to be present to put it in the MedSafe. Staff #19 stated that MedSafe is where medication have to be disposed/destructed. The DON indicated that the importance of following the process for medication disposal/destruction is to ensure medication is not diverted and residents do not inadvertently get medication not meant for them. MedSafe is the used since nobody can get disposed drugs inside. Staff #19 stated that the potential impact of not following the process for medication disposal/destruction is that residents can get the medication, expose residents/staff to allergen, and get medication into the water system. Review of the facility policy titled Discarding and Destroying Medications signed [DATE], indicated that the facility utilizes Tridecon Healthcare Solutions which is a registered biohazardous medical waste transporter approved by the Arizona Department of Environmental Quality to operate Pharmaceutical Waste Management. Medication that cannot be returned to the dispensing pharmacy, excluding controlled substances, will be placed in the Tridecon bin.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to maintain a safe and sanitary kitchen. The deficient practice could result in residents becoming ill. Findings include: On June 3, 2024 at 11:25 a.m. the initial tour of the kitchen was conducted with the Director of Nutritional Services (staff #72). During the tour of the large walk-in refrigerator, a one-pound box of strawberries was observed to have one strawberry with a fuzzy white patch approximately 1 inch by .5 inch. Staff #72 stated that the patch was mold and removed the box of strawberries from the refrigerator. She stated that it is everyone's responsibility to monitor the food and remove old food as needed. There was also a one-pound bag of green grapes that contained one brown grape, and a box of twenty-six green peppers that appeared shriveled and wilted. She stated that the peppers were not good. During a demonstration of the high temperature dishwasher, two cockroaches were observed running on floor from the dishwasher under the sink. Staff #72 told a male staff to get the cockroaches and the male staff used a paper towel to pick the cockroaches up. An interview was conducted on June 6, 2024 at 1:45 p.m. with the Administrator (staff #103), who stated that she supervises staff #72 and it is expectation that staff #72 ensures that quality checks are done daily to ensure that the food is fresh and maintains nutritive value. She also stated that staff #72 should be ensuring that her staff are a part of the process and removing rotten, spoiled, and food that is not fresh. She stated that there is a potential risk of food borne illness if spoiled and/or food that it not fresh is served to the residents. The facility policy, Food Storage and Date Marking states that perishable food such as meat, poultry, fish, dairy products, fruits, vegetables, and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed.

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that garbage/refuse was disposed of properly. The deficient practice could attracted rodents and pests. Findings include: On June 3, 2024 at 11:25 a.m. the initial tour of the kitchen was conducted with the Director of Nutritional Services (staff #72). During a demonstration of the high temperature dishwasher, two cockroaches were observed running on floor from the dishwasher to under the sink. Staff #72 told a male staff to get the cockroaches and the male staff used a paper towel to pick the cockroaches up. Then a tour of the garbage/refuse area was conducted and a large grease trap was observed to the right of the garbage dumpster. Grease was dripping on the ground and a large area of the ground was covered with grease. Small particles of food and grease could also be seen on the grease trap. Staff #72 stated that the the grease was dripping onto the ground and the small particles were food, which created a risk of attracting bugs. An interview was conducted on June 6, 2024 at 1:45 p.m. with the - Interview with Administrator (staff #103), who stated that staff #72 showed her the grease trap and she got staff to clean the ground, grates and the round cylinder. She stated that it is her expectation that staff #72 keeps it clean by by having dietary clean the grease trap and the groundskeeper clean the ground. Staff #103 agreed that a dirty grease trap could attract bugs. The facility policy, Garbage Disposal dated June 1, 2020 states that garbage containing food wastes will be stored in a manner that is inaccessible to pests. Storage areas will be kept clean at all times, and shall not constitute a nuisance.

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that essential kitchen equipment was maintained and in safe operating condition. The deficient practice could result in residents becoming ill. Findings include: On June 3, 2024 at 11:25 a.m. the initial tour of the kitchen was conducted with the Director of Nutritional Services (staff #72). She stated that the high temperature dishwasher needed to rise to 150 degress during the wash cycle and 180 degrees during the rinse cycle in order for the dishware to be properly sanitized. Multiple demonstrations were conducted with the following results: -wash cycle 150 degrees -wash cycle 150 degrees -wash cycle 150 degrees -rinse cycle 145 degrees -rinse cycle 145 degrees -rinse cycle 145 degrees -rinse cycle 150 degrees and dropped instantly back to 145 degrees -rinse cycle 180 degrees Staff #72 stated that there was no risk of the dishes not being sanitized if the rinse cycle runs below 180 degrees, but if the wash cycle doesn't rise to 150 degrees there is a risk of the bacteria not being killed. She stated that they have ordered a new dishwasher and when the dishwasher doesn't rise to the required temperatures, she has the dishwasher wash the dishes in the sink using the three sink method. After the first five demonstrations, the Maintenance Manager (staff #14) came and ran the dishwasher a sixth time and the rinse cycle rose to 150 degrees. He stated that he would need to make some adjustments to the dishwasher. The dishwasher/Nutrition Service Worker I (staff #57) was present during this time and he stated that he has never washed the dishes in the sink and he just keeps running the dishwasher until it rises to correct temperatures. An interview was conducted on June 6, 2024 at 1:45 p.m. with the Administrator (staff #103), who stated that a new dishwasher was just delivered and they did have the current dishwasher working. She stated there is a potential risk of infection if the dishwasher is not rising to the appropriate temperatures because the dishes wouldn't be sanitized. Review of the CMA Dishmachines Owner's Manual states that the high temperature dishwasher temperature for the wash cycle is 155 to 160 degrees and temperature for the rinse cycle is 180 to 195 degrees.

Based on resident, resident representative, and staff interviews and facility documentation, the facility failed to ensure that all alleged violations involving abuse are reported timely for one resident #2. The deficient practice can result in abuse allegations not being reported timely. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease with early onset, dementia, and epilepsy. The resident had an order for a psychiatric consultation dated 5/14/24. Medication orders include 4 capsules of Depakote Sprinkles 125 milligrams (mg) dated 2/16/24, one Abilify 5mg tablet dated 1/31/2024, one Nuedexta 20-10 MG capsule dated 3/14/23, and one Effexor 150 mg tablet daily dated 2/11/24. Quarterly Minimum Data Set (MDS) dated [DATE] shows Brief Interview of Mental Status (BIMS) of 02 which indicated severe cognitive impairment. Documented behaviors included delusions and rejection of care. On the care plan initiated on 3/11/2023, there are interventions for 05/13/2024 to begin cares in pairs and a new intervention for 05/14/2024 to have female caregivers. A progress note by Registered Nurse (RN), Staff #33, timestamp 5/11/2024 at 9:17 am stated that Resident #2 said she was molested to other residents this morning while in the dining area and she also told this to the doctor, Staff #44. Writer planned to update care plan for 2-person cares. A behavior note time stamped on 5/11/2024 3:26 pm further documented resident was heard saying that she had been molested by a guy that walked in the room with [Staff #44]. A female accompanies Dr. [NAME] and 2-person cares is regularly done on [Resident #2]. In an interview with the Administrator, Staff #77 on 5/15/2024 at 3:36 pm, she stated that her DON reported the abuse to her after seeing the word molested in the chart for Resident #2. She stated that the word Molestation means that they stop and immediately start investigating as it can be equated with sexual abuse potentially. In her interview with Resident #2, the resident stated she knew what molest meant and that someone had touched her inappropriately. She stated that after the abuse was reported to her and DON, they updated the care plan to female only caregivers, suspended the staff, and moved the resident immediately to a different secure hall that is all female. On 5/15/2024 at 3:58 pm, during an interview with the Director of Nursing (DON), Staff #66, she stated she found out about Resident #2 reporting abuse on Monday, 05/13/2024. The process for reporting abuse is for whomever finds out about it or witnesses it, reports to supervisor immediately on discovery. If that is a nurse or aid on the floor it would be reported to their supervisor, and then to the DON or Quality Assurance nurse. The staff must report to their supervisor immediately and then the facility has 2 hours to report to state agencies and law enforcement. Staff do receive training on reporting immediately to their supervisor. She reviewed the timeframe of the staff documenting the abuse on 5/11/2024 at 9:17 am and the facility not reporting to the state agency until 5/13/2024 at 5:26 pm. She stated this does not meet her expectation of reporting within the proper timeframe. She stated despite it occurring on a weekend, there is an on-call supervisor for weekends for staff to report abuse to. She did advise that once she saw the abuse noted while she was reviewing the facility's 24-hour summary report, she did report within 2 hours. During an interview with Staff #44, he stated Resident #2 had been a patient of his for while a while. He stated that he did see her on 5/11/2024 with his scribe, Staff #55. She said she had been molested but did not provide specifics and he did not ask for them. She reported it was some man a few nights ago. He stated he reported to the RN who was there for the day, who advised him she was already aware of these allegations. In an interview with RN, Staff #33, on 5/15/2024 at 4:15 pm she stated that she was made aware of allegation of molestation after the fact. The doctor was doing rounds and the assistant, Staff #55 reported to [NAME] that she had been molested. Staff #33 stated the facility did provide abuse training and they are trained reportable abuse can be sexual molestation, hitting a resident, verbally abusive, rough handling, etc. They are trained to notify the supervisor within 2 hours. She stated she did not report the abuse because Resident #2 had very few lucid moments, had a history of making delusional statements, and she had been saying things about a guy earlier at breakfast. She stated that she did not report because she thought charting it would be good enough and updating the care plan to reflect cares in pairs so no staff had to worry about potential false accusations. She stated that also the doctor had heard it all and he did not seem concerned. It did not seem urgent. She went on to say it happened on a weekend and there is not a supervisor on site on weekends, though she does have access to phone one. An interview was conducted on 5/15/2024 at 4:25 pm with the medical records director who stated she did rounds with the doctor on 5/11/2024 and she did recall the resident reporting molestation. She stated her and Staff #44 were rounding and when they went into the room, Resident #2 stated some man in charge of all the patients, who pushed them around had molested her. The resident did not go into any more detail, and she did not ask any further questions. She then reported it to the nurse, Staff #33. Staff #55 stated that the facility does so abuse training at new hire orientation, and she is trained to report abuse to a supervisor immediately. In facility policy titled Abuse Reporting last revised 6/1/2020, it states that all alleged violations involving abuse will be reported to the state licensing/certification agency. Suspected abuse, neglect, exploitation, or mistreatment will be reported within two hours.