Every finding on record at Trevecca Center for Rehabilitation and Healing LLC

Based on facility policy review, medical record review, and interview, the facility failed to have a care plan conference meeting with the resident or resident's representative for 6 of 6 (Residents #30, #88, #91, #103, #137, #150) sampled residents reviewed. The findings include: Review of the undated facility policy titled Care Plans Comprehensive revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS (Minimum Data Set) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission .Each resident's comprehensive person-centered care plan is consistant with the resident's rights to participate in the development and implementation of his or her plan of care . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Morbid Severe Obesity Due to Excess Calories, and Major Depressive Disorder, Recurrent Moderate. Review of the Quarterly MDS for Resident #30 dated 4/17/2023 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the Progress Notes for Resident #30 revealed care conferences were not done quarterly. The last completed care conference was on 2/24/2023. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia, Anoxic Brain Damage, and Persistent Vegetative State. Review of the Annual MDS dated [DATE] revealed no BIMS score. Review of the Progress Notes revealed Resident #88's last care plan conference was conducted on 12/15/2022. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Aftercare following joint replacement surgery, Type 2 Diabetes Mellitus with hypoglycemia, Epilepsy, and Cerebral Infarction. Review of the Significant Change MDS assessment dated [DATE] for Resident #91 revealed, a BIMS score of 00 which indicated the resident was uninterviewable. Review of the Progress Notes for Resident #91 revealed no care conference with resident or resident's representative since 1/2/2023. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses which include Radiculopathy Lumbar Region, Unspecified Fracture of the Left Pubis Subsequent Encounter for Fracture with Routine Healing, Other Intervertebral Disc Degeneration Lumbar Region, and Intervertebral Disc Stenosis of Neural Canal of Lumbar Region. Review of the Quarterly MDS assessment dated [DATE] for Resident #103 revealed a BIMS score of 15 which indicated no cognitive impairment. During an interview on 6/13/2023 at 3:58 PM, Resident #103 stated, I don't know anything about anyone discussing directly with me about my care, this is the closest thing that I have had to talk about my care. Review of the medical record revealed Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Thrombocytopenia, Human Immunodeficiency Virus Disease, Epilepsy, and Unspecified Fracture of Facial Bones. Review of the Significant Change MDS assessment dated [DATE] for Resident #137 revealed, a BIMS score of 2 which indicated severe cognitive impairment. Review of the Progress Notes for Resident #137 revealed no care conference with resident or resident's representative since 2/24/2023. Review of the medical record revealed Resident #150 was admitted to the facility on [DATE] with diagnoses which include Sepsis Unspecified Organism, Chronic Obstructive Pulmonary Disease Unspecified, Arthropathy Unspecified, and Type 2 Diabetes Mellitus Without Complications. Review of the Comprehensive MDS assessment dated [DATE] for Resident #150 revealed a BIMS score of 3 which indicated severe cognitive impairment. During a telephone interview on 6/13/2023 at 2:08 PM, Family Member #7 stated, [Named Resident #150] was having some skin problems to her bottom at one point but they haven't updated me about it. I am not sure about a care plan meeting. During an interview on 6/20/2023 at 3:00 PM, the Social Service Director (SSD) confirmed the care plan conference for the residents (Resident # 30, #88, #91, # 103, #137 and !150) had not been conducted. During an interview on 6/20/2023 at 3:30 PM, the MDS Coordinator confirmed the SSD sets up the care plan meetings and the meetings should be completed quarterly, after admission, and with a significant change. 44724

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow the comprehensive care plan for 1 of 59 (Resident #92) sampled residents reviewed. The findings include: Review of the facility policy titled, Care Plans Comprehensive dated 5/18/2023, revealed, .developed and implemented for each resident .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility policy titled, Lifting Machine Using Mechanical dated 5/19/2023 revealed, .to establish the general principles of safe lifting using a mechanical lifting device .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Supraventricular Tachycardia, and Primary Generalized (Osteo) Arthritis. Review of the comprehensive care plan for Resident #92 dated 5/18/2021 and revised 12/28/2021, revealed, .requires assist with activities of daily living .Total Dependent x2 Staff (Mechanical Lift) for Transfers for Safety . During an observation and interview on 6/12/2023 at 3:24 PM, Certified Nursing Assistant (CNA) #9 was observed coming out of Resident #92's room with a mechanical lift. CNA #9 stated she had transferred Resident #92 using the mechanical lift without another CNA because she could not find anyone to help her with the transfer. CNA #9 confirmed staff was required to use two people for all mechanical lift transfers. During an interview on 6/12/2023 at 3:31 PM, Unit Manager #1 stated for resident safety, staff is required to use two person assist for all mechanical lift use. Unit Manager #1 reviewed Resident #92's Kardex and confirmed she was care planned to use two person assist for mechanical lift.

Based on facility policy review, medical record review, observation, and interview the facility failed to make prompt efforts to resolve grievances for missing personal belongings for 2 of 3 sampled residents (Residents #36 and #155). The findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with a diagnosis which included Multiple Sclerosis. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. During an interview on 6/13/2023 at 10:28 AM, Family Member #6 stated she had reported to Licensed Practical Nurse (LPN) #1 Resident #36 was missing an electric razor charging cord. During a telephone interview on 6/14/2023 at 10:29 AM, LPN #1 stated Family Member #6 had gone to Resident #36's previous room and could not find the cord to his electric razor. LPN #1 told Family Member #6 to call the Housekeeping department to see if they had retrieved the electric razor charging cord, and call the facility and report the item missing for reimbursement. LPN #1 confirmed she [LPN#1] did not tell the weekend supervisor. During an interview on 6/14/2023 at 10:52 AM, LPN #6, the 5th floor Unit Manager, stated the facility had not found the electric razor charging cord. LPN #6 confirmed she had not reported it to the Social Service Director (SSD) .Usually we contact the SSD for any missing item or the Concierge. During an interview on 6/14/2023 at 11:30 AM, the SSD stated, the first person who was informed of the missing item must fill out a grievance form. I have them in the office on the wall they [staff] have access to the logs on the weekends. During an interview on 6/14/2023 at 12:15 PM, the Administrator stated, there were grievance forms which all nurses had access to along with the front desk staff had keys to the SSD office to obtain more forms if needed. Review of the medical record revealed Resident #155 was admitted to the facility on [DATE] with a diagnosis which included Generalized Epilepsy. Review of the Quarterly MDS assessment dated [DATE] for Resident #155 revealed a BIMS score of 15 which indicated no cognitive impairment. During an interview on 6/13/2023 at 10:40 AM, Resident #155 stated, I have lost a very unusual watch it had a black face with gold numbers, a nice watch, hard to replace, I have had it for a long time. The nurses took it off to try and find a vein and after that it come up missing. [Named LPN #1] was the nurse that took it off, it was on 6/5/2023. I told the nurse it was missing. During an interview on 6/14/2023 at 10:55 AM, the SSD stated, I was not notified that [Named Resident #155] had lost his watch. During an interview on 6/15/2023 at 8:50 AM, Resident #155 stated, I still don't have my watch, someone probably took it. During an interview on 6/20/2023 at 8:50 AM, Resident #155 stated, I still haven't heard anything about my watch. 44724

Based on facility policy review, medical record review, and interview, the facility failed to provide a written bed-hold notice to the resident and the resident's representative at the time of hospitalization for 5 of 5 (Resident #91, Resident # 118, Resident #131, Resident #137, and Resident #224) sampled residents reviewed for hospitalization . Review of the facility policy titled, Bed-Holds and Returns, dated 5/18/2023 revealed, .Residents and /or representatives are informed [in writing] of the facility and state [if applicable] bed-hold policies .All residents/representative are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence [hospitalization or therapeutic leave] . Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Aftercare following joint replacement surgery, Type 2 Diabetes Mellitus with hypoglycemia, Epilepsy, and Cerebral Infarction. Resident #91 was transferred out of the facility on 5/30/2023. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] for Resident #91 revealed, a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was not interviewable. Review of the Progress Notes for Resident #91 dated 5/30/2023 revealed, .This resident left facility via [by] 911 per NP [Nurse Practitioner] orders . No documentation was found regarding notice to the resident representative of the bed hold policy upon transfer to the hospital. Review of the medical record revealed Resident #118 was admitted on [DATE] and transferred on 4/22/2023. Resident #118 was readmitted on [DATE] with diagnoses which included Cerebral Infarction due to Embolism of Left Middle Cerebral Artery, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side. No documentation was found in the medical record regarding notice to the resident representative of the bed hold policy. Review of the medical record revealed Resident #131 was admitted on [DATE] and transferred on 4/2/2023. Resident #131 was readmitted on [DATE] with diagnoses which included Chest Pain, Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, and Chronic Obstructive Pulmonary Disease. No documentation was found in the medical record regarding notice to the resident/resident representative of the bed hold policy. Review of the medical record revealed Resident #137 was admitted to the facility on [DATE], transferred on 2/11/2023, and readmitted on [DATE] with diagnoses which included Thrombocytopenia, Human Immunodeficiency Virus Disease, Epilepsy, and Unspecified Fracture of Facial Bones. Review of the Significant Change MDS assessment dated [DATE] for Resident #137 revealed, a BIMS score of 2 which indicated severe cognitive impairment. Review of the progress notes for Resident #137 dated 2/11/2023 revealed, .at approximately 8:30 am pt [patient] was . sent out by EMS [Emergency Medical Services] to hospital . No documentation was found in the medical record regarding notice to the resident representative of the bed hold policy upon transfer to the hospital. Review of the medical record revealed Resident #224 was admitted on [DATE] and transferred on 3/27/2023 with diagnoses which included Unilateral Primary Osteoarthritis, Morbid Obesity, and Type 2 Diabetes Mellitus without complications. No documentation regarding notice to the resident/resident representative of the bed hold policy. During an interview on 6/21/2023 at 11:45 AM, the Administrator confirmed the residents (Residents #91, #118, #131, #137, and#224)and/or resident representatives were not notifed of the bed hold policy prior to transfer. 46831 43466

Based on facility policy review, observation, and interview, the facility failed to ensure 2 of 59 (Resident #11 and Resident #27) sampled residents received their showers/ baths as scheduled, and the facility failed to ensure 1 of 59 sampled residents (Resident #27) had clean and groomed fingernails. The findings include: Review of the policy titled, Bath, Shower/Tub dated 5/19/2023 revealed .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Assist the resident into the bath chair, if applicable .Assist with dressing and grooming as needed .If resident refuses the shower/tub bath, the reason(s) why and the intervention taken .The signature and title of the person recording the date . Review of the policy titled, Activities of Daily Living (ADLs), Supporting dated 5/19/2023 revealed .Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .hygiene (bathing, dressing, grooming, and oral care) . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which include Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified, Unspecified Severe Protein-Calorie Malnutrition, Hyperkalemia, and Dysphagia Oropharyngeal Phase. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Further review revealed Resident #11 required extensive assist with bed mobility, dressing, total assist with toileting, and extensive assist with bathing. Review of the current Comprehensive Care Plan for Resident #11 revealed, a focus for .resident requires assist with activities of daily living related to impaired balance, limited mobility, and Contracture of Right Foot .bathing .extensive assist x 1 staff . During an interview on 6/13/2023 at 10:23 AM, Resident #11 stated, I am not sure when I had a bath. I only get a bed bath, no showers. Review of Resident #11's task documentation for three showers per week scheduled on Tuesday, Thursday, and Saturday, night shift, revealed the following: No bath or shower documented for four days (3/6/2023-3/9/2023), for six days (3/19/2023-3/24/2023), for eleven days (3/27/2023-4/6/2023), for four days (4/8/2023-4/11/2023), for four days (4/19/2023-4/22/2023), for five days (4/24/2023-4/28/2023), for five days (5/2/2023-5/6/2023), for five days (5/22/2023-5/26/2023), and for six days (5/29/2023-6/3/2023). Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Fracture of Tibia or Fibula following insertion of Orthopedic Implant, Joint Prosthesis, of Bone Plate, Left Leg, Local Infection of the Skin and Subcutaneous Tissue, Morbid Obesity, and Hypertension. Review of the Significant Change in Status MDS assessment dated [DATE] revealed Resident #27 had a BIMS score of 3 which indicated severe cognitive impairment. Further review revealed Resident #27 required total assist with bed mobility, total assist with dressing, total assistance with toileting, and extensive assistance with bathing. Review of the current Comprehensive Care Plan for Resident #27 revealed, a focus for .ADL [activities of daily living] Self Care Performance Deficit r/t [related to] Activity Intolerance, Impaired balance, Limited Mobility, Pain . Review of Resident #27's task documentation for three showers per week scheduled on Monday, Wednesday, Friday, Day shift, revealed the following: No bath or shower documented for six days (4/1/2023-4/6/2023), for three days (4/15/2023-4/17/2023), for five days (4/23/2023-4/27/2023), and three days (5/10/2023-5/12/2023). During an observation and interview in Resident #27's room on 6/12/2023 at 3:15 PM, Resident #27 was observed with dried brown debris under her fingernails on both hands. Resident #27 stated, I rarely have my nails cleaned. I don't like the way my nails look, they are dirty . During an observation and interview on 6/12/2023 at 3:20 PM in Resident #27's room, Licensed Practical Nurse (LPN) #11 stated nail care should be provided three times per week and as needed. LPN #11 confirmed Resident #27's fingernails were dirty. During an observation and interview on 6/12/2023 at 3:50 PM, the Director of Nursing confirmed Resident #27's fingernails were dirty and needed cleaning. During an interview on 6/21/2023 at 10:30 AM, Licensed Practical Nurse (LPN) #10 confirmed the task documentation was utilized by Certified Nursing Assistants when resident bathing was completed.

Based on medical record review, observation, and interview, the facility failed to follow physician orders for 1 of 1 sampled residents (Resident #219) related to therapeutic diet. The findings include: Review of the medical record revealed Resident #219 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Dysphagia, Unspecified Severe Protein-Calorie Malnutrition, and Hereditary Spastic Paraplegia. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed coughing or choking during meals or when swallowing medications and complaints of difficulty or pain when swallowing. Review of the physician's orders dated 6/8/2023, revealed .Regular diet Mechanically Altered Ground texture, Nectar Thickened Liquids consistency . Observation on 6/20/2023 at 10:29 AM, revealed Resident #219 drinking a [named brand supplement drink] drink while watching television. During an observation and interview on 6/20/2023 at 10:35 AM in the door way of Resident #219's room, Resident #219 was observed drinking a (named brand supplement drink) drink while watching television. Licensed Practical Nurse (LPN) #8 stated, she gave the (named brand supplement drink) to Resident #219 because she thought it was considered a nectar thickened liquid. LPN #8 confirmed a resident could aspirate if given thin liquids instead of ordered nectar thickened liquids. During an interview on 6/20/2023 at 10:41 AM, LPN #6, acting 5th floor Unit Manager, confirmed the order for the (named brand supplement drink) was discontinued and thought (named brand supplement drink) was considered a thickened liquid. During an interview on 6/20/2023 at 10:54 AM, the Speech Therapist stated a bedside swallow study was completed on Resident #219 and upgraded his liquids to nectar thickened. When asked what the consistency of (named brand supplement drink) is, the Speech Therapist stated she didn't believe the drink was nectar thickened. 48260

Based on facility policy review and medical record review, the facility failed to adequately monitor for side effects or behaviors for 1 of 6 sampled residents (Resident #27) reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Use, dated 3/8/2023 revealed, .Residents will not receive medications that are not clinically indicated to treat a specific condition .Drugs in the following categories are considered psychotropic medication and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications .Antidepressants . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], and readmission on 5/26/2023 with diagnoses which included Fracture of Tibia or Fibula following insertion of Orthopedic Implant, Infection of the Skin and Subcutaneous Tissue, Morbid Obesity, and Hypertension. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the current Comprehensive Care Plan for Resident #27 revealed, a focus for .uses antidepressant medication r/t [related to] depression, insomnia, anorexia .monitor/document/report to MD [medical director] .ongoing s/sx [signs/symptoms] of depression unaltered by antidepressant meds [medications] . Review of the Nurse Practitioner Notes dated 6/8/2023 revealed, .assessment and plan .poor intake .due to her recent loss of her spouse and possible depression, we will add Remeron [Antidepressant] . Review of Resident #27's Medication Administration Record (MAR) dated 6/2023 revealed daily administration of Remeron (Antidepressant) with no monitoring for side effects or behaviors. During an interview on 6/21/2023 at 2:00 PM, the Regional nurse reviewed Resident #27's 6/2023 MAR and was asked if she noted any monitoring for behaviors or side effects for the use of the Antidepressant. The Regional Nurse stated, If the resident has a diagnosis of Depression. Regional Nurse was asked if the resident should be monitored for adverse side effects? The Regional Nurse stated, .I don't know .

Based on facility policy review, observation, and interview, the facility dietary department failed to maintain and serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 2 meal service observed. The findings include: Review of the undated facility policy titled, Food Production and Food Safety revealed .All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 F . During an observation on 6/12/2023 at 11:17 AM in the dietary department, the Certified Dietary Manager (CDM) was taking temperatures of the food on the steam table. During observation and interview on 6/12/2023 in the dietary department beginning at 11:40 AM through 11:42 AM, with the CDM present, the mid-day meal trayline service was in progress. Further observations of food temperatures revealed the chicken noodle soup was 130 degrees F, tomato soup was 129 degrees F, and the vegetable beef soup was 129 degrees F. Further observation revealed one tray cart had already been sent to the 500 hall. During an interview on 6/14/2023 at 9:52 AM, the CDM and Senior Food Service Director, confirmed the soups were not at the appropriate temperature on the steam table.

Based on facility policy review, medical record review, and interview, the facility failed to accommodate dietary preferences for 5 of 5 (Resident #157, #170, #185, #186 and #194)sampled residents reviewed for dietary preferences. The findings include: Review of the facility policy titled, Resident Food Preferences, dated 5/18/2023, revealed, .determine current food preferences .If resident refuses or is unhappy with his or her diet, the staff will discuss a plan that the resident is satisfied with . Review of the facility's undated policy titled, Dining/Meal Service revealed, .A meal identification and food preferences card (meal ID (identification) card/ticket) will be used to properly identify each individual's needs, including food and beverage preferences .permanent meal ID card/ticket should include the name of the individual, diet order, beverage preferences, food dislikes and any other applicable diet information . Review of the medical record revealed Resident #157 was admitted to the facility on [DATE] with diagnoses which included Methicillin Resistant Staphylococcus Aureus (MRSA) Infection as the cause of diseases classified elsewhere, Human Immunodeficiency Virus (HIV) disease, and Tachycardia. Review of the Care Plan for Resident #157 dated 8/20/2021 revealed, .risk for weight loss/gain r/t (related to) .mouth pain . Interventions dated 12/9/2020 revealed, .Monitor weight, diet as ordered .encourage intake, food preferences . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #157 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. During an interview on 6/12/2023 at 12:30 PM, Resident #157 stated, I have talked with [Certified Dietary Manager-CDM] multiple times about wanting ground up hamburger in my soup because it is easier to eat. [CDM] said they couldn't grind up the hamburger patty for me, staff would have to cut it up for me. I have to depend on someone else to come in and do it for me, why can't I just get it where I don't have to worry about it. I had my back teeth pulled but I manage with most of the food by chewing with my front teeth. The soup is hard to manage with my front teeth. I also talked to him about the wasted juice because they are constantly sending me apple and cranberry juice that I have told them I do not like. Review of the tray card dated 6/12/2023 revealed there were no dislikes or preferences specified for Resident #157. During an interview on 6/12/2023 at 4:30 PM Dietary Aide #1 stated, I check trays to make sure everything is right before they go on the cart. Allergies are listed on the tray ticket, food preferences are not on the ticket. If the ticket list grape juice and we run out of grape juice we put a substitute like cranberry juice on the tray. I would not know if the resident liked cranberry juice unless I looked at the computer. We do not look at the computer during tray line. The resident could get something they don't like as a substitute. During an interview on 6/12/2023 at 5:25 PM, the CDM reviewed the facility policy titled, Dining/Meal Service and Resident #157's tray ticket. The CDM confirmed the resident's dislikes were not printed on the tray ticket. The CDM stated, With the new system, the dislikes are not printed on the ticket. The system knows the resident's preferences and does not put foods and beverages the resident does not want on the ticket to be served. We [facility] just initiated the new system [computerized system to monitor resident diets including dietary preferences] about 2 months ago. The current policy does not reflect the new system printed tray cards. When asked if he had spoken to Resident #157 about his preference to have a beef patty ground and put into his soup, the CDM replied, I have spoke to [Resident #157 a few different times about the ground beef patty in his soup. I explained to him that we could not stop the tray line for 1 special request or we could not serve food in a timely manner. [Dietary] sends a beef patty up on his meal tray and staff cuts it up for [Resident #157] to put in his soup. [Resident #157] doesn't like it and wants to have the patty ground by the dietary department. We just cannot do that for every resident, it isn't feasible. During an interview on 6/15/2023 at 4:58 PM, the Registered Dietician (RD) stated she expected a resident's reasonable dietary preference to be honored by staff. The RD stated she did not feel that having a beef patty ground and put in vegetable soup was an unreasonable request. The RD stated the she works with the staff to interview residents about food preferences at least quarterly and updates the chart accordingly with any changes. Review of the medical record revealed Resident #186 was admitted to the facility on [DATE] with diagnoses which included Transient Cerebral Ischemic Attack, Unspecified Fall, and Essential Tremor. Review of the Annual MDS assessment dated [DATE] revealed Resident #186 had a BIMS score of 11, which indicated moderate cognitive impairment. During an interview on 6/13/2023 at 11:28 PM, Resident #186 stated, I have been asking dietary for a fruit plate for a really long time and they just do not send it to me. I have told [dietary] so many times I don't like eggs and oatmeal, but they keep on sending it to me. I also told [Unit Manager #1] and she said it would be taken care of right away. Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses which included Left Bundle-Branch Block, Bradycardia, and Presence of Cardiac Pacemaker. Review of the Significant Change in Status MDS assessment dated [DATE] revealed Resident #185 had a BIMS score of 15, which indicated no cognitive impairment. During an interview on 6/13/2023 at 11:38 AM, Resident #185 stated, I have high blood pressure and they always send foods that contain a lot of salt. I have talked to the dietician [could not recall name, specified a female] and complained about the salty food and nothing has changed in my diet. Review of the medical record revealed Resident #170 was admitted to the facility on [DATE] with diagnoses which included Elevated [NAME] Blood Cell Count, Type 2 Diabetes Mellitus with Foot Ulcer, and Morbid (Severe) Obesity Due to Excess Calories. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #170 had a BIMS score of 15, which indicated no cognitive impairment. During an interview on 6/13/2023 at 11:40 AM, Resident #170 stated, I don't like onions, I still get food with onions present. Dietary has known about my dislike of onions for as long as I have been here. I have told several people including nurses, techs, and the Dietician. It just keeps happening, thankfully I usually have something to eat here in my room. Review of the medical record revealed Resident #194 was admitted to the facility on [DATE] with diagnoses which included Benign Paroxysmal Vertigo, Cerebral Infarction Due to Embolism of Left Cerebellar Artery, and Brain Stem Stroke Syndrome. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #194 had a BIMS score of 15, which indicated no cognitive impairment. During an interview on 6/13/2023 at 11:55 AM, Resident #194 stated, I have filed a grievance because I got tired of telling dietary they were sending food on my tray that I specifically told them I didn't like to eat. I have repeatedly told dietary I don't want cream corn, green peas, and pudding, yet I continue to have them on my plate. I have had to buy my own condiments such as crackers, ketchup, and salt, because they never include them on my trays. I spoke with [CDM] after my grievance .but they continue to send the wrong food items occasionally and especially on the weekends. [CDM] told me they are implementing a new system and working out the process. 44724

Based on facility policy review, observation, and interview, the dietary department failed to maintain and clean the range hoods during 1 of 3 observations. The findings include: Review of the undated facility's policy titled, Cleaning Instructions revealed .Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly . During observation in the dietary department on 6/12/2023 10:31 AM, the range hood was covered with clear and shiny debris. During an interview on 6/12/2023 at 12:05 PM, the Certified Dietary Manager (CDM) confirmed the range hood was covered with clear and shiny debris. The CDM stated the hood was cleaned only twice a year. The last time it was clean was 2/9/2023.

Based on medical record review and interview, the facilty failed to ensure proper treatment and assistive devices to maintain vision for 1 of 59 (Resident #155) residents reviewed for visual decline. The findings include: Review of the medical record revealed Resident #155 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Generalized Epilepsy, Heart Failure, and Hypertension. Review of the Comprehensive Care Plan revealed Resident #155 had a focus for .resident has impaired visual function .arrange consultation with eye care practitioner as required . Review of the Nursing Progress Note dated 1/25/2022 revealed, .Resident informed nurse that he was concerned about his previous loss of vision to his right eye r/t [related to] a history of seizure activity. Resident expressed that he wanted to see a specialist for his eye. Signee informed resident that she would make NP [nurse practitioner] aware . Review of the Physician Progress Notes dated 8/3/2022 revealed .Reported poor right eye vision .We will request ophthalmology consult/referral . Continued review of the Physician Progress Notes dated 8/8/2022, revealed .decreased visual acuity noted on right eye .Placed consult order for Ophthalmology at [named hospital] . Review of the Order Summary Report for Resident #155 revealed an order dated 9/9/2022, .consult: may be seen and treated by an optometrist/ophthalmology, for poor blurry vision . During an interview on 6/13/2023 at 10:15 AM, Resident #155 was performing a word search puzzle. Resident #155 stated, The doctor said he was going to send me to the eye doctor but I haven't got to go. During an interview on 6/14/2023 at 5:35 PM, with the Social Service Director (SSD) and the Business Office Manager (BOM), the SSD stated, We did not know he was having eye issues . he could go out to have an eye exam . During an interview on 6/15/2023 at 8:50 AM, Resident #155 stated, I am going blind in my right eye. I was suppose to have cataract surgery in the eye . Since I had that seizure, my vision became worse. I I told them about it and they said they would check into it. I can't see out of it. I have to turn my head so I can look through my left eye.

Based on facility policy, observation and interview the facility failed to provide needed bath linens to support a comfortable and homelike environment for 222 residents in the facility. The findings include: Review of the facility's policy titled, Departmental Laundry and Linen, dated 2/22/2021 revealed .The Purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen .separate soiled and clean linen at all times . Review of the facility's policy titled, Bath, Shower/Tub, dated 2/22/2021 revealed .Equipment and Supplies .the following equipment and supplies will be necessary when performing this procedure .face cloth and bath towels .place one (1) towel in the tub for the resident to sit on .place a towel in the bath chair for the resident to sit on .dry lower torso . Review of the grievance logs for the last 6 months a grievance was noted on 6/13/2022 at 12:30 PM revealed concern in detail, family states upon request for wash clothes there was a delay. The findings of the investigation revealed, .Housekeeping was notified of the towel shortage .laundry was notified of shortage of linen . Review of the Resident Council Meeting Minutes week of 2/25/2022 revealed .Housekeeping/Laundry: would like laundry to be done more often . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] of Right Lower Limb, Heart Failure, and Diabetes Mellitus. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had a Brief Interview Minimum (BIMS) score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed one person assist was needed with bathing. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] ([CONDITION(S)]), Chronic Respiratory Failure, and [CONDITION(S)]. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #15 had a BIMS score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed one person assist for supervision required with bathing. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], Arthropathy, and Acute Kidney Failure. Review of the Annual MDS assessment dated [DATE], revealed Resident #16 had a BIMS score of 13 which indicated no cognitive impairment. Continued review of the MDS revealed one-person physical assist with bathing. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses which included Elevated White Blood Cell Count, Other Intervertebral Disc Degeneration, Muscle Weakness, and Repeated Falls. Review of the Significant Change in Status MDS assessment dated [DATE], revealed Resident #20 had a BIMS score of 13, which indicated cognitively intact. Resident #20 required supervision with eating and limited to extensive assistance of one to two person physical assistance with all bathing. Observation an interview on 7/27/2022 at 7:30 AM, Resident #16 revealed she goes to the shower on her own and the staff assist her as needed. Resident #16 stated, When it is time for my shower, I ask the staff to bring me a washcloth and towel the night before so I can put it in my room because there are times, they don't have much so I prepare myself. Observation and interview on 7/27/2022 at 8:00 AM, Resident #15 stated, I usually take my bath 3 times per week. Resident #15 stated, You can get linen if you get it early, I try to get it and hide away the towel and wash cloth so I will have them. Observation and interview on 7/27/2022 at 8:30 AM, Resident #14 revealed she gets her baths when she reminds the staff. Resident #14 was asked if she ever had any difficulty with obtaining needed supplies for bathing, she stated, Oh yea we never have enough towels and wash clothes, the Certified Nursing Assistants (CNAs) have had to use towels to wash me because there were no wash clothes. During an interview on 7/26/2022 at 11:23 AM, Resident #20 stated there are times when linens such as towels and wash cloths are scarce and her bath schedule has to be changed. During an interview on 7/26/2022 at 1:41 PM, Unit Manager #3 stated items such as wash cloths and linens, were short at least weekly, and sometimes daily. She stated there were complaints from both staff and residents about not being able to give baths and showers consistently. During an interview on 7/26/2022 at 3:10 PM on the 2nd floor, Certified Nursing Assistant (CNA) #5 stated, It is hard to get baths done, we never have enough towels and wash clothes, it's a waiting game. She further stated, We had 6 wash clothes in the linen room this morning. CNA #5 walked this surveyor to the linen room which revealed 4 wash clothes and 14 towels on the shelves. CNA #5 stated, Not having enough linen hinders getting the baths completed. CNA #5 stated, Every CNA knows [Named Facility] don't have linen and it's always a struggle. During an interview on 7/26/2022 at 3:30 PM on 3rd floor with Licensed Practical Nurse (LPN) #6 and Registered Nurse (RN) #2 was asked if the CNAs have the needed supplies to provide bathing for the residents. Both employees confirmed the CNAs have a hard time completing the resident baths because the facility does not have enough towels and wash clothes. During an interview on 7/26/2022 at 4:04 PM, LPN #7 stated, There have been several shifts when baths and showers had to be rescheduled due to issues with linens not being available. During an interview on 7/26/2022 at 4:41 PM, CNA #6 stated there are times when supplies such as the correct size of briefs are not available. She stated there are times when baths have to be put off because towels and wash cloths are not available. She stated the baths get done, they just have to be rescheduled. She stated the residents are not happy with a shower being moved to another CNA or time. During an interview and observation on 7/26/2022 from 3:45 PM through 5:00 PM, Administrator and Unit Manger #2 accompanied this surveyor to evaluate the bathing supplies in each linen room, linen carts, and laundry in the facility. Observation on the 2nd floor revealed the linen room had 2 wash clothes and 13 towels; two linen carts on the 2nd floor revealed no wash clothes or towels on the carts. Continued observation on the 3rd floor revealed the linen room had 1 wash cloth and 7 towels; no linen carts were on the 3rd floor. Observation on the 4th floor revealed the linen room had no wash clothes and 12 towels; no linen carts were on the 4th floor. Observation on the 5th floor revealed the linen room had no wash clothes or towels; no linen carts were on the 5th floor. Further observation in the basement revealed laundry staff folding linen and had a large clean cart of linen beside folding table. The laundry staff counted 8 wash clothes and 25 towels clean and would be sent up to distribute to the floors. The Administrator and Unit Manager #2 confirmed a total of 57 towels and 11 wash clothes were clean and available for the facility. The Administrator revealed 4 boxes of dry wipes that were available for staff to use also. He further stated, We are probably going to the disposable wash clothes. The Administrator stated, Well that doesn't include what is currently in the soiled carts on the halls or here in laundry. Continued observation on 7/26/2022 at 4:30 PM, with the Administrator and Unit Manager #2 revealed a large, soiled linen cart that was covered with an elastic vinyl cover in the basement. The Unit Manager #2 and this surveyor donned gloves to pull up a corner of the elastic cover from soiled cart and we were able to visualize approximately 10 clear bags of linen that revealed some dirty wash clothes and towels. The Administrator and Unit Manager #2 was asked do you feel the other floors in the building would have some soiled linen and both stated Yes, so we proceeded to go to each floor again in the facility. Further interview and observation on the 2nd floor revealed a large, soiled cart in the soiled linen room, gloves were donned, and Unit Manager #2 pulled elastic vinyl cover up at the corner which revealed approximately 6 clear closed bags of soiled linen. We could visualize some soiled wash clothes and towels. Observation on the 3rd and 4th floor revealed no soiled linen in the soiled linen rooms. Further observation and interview with the Administrator and Unit Manager #2 while getting off the elevator to floor 2 the housekeeper had a large, soiled linen cart which contained approximately 10-15 clear soiled bags of linen that she had just removed from other floors. Further interview on 7/26/2022 at 5:00 PM, Administrator was asked what the current census of residents for the facility was and he stated, 222. The Administrator was asked if the 222 residents in the facility wanted to wash their hands prior to supper or wash their face prior to bed did the facility have enough wash clothes and towels to provide this care and he confirmed, Not at the moment.

Based on facility policy review, facility record review, and interview, the facility failed to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse, which had the potential to affect all 222 residents in the facility. The findings include: Review of the facility's undated policy titled, Abuse Policy, revealed, .It is the policy of this facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property .Administrator/designee is responsible for operationalizing all policies and procedures that prohibit abuse, neglect and exploitation. They are also required to report instances of suspected or actual abuse, neglect or exploitation occurring within the facility .The Abuse Prohibition Coordinator will coordinate all investigations while ensuring the residents safety, and will report findings to the regulatory agencies as required .It is the responsibility of all staff to identify inappropriate behaviors towards residents, which may include but is not limited to: use of derogatory language; rough handling or residents .directing residents who need toileting assistance to urinate/defecate in their clothing, etc .The facility screens potential employees to determine their appropriateness in working with individuals with specific conditions and needs: Screens all potential employees for any previous history of abuse, neglect or mistreating of residents as defined by applicable requirements .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing as soon as possible and initiate gathering requested information .Upon receiving reports of physical or sexual abuse involving an employee the DON/designee will remove the employee from the premises until the investigation is complete .For any allegations of physical assault with evidence of injury or witnessed physical assault the police will be contacted immediately . Review of the facility's policy titled, Resident Rights, dated 2/22/2021, revealed, .Employees shall treat all residents with kindness, respect, and dignity .be free from abuse, neglect, misappropriation of property, and exploitation . Review of the newly hired employees over the past 90 days, and review of the employee time-clock punches, revealed 22 of 70 newly hired employees did not have either a background check completed, or the Abuse Registry checked prior to them working with or around residents. During an interview on 7/26/2022 at 8:40 AM, the Human Resource Director confirmed there were newly hired employees who did not have a background check completed or the Abuse Registry check done upon hire. She confirmed all new employees should have a background check completed an the Abuse Registry checked upon hire. She confirmed herself and her assistant are responsible for checking to make sure new employees were not on the Abuse Registry. During an interview on 7/26/2022 at 8:56 AM, the Administrator confirmed the Abuse Registry must be checked, and a background check must be completed on every new hire before they are allowed to have access to residents, and there were some new employees whom he confirmed did not have a background check completed and the Abuse Registry was not checked. He stated himself and the Human Resource Director are responsible for checking the abuse registry. During an interview on 7/27/2022 at 4:16 PM, the Regional Human Resource Director confirmed there were active employees who had not had a background check or the Abuse Registry checked before they had access to residents in the facility. He stated the on-boarding system the facility uses allows the new hires to do most of the on-boarding at home, and at that time, they sign consent for a back ground check to be done. He stated the system is supposed to automatically request a back ground check, which includes the Abuse Registry check, and the system had failed to work correctly. He confirmed all new employees must have a back ground check, including the Abuse Registry check, before they are allowed to have access to residents.

Based on facility policy review, observation, and interview, the facility failed to store, distribute, and serve ice in accordance with professional standards for food service safety, for 2 of 4 floors observed. The findings include: Review of the facility's undated policy titled, Food Production & Food Safety, revealed, .Ice will be produced and handled in a manner to keep it free from contamination .Ice will not be handled with bare hands, but rather with a sanitized scoop and container for transport and distribution .Ice scoop will not be stored in the ice machine unless a scoop holder is installed in the machine by the manufacturer . Observation on 4th floor, Long Hall, on 7/25/2022 at 10:21 AM, revealed a cooler filled with ice and a metal ice scoop inside the cooler. Observation and interview on the 4th floor, Long Hall, on 7/25/2022 at 1:35 PM, revealed a cooler filled with ice and a metal ice scoop inside the cooler. During an interview with the Certified Nurse Assistant (CNA) #1, she stated, The ice scoop should not be in the ice. Continued interviews with Licensed Practical Nurse (LPN) #1 and Unit Manager (UM) #1, they both stated the ice scoop should not be in the ice for infection control reasons, and the cooler should not be on the hallway; it should be put back in the nourishment room after the hydration pass. Observation and interview on 5th floor, Hall on 7/25/2022 at 3:25 PM, revealed an ice chest and cart sitting on right side of the hall, with two clear plastic cups in the pouch provided for the ice scoop. Interview with the Unit Manager #2, she stated there should be a scoop in the pouch provided on the cart, but today it looked like they were using the plastic cups to scoop ice. She stated the ice chest stays in the hallway for staff to pass ice to the residents. She confirmed staff should not use the plastic cups to scoop the ice. During an interview on 7/25/2022 at 2:00 PM, with the Regional Nurse Consultant, when asked if the ice scoop should be down in the ice, inside the cooler, she stated, I will neither confirm or deny anything. I don't work in this building. During an interview on 7/25/2022 at 3:23PM, with the Administrator, he confirmed an ice scoop should never be left inside the ice cooler. He confirmed it should be placed in a holder on the outside of the ice chest.

Based on facility policy review, record reviews, and interviews, the facility failed to ensure medications and treatments were administered per physician's orders for 1 of 3 residents (Resident #5) reviewed with Midline Catheters and medications. The findings include: Review of the facility policy titled, Medication Administration, dated 2/22/2021, revealed, Medications shall be administered in a safe and timely manner, and as prescribed . Review of the facility policy titled, 021-Reconciliation/Medication/Admission, dated 2/22/2021, revealed, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission . Review of the facility policy titled, 013 Midline Dressing Changes, dated 2/22/2021, revealed, .The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Infection and [CONDITION(S)] Reaction Due to Internal Left Hip Prosthesis, Other Acute [CONDITION(S)], Left Femur, and Other Seizures. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #5 required supervision with eating and limited to extensive assist with one person physical assistance with all other Activities of Daily Living (ADL)s. Resident #5 was occasionally incontinent of bowel and bladder during the look back period. Resident #5 received an antibiotic during her stay and had IV (intravenous) medications. Review of the Comprehensive Care Plan revealed Resident #5's plan of care included, .Mid-Line administration of IV Fluids, Administration of Medications . Review of the pharmacy manifest dated 6/8/2022, revealed the facility received [MEDICATION(S)] 300 mg (milligram) on 6/8, 6/15, and 6/16/2022. Review of the Order Summary Report dated 6/8-6/20/2022, revealed Resident #5 had orders which included .IV [intravenous] Midline Catheter [no start date] change catheter site dressing .IV Midline catheter monitor lab work [no start date] .IV Midline catheter observe site [no start date] .IV flushing Midline catheter [no start date] .IV site check [no start date] .[MEDICATION(S)] Solution Reconstituted 500 mg .[MEDICATION(S)] Capsule 300 mg .[MEDICATION(S)] Solution refilled syringe 300 mcg/0.5 ml injection . Review of the Medication Administration Record (MAR) dated 6/2022, for Resident #5 revealed no documentation of administration of [MEDICATION(S)] 300 mg on 6/15/2022 at 1700 and no supporting progress note for missed administration explanation. Continued review revealed [MEDICATION(S)] injection was not administered on 6/9/2022 with no progress note for missed administration explanation. Review of the Treatment Administration Record (TAR) dated 6/2022, revealed Resident #5 had unscheduled other orders which included .a midline catheter dressing change, observation of catheter site, document in notes at least every shift, monitor site . During an interview on 7/26/2022 at 1:41 PM, Unit Manager #3 stated Resident #5's daughter brought the Zario injection (medication for [CONDITION(S)]) to the facility a few days after she was admitted . She could not recall the midline dressing change. During an interview on 7/27/2022 at 12:18 PM, Unit Manager #2 stated when a resident was admitted their orders were put into the computer and then reconciled by the Physician. If the nurse needs a medication that has not arrived from pharmacy, it should be available in the Pixus (medication vending machine) for emergency dispensing. She stated [MEDICATION(S)] was available in the Pixus. If a medication was needed that was not in the Pixus, the nurse would contact pharmacy for a stat delivery. She reviewed Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 6/2022 and confirmed there was not an order or documentation for Midline catheter dressing change. She reviewed the Physician Order Summary dated 6/2022 for Resident #5 and confirmed there was an order for the Midline catheter dressing change without a start date. She stated there was no documentation for administration of [MEDICATION(S)] 300 mg on 6/15/2022 at 1700. She stated the MAR was initialed on 6/9/2022 with code 9 which indicated see progress note for explanation. She reviewed the Progress Notes for Resident #5 and confirmed there were no progress notes documented for the IV Midline Catheter dressing change. She confirmed there were no notes documented related to missed medication administrations. During a telephone interview on 7/27/2022 at 12:45 PM, the previous Director of Nursing (DON) stated Resident #5's family supplied the [MEDICATION(S)] Injection due to high cost of the medication. She was unaware of any problems reported due to availability of medications to Resident #5. She stated her expectations were that medications be administered per physician's order, with documentation of exceptions to administration. During a telephone interview on 7/27/2022 at 12:53 PM, family member #4 stated the IV Midline Catheter dressing had only been changed once during the resident's stay in the facility. She stated the dressing was changed the day before she was discharged from the facility. She stated she had taken Resident #5 to the doctor and brought back another order to change the dressing after being told the facility did not have an order for the dressing change. She stated the dressing continued to be unchanged until the day before discharge.

Based on facility policy review, record review, and interviews, the facility failed to ensure that residents received care according to professional standards of practice for 5 of 5 residents (Residents #2, #5, #19, #20, and #21) reviewed with complaints of call lights not being answered, care not provided in a timely manner and failure to provide peri-care. The findings include: Review of the facility policy titled, Answering the Call Light, revised 3/2021, revealed, .The purpose of this procedure is to ensure timely responses to the resident's request and needs . Review of the facility policy titled, Urinary Continence and Incontinence-Assessment and Management, revised 9/2010, revealed, .A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments .The primary goals are to maintain dignity and comfort and to protect the skin . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission Minimum Data Set (MDS) assessment, dated 5/12/2022, revealed Resident #2 had a Brief Interview For Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Continued review revealed Resident #2 required total assistance with two staff members for bed mobility and additional total assistance with one staff member for toileting. Resident #2 was incontinent of bowel and bladder. Review of Resident #2's Significant Change MDS assessment dated [DATE] revealed Resident #2 required total assistance from one staff member for bed mobility and toileting. Continued review revealed Resident #2 was incontinent of bowel and bladder. Review of Resident #2's kardex dated 7/25/2022 revealed .Notify nurse immediately of any new areas of skin breakdown. Redness, Blisters, Bruises, discoloration noted during a bath or daily care . Review of Resident #2's physician orders dated May 2022 revealed .sacrum down bil [bilateral] buttocks: MASD [Moisture Associated Skin Disorder]: cleanse with normal saline, apply [MEDICATION(S)] powder and cover with bordered foam dressing .Physical Therapy Frequency & Duration: PT to eval and treat 5 days per week for 4 weeks for ther [therapy] . OT [occupational] eval and treat . Review of Resident #2's physician orders dated June 2022 revealed .bilateral buttocks: fungal appearance: cleanse with normal saline and apply anti-fungal cream . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 15, which indicated no cognitive impairment. Resident #5 required supervision with eating and limited to extensive assist with one person physical assistance with all other Activities of Daily Living (ADL)s. Resident #5 was occasionally incontinent of bowel and bladder during the look back period. Review of the Comprehensive Care Plan revealed Resident #5's plan of care included, .chronic [CONDITION(S)] [urinary tract infection] .bowel and bladder incontinence . Review of the hospital discharge documents dated 6/8/2022, revealed Resident #5 had urge incontinence and [CONDITION(S)] while in the hospital before discharge. Review of the Complaint/Grievance Report dated 6/10/2022, revealed the complainant filed a grievance related to Resident #5 being left on a bed pan for an hour and call light was not answered. The grievance was investigated and found to be substantiated by Unit Manager #3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #19 had a BIMS score of 14, which indicated cognitively intact. Resident #19 required supervision with eating and limited to total dependence of one to two person physical assist with all other ADLs. Review of the Comprehensive Care Plan for Resident #19 revealed care plans which included, .bowel and bladder incontinence .requires assistance with ADLs .risk for falls . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status MDS assessment dated [DATE], revealed Resident #20 had a BIMS score of 13, which indicated cognitively intact. Resident #20 required supervision with eating and limited to extensive assistance of one to two person physical assistance with all other ADLs. Resident #20 was occasionally incontinent of bladder during the look back period. Review of the Comprehensive Care Plan for Resident #20 revealed care plans which included, .potential for bowel incontinence .[CONDITION(S)] .diuretic therapy .bladder incontinence .assist with ADLs .falls . During a telephone interview on 7/25/2022 at 10:39 AM, Family Member #5 stated he came every morning from 9 AM to 11 AM and then returned to the facility from 5 PM and 7 PM. During Family Member #5's visitation, he observed Resident #2's brief was soiled and would alert the staff to have Resident #2's brief changed. When staff was alerted of the soiled brief, they would tell Family Member #5 to wait until after the tray pass and change the dirty brief. The wait ranged from two to three hours. Family Member #5 then decided to learn how to change Resident #2's brief because he provided them during Resident #2's stay. Continued interview revealed Resident #2 started developing skin rash in her inner thighs, groin, genitals, and labia. Family Member #5 alerted the nursing staff of the rash, and they told Family Member #5 they would apply a cream. During an interview on 7/25/2022 at 3:16 PM, Resident #21 stated the staff were not answering the call lights because the facility was short staffed. Resident #21 sated she waited four hours the other day because the night shift CNA had promised to change her and her roommate before the shift ended. The night shift CNA did not come back to change them at the end of her shift and the day shift CNAs assumed they were changed and already started other tasks in the morning. During a telephone interview on 7/25/2022, at 4:14 PM, Licensed Practical Nurse (LPN) #8 stated Resident #5's daughter had called to complain about the resident not getting help to the bathroom for 1-2 hours after putting on call light. She stated at the time, the CNAs would not answer call lights during the shift. She stated Resident #5 was often soaked in urine when she had to answer her call light. She stated she had taken pictures of staff sleeping and reported the problem with staff and the complaints from the residents related to care to the DON (Director of Nursing) and ADON (Assistant Director of Nursing). During a telephone interview on 7/26/2022 at 9:31 AM, the Interim DON stated she had been made aware of the complaints of residents not receiving care and call lights not being answered. She stated the poor care was obvious when some of the resident's mattresses had to be cleaned and aired out due to severely saturated with urine and feces. During an interview on 7/26/2022 at 11:23 AM, Resident #20 stated she had waited as long as 1 hour for staff to answer call lights at times. During an interview on 7/26/2022 at 1:41 PM, Unit Manager #3 stated the Certified Nursing Assistant (CNA)s did not answer call lights in a timely manner. She stated she had several discussions with the DON and the Administrator about the call lights. She stated the DON had monitored the night shift staff and found staff were sleeping and not providing care through the shift. During an interview on 7/26/2022 at 2:50 PM, the Wound Care Nurse stated Resident #2 had a scalp surgical incision with steri-strips in. Continued interview confirmed Resident #2 had MASD, fungus, and a g-tube. The Wound Care Nurse stated that MASD likely came from constant moisture and loose stool. During an interview on 7/27/2022 at 10:36 AM, Resident #19 stated she filed a grievance about staff not answering call lights in March 2022. She stated the Social Worker talked to her the staff had been talked to and given education. She stated she had to file another grievance in June 2022 because staff continues to leave her without providing care for long periods of time. She stated the CNAs will come into the room and turn off the call light and say they will return, then take hours to come back. She stated she has waited up to 4 hours because the CNAs going off shift will tell her the on coming shift will make rounds and provide care. She stated the on-coming shift had taken up to 4 hours to get to her room for care. During a telephone interview on 7/27/2022 at 12:13 PM, the Interim DON stated she was not aware of Resident #2 having MASD and then developing a fungus infection to the peri-area, inner thighs, and buttocks. Continued interview revealed the Interim ADON assumed the MASD and fungus developed from not receiving timely brief changes. However, she was unsure if it could be applied to Resident #2. During a telephone interview on 7/27/2022 at 12:27 PM, the former DON stated she was unaware that Resident #2 had MASD and a fungus in the peri area and buttocks. The former DON noted that for some residents, it could be unavoidable. The resident needed to be changed as frequently and timely as possible and to wear dry loose-fitting clothes. The former DON expected staff to find another staff member to assist the resident family if a resident had a soiled brief during a tray pass. During a telephone interview on 7/27/2022 at 12:53 PM, family member #4 stated Physical Therapy staff had not been able to provide therapy before getting the resident cleaned up because she was saturated with urine. She stated Resident #5 had complained because she was told that as long as she wore a brief, staff did not have to toilet her. During an interview on 7/27/2022 at 2:02 PM, LPN #10 stated that the husband changed Resident #2's brief and pointed out the rash and redness to LPN #10. LPN #10 stated she knew of Family Member #5 chnaging Resident #2's briefs. During a telephone interview on 7/27/2022 at 2:16 PM, a private caregiver stated Resident #5 had waited up to 3 hours for care after pushing the call light the weekend before she left the facility. She stated she had notified the nurse and was told they were short staffed so it would be a while before care would be provided. The caregiver stated she saw staff sleeping at the desk that evening.

Based on facility policy review, medical record review, and interviews, the facility failed to investigate an alleged incident of abuse for 3 of 3 residents (Residents #4, #5, and #13) reviewed for allegations of abuse. The findings include: Review of the facility's undated policy titled, Abuse Policy, revealed, .It is the policy of this facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property .Administrator/designee is responsible for operationalizing all policies and procedures that prohibit abuse, neglect and exploitation. They are also required to report instances of suspected or actual abuse, neglect or exploitation occurring within the facility .The Abuse Prohibition Coordinator will coordinate all investigations while ensuring the residents safety, and will report findings to the regulatory agencies as required .It is the responsibility of all staff to identify inappropriate behaviors towards residents, which may include but is not limited to: use of derogatory language; rough handling or residents .directing residents who need toileting assistance to urinate/defecate in their clothing, etc .The facility screens potential employees to determine their appropriateness in working with individuals with specific conditions and needs: Screens all potential employees for any previous history of abuse, neglect or mistreating of residents as defined by applicable requirements .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing as soon as possible and initiate gathering requested information .Upon receiving reports of physical or sexual abuse involving an employee the DON/designee will remove the employee from the premises until the investigation is complete .For any allegations of physical assault with evidence of injury or witnessed physical assault the police will be contacted immediately . Review of the medical record for Resident #4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status assessment for Resident #4 dated 7/1/2022 revealed he had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Continued review revealed no behaviors captured during the assessment period. Review of the Progress Note for Resident #4 dated 5/28/2022 at 15:09 (3:09 PM) revealed, .Pt was witnessed by activities aide with his hand underneath another resident's [Resident #13] dress in the dayroom. His hand was moving upward trying to get farther up her dress. Activity aide intervened and separated him from female resident. This nurse examined female resident and notified the house supervisor. NP was notified. NP will notify MD of incident. No new orders were made. Will continue to monitor resident . Continued review revealed, .15:20 [3:20 PM] Pt had a inappropriate altercation with a female resident this shift. Currently being observed by staff to prevent further encounters until NP follows up. Supervisors and administrator made aware . Review of the Care Plan for Resident #4 revealed assessments/problems for, .Resident exhibits behavior symptoms such as: socially inappropriately/verbally aggressive/abusive; physically aggressive/abusive; hallucinations; delusions; wandering behavior; Sexual Comments to Staff, due to Cognitive Impairment, Will Urinate in His Water Pitcher, Trash Can, Floor . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a BIMS score of 15, which indicated no cognitive impairment. Resident #5 required supervision with eating and limited to extensive assist with one person physical assistance with all other Activities of Daily Living (ADL)s. Resident #5 was occasionally incontinent of bowel and bladder during the look back period. Review of the Comprehensive Care Plan revealed Resident #5's plan of care included, .chronic [CONDITION(S)] [urinary tract infection] .bowel and bladder incontinence . Review of LPN #8's employee file revealed a current LPN license, records of Abuse in-service on hire and a separation notice dated 6/21/2022. Circumstances listed on the separation notice state Care Concerns under leadership. A statement dated 6/21/2022, related to allegations reported by Resident #5's daughter revealed, .night nurse .provided care and was rough with her care and signed by the Admissions Director. Continued review revealed an employee warning notice dated 5/6/2022, stated Failed to ensure staff are providing adequate care to residents at night. Review of the medical record for Resident #13 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment for Resident #13 dated 2/4/2022 revealed a BIMS score of 0, which indicated severe cognitive impairment. Continued review revealed she required limited assistance with bed mobility, and extensive assistance with transfers, dressing, toilet use and personal hygiene. Review of the Progress Notes for Resident #13 revealed no documentation regarding the incident which occurred with Resident #4 on 5/28/2022 in the dayroom. Review of the Care Plan for Resident #13 revealed assessments/problems addressing, .Resident is end of life Hospice .Impaired cognitive function or thought process R/T [related to] Dementia, Bi-polar, agitation, sun downing . During a phone interview on 7/25/2022 at 2:46 PM with Activities Assistant, she stated she witnessed Resident #4 in the Day Room on the 4th floor a couple of months ago, sitting beside a female resident (Resident #13) and had his hand on her leg and was pushing his hand under the resident's gown. She stated she pulled the resident (Resident #4) away from (Resident #13) and told him no, and reported the incident to the charge nurse. During an interview on 7/25/2022 at 3:18 PM with the Regional Nurse Consultant, she stated she was able to get into the Unusual Incident Report System, and the incident which occurred on 5/28/2022 involving Resident #4 and Resident #13 was not reported to the State Agency when it occurred, and she stated she could not find an investigation for the incident. She confirmed the incident should have been reported within 2 hours and an investigation should have been completed within 5 days. During a telephone interview on 7/25/2022, at 4:14 PM, Licensed Practical Nurse (LPN) #8 stated she had been terminated and was told the reason was because Resident #5 had complained to her daughter that she was rough with her while providing care. She stated she had also taken pictures of staff sleeping and reported the problem with staff and the complaints from the residents related to care to the DON (Director of Nursing) and ADON (Assistant Director of Nursing). She stated they blamed her with the CNA problem and told her she should not have taken pictures of the sleeping staff, then she was terminated. During a telephone interview on 7/26/2022 at 9:31 AM, the Interim DON stated she had been notified that Resident #5 had reported rough care provided by LPN #8. She stated she did not investigate the allegation of rough handling by the nurse because the DON was aware of it and she was responsible for any investigations of possible abuse. She stated she was not aware of any investigations about the complaint, the nurse accused of the rough handling was terminated related to that allegation and poor management of staff. During an interview on 7/26/2022 at 10:08 AM, the Admissions Director stated she spoke with Resident #5's daughter about the complaint of rough care provided by LPN #8. She stated she called and reported the allegations to the Administrator the same day she received the complaint. She stated she also reported the allegations to the ADON, now known as the Interim DON on the day she received the complaint. During an interview on 7/27/2022 at 7:15 AM, the Administrator confirmed the incident which occurred on 5/28/2022 between Resident #4 and Resident #13 should have been reported to the State Agency and an investigation should have been completed and was not. During a telephone interview on 7/27/2022 at 12:45 PM, the previous DON stated an allegation of rough handling with a resident would require report to the State withing 2 hours and an investigation. During a telephone interview on 7/27/2022 at 12:53 PM, family member #4 stated she reported the incident of rough handling of Resident #5 by LPN #8 to the Admissions Director on 6/20/2022. During an interview on 7/27/2022 at 4:05 PM, the Administrator stated the allegation of rough handling was reported to him on 6/21/2022. He stated he did not report to the State and no investigation was completed because he did not consider rough with care to be abuse.

Based on facility policy review, medical record review, and interviews, the facility failed to report to the State Agency an alleged incident of abuse for 2 of 2 residents (Residents #5, #13) reviewed. The findings include: Review of the facility's undated policy titled, Abuse Policy, revealed, .It is the policy of this facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property .Administrator/designee is responsible for operationalizing all policies and procedures that prohibit abuse, neglect and exploitation. They are also required to report instances of suspected or actual abuse, neglect or exploitation occurring within the facility .The Abuse Prohibition Coordinator will coordinate all investigations while ensuring the residents safety, and will report findings to the regulatory agencies as required .It is the responsibility of all staff to identify inappropriate behaviors towards residents, which may include but is not limited to: use of derogatory language; rough handling or residents .directing residents who need toileting assistance to urinate/defecate in their clothing, etc .The facility screens potential employees to determine their appropriateness in working with individuals with specific conditions and needs: Screens all potential employees for any previous history of abuse, neglect or mistreating of residents as defined by applicable requirements .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing as soon as possible and initiate gathering requested information .Upon receiving reports of physical or sexual abuse involving an employee the DON/designee will remove the employee from the premises until the investigation is complete .For any allegations of physical assault with evidence of injury or witnessed physical assault the police will be contacted immediately . Review of the medical record for Resident #4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status assessment for Resident #4 dated 7/1/2022 revealed he had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Continued review revealed no behaviors captured during the assessment period. Review of the Progress Note for Resident #4 dated 5/28/2022 at 15:09 (3:09 PM) revealed, .Pt was witnessed by activities aide with his hand underneath another resident's [Resident #13] dress in the dayroom. His hand was moving upward trying to get farther up her dress. Activity aide intervened and separated him from female resident. This nurse examined female resident and notified the house supervisor. NP was notified. NP will notify MD of incident. No new orders were made. Will continue to monitor resident . Continued review revealed, .15:20 [3:20 PM] Pt had a inappropriate altercation with a female resident this shift. Currently being observed by staff to prevent further encounters until NP follows up. Supervisors and administrator made aware . Review of the Care Plan for Resident #4 revealed assessments/problems for, .Resident exhibits behavior symptoms such as: socially inappropriately/verbally aggressive/abusive; physically aggressive/abusive; hallucinations; delusions; wandering behavior; Sexual Comments to Staff, due to Cognitive Impairment, Will Urinate in His Water Pitcher, Trash Can, Floor . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a BIMS score of 15, which indicated no cognitive impairment. Resident #5 required supervision with eating and limited to extensive assist with one person physical assistance with all other Activities of Daily Living (ADL)s. Resident #5 was occasionally incontinent of bowel and bladder during the look back period. Review of the Comprehensive Care Plan revealed Resident #5's plan of care included, .chronic [CONDITION(S)] [urinary tract infection] .bowel and bladder incontinence . Review of LPN #8's employee file revealed a current LPN license, records of Abuse in-service on hire and a separation notice dated 6/21/2022. Circumstances listed on the separation notice state Care Concerns under leadership. A statement dated 6/21/2022, related to allegations reported by Resident #5's daughter revealed, .night nurse .provided care and was rough with her care and signed by the Admissions Director. Continued review revealed an employee warning notice dated 5/6/2022, stated Failed to ensure staff are providing adequate care to residents at night. Review of the medical record for Resident #13 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment for Resident #13 dated 2/4/2022 revealed a BIMS score of 0, which indicated severe cognitive impairment. Continued review revealed she required limited assistance with bed mobility, and extensive assistance with transfers, dressing, toilet use and personal hygiene. Review of the Progress Notes for Resident #13 revealed no documentation regarding the incident which occurred with Resident #4 on 5/28/2022 in the dayroom. Review of the Care Plan for Resident #13 revealed assessments/problems addressing, .Resident is end of life Hospice .Impaired cognitive function or thought process R/T [related to] Dementia, Bi-polar, agitation, sun downing . During a phone interview on 7/25/2022 at 2:46 PM with Activities Assistant, she stated she witnessed Resident #4 in the Day Room on the 4th floor a couple of months ago, sitting beside a female resident (Resident #13) and had his hand on her leg and was pushing his hand under the resident's gown. She stated she pulled the resident (Resident #4) away from (Resident #13) and told him no, and reported the incident to the charge nurse. During an interview on 7/25/2022 at 3:18 PM with the Regional Nurse Consultant, she stated she was able to get into the Unusual Incident Report System, and the incident which occurred on 5/28/2022 involving Resident #4 and Resident #13 was not reported to the State Agency when it occurred, and she stated she could not find an investigation for the incident. She confirmed the incident should have been reported within 2 hours and an investigation should have been completed within 5 days. During a telephone interview on 7/25/2022, at 4:14 PM, Licensed Practical Nurse (LPN) #8 stated she had been terminated and was told the reason was because Resident #5 had complained to her daughter that she was rough with her while providing care. She stated she had also taken pictures of staff sleeping and reported the problem with staff and the complaints from the residents related to care to the DON (Director of Nursing) and ADON (Assistant Director of Nursing). She stated they blamed her with the CNA problem and told her she should not have taken pictures of the sleeping staff, then she was terminated. During a telephone interview on 7/26/2022 at 9:31 AM, the Interim DON stated she had been notified that Resident #5 had reported rough care provided by LPN #8. She stated she did not investigate the allegation of rough handling by the nurse because the DON was aware of it and she was responsible for any investigations of possible abuse. She stated she was not aware of any investigations about the complaint, the nurse accused of the rough handling was terminated related to that allegation and poor management of staff. During an interview on 7/26/2022 at 10:08 AM, the Admissions Director stated she spoke with Resident #5's daughter about the complaint of rough care provided by LPN #8. She stated she called and reported the allegations to the Administrator the same day she received the complaint. She stated she also reported the allegations to the ADON, now known as the Interim DON on the day she received the complaint. During an interview on 7/27/2022 at 7:15 AM, the Administrator confirmed the incident which occurred on 5/28/2022 between Resident #4 and Resident #13 should have been reported to the State Agency and an investigation should have been completed and was not. During a telephone interview on 7/27/2022 at 12:45 PM, the previous DON stated an allegation of rough handling with a resident would require report to the State withing 2 hours and an investigation. During a telephone interview on 7/27/2022 at 12:53 PM, family member #4 stated she reported the incident of rough handling of Resident #5 by LPN #8 to the Admissions Director on 6/20/2022. During an interview on 7/27/2022 at 4:05 PM, the Administrator stated the allegation of rough handling was reported to him on 6/21/2022. He stated he did not report to the State and no investigation was completed because he did not consider rough with care to be abuse.

Based on facility policy, medical record review, and interview, the facility failed to prevent resident to resident altercation for 1 of 20 sampled residents (Resident #8). The findings include: Review of the facility's policy titled, Abuse Policy, dated 2/22/2021 revealed, .It is the policy of the facility that acts of physical, verbal, mental, and financial abuse including neglect and exploitation directed against residents are absolutely prohibited .each resident has the right to be free from .verbal .physical .mental abuse .prevention .incidents are reviewed to identify areas for improvement and needed policy changes or interventions to be implemented .includes .specific environmental, operational, staffing issues, educational and supervisory issues .protection .the facility protects residents from harm during the investigation of any allegations of abuse or neglect .the nurse shall closely monitor the affected resident .for behavioral, emotional, or physical manifestations of the alleged event and document the findings .investigation and a summary of corrective actions taken to prevent such incident from recurring as appropriate . Review of the medical record revealed Resident #7 was initially admitted on [DATE] and readmitted on [DATE]. Resident #7 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) of 3 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 was independent for walking and locomotion on unit. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 3 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #8 required supervision with locomotion on/off unit. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #9 had a BIMS score of 7 which indicated severe cognitive impairment. Further review of the MDS revealed Resident #9 could not walk and locomotive on/off unit required one-person physical assistance. Review of the Facility Reported Investigation (FRI) # 255 revealed on 5/27/2022 at 11:50 AM Resident #9 was sitting in the hallway in her wheelchair and was hit in the mouth area by Resident #7. The altercation was witnessed by a staff member and was reported to the nurse. New order was received to send Resident #7 out for an inpatient psych stay. Resident #7 was scheduled non-emergent transport for psych facility. Review of the second FRI # 119 revealed on 5/27/2022 at 5:15 PM, Resident #7 was involved in another resident-to-resident altercation. Continued review of the FRI revealed Certified Nursing Assistant (CNA) heard Resident #8 holler out and Resident #7 had taken her walker. The CNA approached the resident to intervene but before she could Resident #7 hit Resident #8 in the face. During an interview on 7/26/2022 at 2:30 PM the Administrator reviewed FRI # 255 that occurred on 5/27/2022 at 11:50 AM and FRI # 119 that occurred on 5/27/2022 at 5:15 PM that also involved Resident #7. The Administrator confirmed if Resident #7 had been closely monitored while awaiting to go out to the psych hospital, the 2nd abuse altercation could have been prevented.

Based on facility policy, record review, observation, and interview the facility failed to promote and facilitate resident self-determination of resident's choice to get up daily from bed for 1 of 5 sampled residents (Resident #1), which had the potential to decrease autonomy regarding those things that are important in her life. Review of the facility's undated policy titled, Resident Rights, revealed, .Employees shall treat all resident with kindness, respect, and dignity these resident include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; be free from abuse, neglect, misappropriation of property, and exploitation; be free from corporal punishment or involuntary seclusion, and physical or chemical restratints not required to treat the resident's symptoms; self-determination; communication with and access to people and services, both inside and outside the facility; exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; be supported by the facility in exercising his or her rights; exercise his or her rights without interference, coercion, discrimination or reprisal from the facility . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/17/2021 at 9:25 AM, Resident #1 stated, I got this rash on my back, its a fungal rash. Resident #1 stated, I haven't been up for over 2 weeks. er. Resident #1 was able to give the correct date, day of week, and year during her interview. Resident reported the staff can use a lift to get her up but usually the facility can't find a sling or a chair to transfer her. Resident #1 stated, It's always some horse[OBSCENITY]excuse. During an interview with Activity Director on 11/18/2021 at 12:43 PM, she reported Resident #1 doesn't go to any group activities. Activity Director was asked about Resident #1 getting up from the bed she stated, I have seen her up on the shower bed but never up in a chair. During an interview with the Certified Occupational Therapy Assistant (COTA) Director on 11/18/2021 at 1:00 PM, she was asked about therapy with Resident #1. COTA Director stated, Patient wants to walk that is not something she can do, we had a goal to get her out of bed. It's not really a therapeutic thing to get her up to a hoyer lift. COTA denied resident ever asked to come to therapy gym and further stated, I don't think this would be good for her. COTA further stated, It takes 30 minutes for everything we need to do with her, upper body and active range of motion maintenance program, which basically is not billable. COTA also verified that in 8/2021 a schedule was discussed with nurse manger to get resident up routinely. During an interview with Registered Nurse (RN) #1 on 11/18/2021 at 1:30 PM, she was asked about Resident #1 getting up from bed. She stated, There has been issues getting her up, establishing a schedule, then it doesn't happen, we just need to make a hard schedule for her to get up. RN #1 confirmed Resident #1 has not been out of bed.