Every finding on record at Valley Rehabilitation and Nursing Center

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests and physical, mental, and psychosocial well-being for 4 of 35 sampled residents, Resident #2, Resident #15, Resident #75, and Resident #13. The findings included:1. For Resident #2, the facility staff failed to provide an ongoing, person-centered, activity program to support resident choice, interests, and physical, mental, and psychosocial well-being. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, difficulty in walking, dementia, depression, anxiety disorder, macular degeneration-bilateral, and legal blindness. The most recent significant change MDS with an assessment reference date (ARD) of 9/30/25 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. On 12/9/25 a 2:11 PM, this surveyor observed Resident #2 lying in bed with a radio playing in the room. A review of the clinical record disclosed the following documentation: An activity progress note dated 7/31/25 read in part, .Soothing for the Soul.7/29/25 14:00 (2:00 PM).Location: Activity Room.Resident Attended: Yes. A review of an activity admission assessment dated [DATE] disclosed that reading the Bible and true stories, listening to gospel music, watching the news on TV, doing things with groups of people, Bible quizzes, being around dogs, and going outside in nice weather were very important to Resident #2. A review of the most recent activity assessment dated [DATE] disclosed that listening to music (plays radio in room all day) was very important to Resident #2. Being around animals such as pets was coded as somewhat important to the resident. Reading, was coded as not very important to the resident and keeping up with the news, doing things with groups of people, doing favorite activities, and being outside in nice weather were coded as no response or non-responsive. A review of the comprehensive person-centered care plan disclosed a focus which read in part, .Resident prefers to pursue independent activities such as music and TV. Encourage resident to participate in group activities. At times enjoys socializing with other residents. The interventions for the focus read in part, .assist resident to group activities as needed.review resident preferences for group activities as needed. On 12/10/25 at 10:30 AM, in an interview with the activity director#1 (AD#1), this surveyor requested evidence of Resident #2's activity participation and/or any evidence of social activities completed with the resident. AD#1 informed this surveyor she did not have any evidence of activity engagement for the resident. On 12/10/25 at 1:31 PM, the facility administrator informed this surveyor only the activity assessments could be located for Resident #2 and there was no evidence of activity participation since July 2025. The administrator stated she feels like the activity staff are doing activities with the resident but are not documenting it properly and agreed there is an issue. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Activities Programming with an effective date of 11/1/23 which read in part, .The recreation department will provide, based on the comprehensive assessment and care plan and the preferences of each patient, an ongoing program to support patients in their choice of activities, both facility sponsored group, individual activities, and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction.1.activities must.Reflect the.preferences, goals, choices, and rights of patients.Are person appropriate.Are appropriate for those with cognitive impairments.Are related to the patient's previous work, life roles, life-long interests, culture, spiritual preference.Are inclusive indoors and outdoors.Allow for socializing with other patients, staff, and with people from outside the Center.Are routine on consistent days.Give the patients a sense of purpose or belonging.Encourage.interaction. No further information was provided to the survey team prior to exit on 12/12/25. 2. For Resident #15, the facility staff failed to provide an ongoing, person-centered, activity program to support resident choice, interests, and physical, mental, and psychosocial well-being. Resident #15's diagnosis list indicated diagnoses that included, but were not limited to, Alzheimer's Disease with early onset, anxiety disorder, depression, bipolar disorder, and tracheostomy. The most recent quarterly MDS with an assessment reference date (ARD) of 10/17/25 assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. On 12/9/25 at 1:30 PM, this surveyor observed Resident #15 lying in bed with eyes open. The television in the room was not observed to be turned on and the room was dark and quiet. A review of the clinical record disclosed the following: An activity progress note dated 4/24/25, read in part, .Resident participated in an in room visit by activity staff. She read a book to her (Resident #15) until she fell asleep. A review of an activities assessment dated [DATE] did not disclose any previous interests of the resident and was coded to reflect Resident #15 wished to participate in activities while in the center and wished for one-to-one activities and self-directed activities. The assessment also disclosed Resident #15 had mental and physical impairments that limited scope of activity participation, required 1:1 room visits as tolerated, and required assistance with mobility and daily routine. Activities would need to be modified to accommodate for cognitive deficits and assistance should be provided to get the resident to the activities. A review of the comprehensive person-centered plan of care disclosed a focus/goal which read in part, .Resident is most at ease when she can watch TV.encourage resident to participate in individual activities. On 12/10/25 at 10:21 AM this surveyor interviewed activity director#1 (AD#1) and reviewed the activity assessment mentioned above and Resident #15's activity plan of care. AD#1stated TV is Resident #15's individual preference, as she becomes overstimulated in group activity settings. She agreed staff should assist the resident with TV and should be providing individual activities. This surveyor requested evidence of activity participation for Resident #15 for October, November, and December 2025. On 12/10/25 at 10:33 AM, this surveyor observed Resident #15 in her room lying in bed. A television in the room was not observed to be turned on and the room was dark and quiet. On 12/10/25 at 10:55 AM, AD#1 informed surveyor she does not have anything documented for Resident #15's activity engagement and agreed the resident could not turn the TV on in her room independently. AD#1 informed surveyor resident used to enjoy cartoons when she was on another floor in the facility. She stated she had corrected the issue with the TV not being on in the resident's room. On 12/10/25 at 11:13 AM, AD#1 returned to this surveyor and provided with surveyor with the most recent activity assessment dated [DATE] and stated this was a staff assessment of the resident, as the resident could not communicate effectively and it is difficult to get in touch with the resident's family. AD#1 agreed there are no activity participation records for the resident since April 2025. On 12/11/25 at 9:30 AM, this surveyor observed Resident #15 lying in her bed and observed the television in her room to be on a cartoon channel. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Activities Programming with an effective date of 11/1/23 which read in part, .The recreation department will provide, based on the comprehensive assessment and care plan and the preferences of each patient, an ongoing program to support patients in their choice of activities, both facility sponsored group, individual activities, and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction.1.activities must.Reflect the.preferences, goals, choices, and rights of patients.Are person appropriate.Are appropriate for those with cognitive impairments.Are related to the patient's previous work, life roles, life-long interests, culture, spiritual preference.Are inclusive indoors and outdoors.Allow for socializing with other patients, staff, and with people from outside the Center.Are routine on consistent days.Give the patients a sense of purpose or belonging.Encourage.interaction. No further information was provided to the survey team prior to exit on 12/12/25. 3. For Resident #75 the facility staff failed to provide an ongoing, person-centered, activity program to support resident choice, interests, and physical, mental, and psychosocial well-being. Resident #75's diagnosis list indicated diagnoses that included, but were not limited to, dementia, chronic pain, anxiety disorder, depression, muscle wasting and atrophy, and difficulty walking. The most recent quarterly MDS with an assessment reference date (ARD) of 10/29/25 coded the resident in Section C (Cognitive Patterns) as being rarely/never understood with short and long-term memory problems. The resident was coded as being severely impaired in cognitive skills for daily decision making and never/rarely made decisions. On 12/9/25 at 2:40 PM, this surveyor observed Resident #75 lying in bed awake and the television in the room was not observed to be on. A review of the clinical record disclosed the following documentation: An activity progress note dated 6/30/24 read in part, .Picnic.6/26/24 14:00 (2:00 PM).Location: Activity Room.Resident Attended: Yes. A review of an activity assessment dated [DATE] disclosed that reading a variety of materials, being around animals (dogs), and keeping up with the news were somewhat important to Resident #75. Listening to country/gospel music and participating in religious services were coded to reflect that these activities were very important to the resident and the resident preferred Presbyterian services. The resident was coded to have wished to participate in activities while at the center and would enjoy self-directed activities. Resident #75 was also coded to have physical and mental impairments. A review of the most recent activity assessment dated [DATE] did not disclose any previous/current interests of the resident. The assessment was coded to reflect the resident wished to participate in self-directed activities without modifications to accommodate cognitive deficits and that assistance should be provided to get the resident to activities. The assessment also disclosed that Resident #75 had physical limitations. A review of the comprehensive person-centered plan of care disclosed a focus and interventions which read in part, .resident prefers to participate in self-directed activities such as watching tv programs in their room.assist the resident to perform self-directed activities as needed.provide materials for self-directed activities per resident request if able.review with resident what their self-directed preferences are. On 12/10/25 at 10:30 AM, in an interview with the activity director#1 (AD#1), this surveyor requested evidence of Resident #75's activity participation and/or any evidence of social activities completed with the resident. AD#1 informed this surveyor she did not have any evidence of activity engagement for the resident. On 12/10/25 at 1:41 PM, this surveyor interviewed the facility administrator, and she agreed Resident #75 did not have a person-centered activity care plan and agreed no evidence of documentation for activity participation could be located for the resident since 6/30/24. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Activities Programming with an effective date of 11/1/23 which read in part, .The recreation department will provide, based on the comprehensive assessment and care plan and the preferences of each patient, an ongoing program to support patients in their choice of activities, both facility sponsored group, individual activities, and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction.1.activities must.Reflect the.preferences, goals, choices, and rights of patients.Are person appropriate.Are appropriate for those with cognitive impairments.Are related to the patient's previous work, life roles, life-long interests, culture, spiritual preference.Are inclusive indoors and outdoors.Allow for socializing with other patients, staff, and with people from outside the Center.Are routine on consistent days.Give the patients a sense of purpose or belonging.Encourage.interaction. No further information was provided to the survey team prior to exit on 12/12/25. 4. For Resident #13, the facility staff failed to provide an individualized on-going person-centered activity program. Resident #13's diagnoses included respiratory failure, altered mental status, hypotension, and muscle weakness. Section C (cognitive patterns) of Resident #13's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/26/25 included a brief interview for mental status (BIMS) score of 3 out of 15 points. Indicating Resident #13 was severely impaired in cognitive skills for daily decision making. Resident #13's comprehensive care plan included the focus area of has impaired vision related to macular degeneration, resident prefers self-directed activities such as watching tv programs in their room, stated she doesn't prefer group activities, she enjoys listening to tv in her room. Interventions included assist the resident to perform self-directed activities, respect choice in regard to limited/no group participation, and review with the resident what their self-directed preferences are. Resident #13's clinical record included an activities assessment completed 11/14/25. Under the questions how important is it to you to listen to music you like, be around animals such as pets, keep up with the news, go outside to get fresh air when the weather is good, and participate in religious services or practices the facility staff had marked Resident #13's response as Very important. On 12/10/25 at 9:55 a.m., Resident #13 was observed in their room, resting on bed, their TV was off, and an envelope/mail was observed on their over the bed table. When asked about this envelope/mail Resident #13 stated she was not aware she had any mail on her over the bedtable, and no one had read it to her. On 12/10/25 at 10:30 a.m., the surveyor requested from the Activities Director a 1:1 activity participation record and/or any evidence of social activities completed with this resident. The Activities Director stated she did not have the requested item(s), and she had not done any with this resident as she's usually lethargic. After this interview the surveyor and the Activities Director entered Resident #13's room. Resident #13's TV was again observed to be off. The Activities Director asked the resident if she would like a radio and the resident stated that would be nice. When asked about the unopened mail/envelope on the over the bed table this staff stated they had been the one to lay it on the over the bed table and the resident was asleep when she brought it in. Resident #13 stated she would like to have someone read it to her. On 12/10/25 at 1:05 p.m., the surveyor observed Resident #13 in their room, resting on bed. The TV remained off and there was no radio in the room. On 12/10/25 during an end of the day meeting with the Administrator, Director of Nursing, and Regional Director of Clinical Services the above issues were reviewed. The Administrative staff provided the survey team with a copy of policy titled, Activities Programming. This policy read in part, The recreation department will provide, based on the comprehensive assessment and care plan and the preferences of each patient, an ongoing program to support patients in their choice of activities.designed to meet the interests of an support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community.These activities must.Reflect the schedule, preferences, goals, choices, and rights of the patients.Are person appropriate.Give the patient a sense of purpose or belonging. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review the facility staff failed to develop/implement a person-centered comprehensive care plan for 4 of 35 residents, Resident #2, Resident #15, Resident #75, and Resident #13. The findings included:1. For Resident #2 the facility staff failed to develop and or implement a comprehensive person-centered activity care plan to address the resident's activity preferences, interests, and psychosocial needs. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, difficulty in walking, dementia, depression, anxiety disorder, macular degeneration-bilateral, and legal blindness. The most recent significant change MDS with an assessment reference date (ARD) of 9/30/25 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. A review of an activity admission assessment dated [DATE] disclosed that reading the Bible and true stories, listening to gospel music, watching the news on TV, doing things with groups of people, Bible quizzes, being around dogs, and going outside in nice weather were very important to Resident #2. A review of the most recent activity assessment dated [DATE] disclosed that listening to music (plays radio in room all day) was very important to Resident #2. Being around animals such as pets was coded as somewhat important to the resident. Reading was coded as not very important to the resident and keeping up with the news, doing things with groups of people, doing favorite activities, and being outside in nice weather were coded as no response or non-responsive. A review of the comprehensive person-centered care plan disclosed a focus which read in part, .Resident prefers to pursue independent activities such as music and TV. Encourage resident to participate in group activities. At times enjoys socializing with other residents. The interventions for the focus read in part, .assist resident to group activities as needed.review resident preferences for group activities as needed. On 12/10/25 at 1:31 PM, the facility administrator informed this surveyor she believes the activity staff are doing activities with the resident but are not documenting it properly and agreed there is an issue with activity care plans. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Care Planning with an effective date of 11/1/19, which read in part, .develops and implements an individualized plan of care for each patient in order to provide effective, person-centered care, and the necessary.services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. No further information was provided to the survey team prior to exit on 12/12/25. 2. For Resident #15, the facility staff failed to develop and or implement a comprehensive person-centered activity care plan to address the resident's activity preferences, interests, and psychosocial needs. Resident #15's diagnosis list indicated diagnoses that included, but were not limited to, Alzheimer's Disease with early onset, anxiety disorder, depression, bipolar disorder, and tracheostomy. The most recent quarterly MDS with an assessment reference date (ARD) of 10/17/25 assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. A review of the clinical record disclosed the following: A review of an activities assessment dated [DATE] did not disclose any previous interests of the resident and was coded to reflect Resident #15 wished to participate in activities while in the center and wished for one to one activities and self-directed activities. The assessment also disclosed Resident #15 had mental and physical impairments that limited scope of activity participation, required 1:1 room visits as tolerated, and required assistance with mobility and daily routine. Activities would need to be modified to accommodate for cognitive deficits and assistance should be provided to get the resident to the activities. A review of the comprehensive person-centered plan of care disclosed a focus/goal which read in part, .Resident is most at ease when she can watch TV.encourage resident to participate in individual activities. The interventions read in part, .Activity calendar.Assist to and from activities.Respect choice in regard to limited or no activity participation. On 12/10/25 at 11:13 AM, AD#1 returned to this surveyor and provided with surveyor with the most recent activity assessment dated [DATE] and stated this was a staff assessment of the resident, as the resident could not communicate effectively and it is difficult to get in touch with the resident's family. AD#1 agreed the resident's activity care plan needs to be updated. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Care Planning with an effective date of 11/1/19, which read in part, .develops and implements an individualized plan of care for each patient in order to provide effective, person-centered care, and the necessary.services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. No further information was provided to the survey team prior to exit on 12/12/25. 3. For Resident #75, the facility staff failed to develop and/or implement a comprehensive person-centered activity care plan to address the resident's activity preferences, interests, and psychosocial needs. Resident #75's diagnosis list indicated diagnoses that included, but were not limited to, dementia, chronic pain, anxiety disorder, depression, muscle wasting and atrophy, and difficulty walking. The most recent quarterly MDS with an assessment reference date (ARD) of 10/29/25 coded the resident in Section C (Cognitive Patterns) as being rarely/never understood with short and long-term memory problems. The resident was coded as being severely impaired in cognitive skills for daily decision making and never/rarely made decisions. A review of the clinical record disclosed the following documentation: A review of an activity assessment dated [DATE] disclosed that reading a variety of materials, being around animals (dogs), and keeping up with the news were somewhat important to Resident #75. Listening to country/gospel music and participating in religious services were coded to reflect that these activities were very important to the resident and the resident preferred Presbyterian services. The resident was coded to have wished to participate in activities while at the center and would enjoy self-directed activities. Resident #75 was also coded to have physical and mental impairments. A review of the most recent activity assessment dated [DATE] did not disclose any previous/current interests of the resident. The assessment was coded to reflect the resident wished to participate in self-directed activities without modifications to accommodate cognitive deficits and that assistance should be provided to get the resident to activities. The assessment also disclosed that Resident #75 had physical limitations. A review of the comprehensive person-centered plan of care disclosed a focus and interventions which read in part, .resident prefers to participate in self-directed activities such as watching tv programs in their room.assist the resident to perform self-directed activities as needed.provide materials for self-directed activities per resident request if able.review with resident what their self-directed preferences are. On 12/10/25 at 1:41 PM, this surveyor interviewed the facility administrator, and she agreed Resident #75 did not have a person-centered activity care plan. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Care Planning with an effective date of 11/1/19, which read in part, .develops and implements an individualized plan of care for each patient in order to provide effective, person-centered care, and the necessary.services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. No further information was provided to the survey team prior to exit on 12/12/25. 4. For Resident #13 the facility staff failed to develop and implement an individualized comprehensive care plan (CCP). Resident #13's diagnoses included respiratory failure, altered mental status, hypotension, and muscle weakness. Section C (cognitive patterns) of Resident #13's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/26/25 included a brief interview for mental status (BIMS) score of 3 out of 15 points. Indicating Resident #13 was severely impaired in cognitive skills for daily decision making. Resident #13's CCP included the focus area of impaired vision related to macular degeneration, resident prefers self-directed activities such as watching tv programs in their room, stated she doesn't prefer group activities, she enjoys listening to tv in her room. Interventions included assist the resident to perform self-directed activities, respect choice in regard to limited/no group participation, and review with the resident what their self-directed preferences are. Resident #13's clinical record included an activities assessment completed 11/14/25. Under the questions how important is it to you to listen to music you like, be around animals such as pets, keep up with the news, go outside to get fresh air when the weather is good, and participate in religious services or practices the facility staff had marked Resident #13's response as Very important. On 12/10/25 at 9:55 a.m., Resident #13 was observed in their room, resting on bed, their TV was off. On 12/10/25 at 10:30 a.m., the surveyor requested from the Activities Director a 1:1 activity participation record and/or any evidence of social activities completed with this resident. The Activities Director stated she did not have the requested item(s), and she had not done any with this resident as the resident is usually lethargic. After this interview the surveyor and the Activities Director entered Resident #13's room. Resident #13's TV was again observed to be off. The Activities Director asked the resident if she would like a radio and the resident stated that would be nice. On 12/10/25 at 1:05 p.m., the surveyor again observed Resident #13 in their room, resting on bed. The TV remained off and there was no radio in the room. Under the census tab in Resident #13's clinical record Resident #13's payor source was identified as Medicaid Pace (Program of all-inclusive care for the elderly). The surveyor was unable to locate any reference to this program on this Residents CCP. On 12/11/25 at 11:29 a.m., during an interview with the Administrator, this staff stated this resident has always been PACE and had been admitted on PACE. The Administrator provided the surveyor with evidence to indicate the staff from PACE visited the resident at the facility and she did not attend any off-campus programs with PACE. On 12/11/2025 at 11:30 a.m., Registered Nurse (RN) #1 stated she was not aware the resident was receiving services at the facility from PACE. This surveyor confirmed with the Administrator that the staff from PACE were providing services at the facility for this resident. After hearing this conversation RN #1 stated yes, it should have been on the residents CCP. On 12/11/25 at 3:30 p.m., during and end of the day meeting with the Administrator, Director of Nursing, and Regional Director of Clinical Services the issue with the resident's CCP not being individualized to this resident and the resident's PACE services not being on the CCP was reviewed. The Administrative staff provided the survey team with a copy of their policy titled, Care Planning this policy read in part, .the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, and clinical record review the facility staff failed to ensure an accurate minimum data set assessment for 4 of 35 residents, Resident #18, Resident #2, Resident #61, and Resident #69. The findings included:1. For Resident #18 the facility staff incorrectly coded high-risk medications on the minimum data set. Resident #18's clinical record included diagnoses which included but not limited to Alzheimer's disease, dementia, anxiety, and depression. Resident #18's most recent quarterly minimum data set (MDS) with an assessment reference date of 09/12/25 coded the resident as having both long- and short-term memory loss with severely impaired skills for daily decision making, in Section C, cognitive pattern. Section N, subsection N0415, High-Risk Drug Classes: Use and Indication, coded the resident as receiving hypnotic, anticoagulant, antibiotic, diuretic, opioid, antiplatelet, hypoglycemic, and anticonvulsant medications without indications for use. Resident #18's physician's order summary for September 2025 through December 2025 was reviewed and contained an order for Ceftriaxone Sodium Solution Reconstituted 1 GM (gram). Inject 1 gram intramuscularly every 24 hours for pharyngitis for 5 days. This antibiotic medication was ordered on 09/01/25 and discontinued on 09/06/25. Surveyor could not locate any medications in the other classifications indicated on the MDS. Surveyor spoke with MDS coordinator on12/09/25 at 4:05 pm regarding Resident #18's medications and coding the current MDS. MDS coordinator stated the medications were coded in error, and she would do a correction. The concern of incorrectly coding high-risk medications on Resident #18's MDS was discussed with the administrator, director of nursing, and regional director of clinical services on 12/10/25 at 3:30 pm. No further information was provided prior to exit. 2. For Resident #2 the facility staff inaccurately coded the resident as receiving discontinued antianxiety medication on a significant change MDS (minimum data set) assessment dated [DATE]. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic polyneuropathy, dementia, depression, and anxiety disorder. The most recent significant change MDS with an assessment reference date (ARD) of 9/30/25 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. Section N (Medications) was coded to indicate Resident #2 received antianxiety medication during the 7-day look-back period. A review of a medical provider orders included an order dated 8/7/25, that read in part, .Clonazepam.give 0.5 tablet by mouth in the afternoon for anxiety.D/C (discontinue) date 9/3/25. A review of the September 2025 MAR (medication administration record) revealed Resident #2 received the medication from 9/1/25 through 9/3/25 on the discontinued date. On 12/11/25 at 11:19 AM, this surveyor spoke with registered nurse #1 (RN#1) and she agreed Resident #2's antianxiety medication should not have been coded on the MDS, as it was discontinued on 9/3/25. RN#1 stated she would do a modification of the 9/30/25 MDS. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. A review of Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 October 2024, read in part, .(p. N-1).Section N: Medications.Intent: The intent of the items in this section is to record the number of days, during the last 7 days.that any type of.medications were received by the resident.(p. N-7).N0415B1. Antianxiety: Check if an anxiolytic medication was taken by the resident at any time during the 7-day look-back period. No further information was provided to the survey team prior to exit on 12/12/25. 3. For Resident #61, the facility staff failed to code the resident's admission minimum data set (MDS) assessment for dialysis. Resident #61 was receiving hemodialysis three times a week. During the entrance conference the team leader asked for a completed matrix for the residents of the facility. This matrix identified Resident #61 as receiving hemodialysis. Resident #61's diagnoses included end stage renal disease and dependence on renal dialysis. Section C (cognitive patterns) of Resident #61's admission MDS assessment with an assessment reference date (ARD) of 11/26/25 included a brief interview for mental status (BIMS) score of 7 out of a possible 15 points. Per the MDS manual a score of 7=severe impairment in cognitive skills for daily decision making. Section O (special treatments/procedures/programs) was not coded to indicate this resident was receiving dialysis. Resident #61's comprehensive care plan included the focus area dialysis, receives dialysis three times a week. Resident #61's current medication summary included provider orders for dialysis every Tuesday/Thursday/Saturday. On 12/10/25, during an interview with Resident #61 this resident stated they had dialysis three days a week. On 12/10/25 at 9:05 a.m., the surveyor interviewed Registered Nurse (RN) #1 regarding the MDS. RN #1 confirmed dialysis was not marked on this resident's MDS assessment and they would be completing a modification. The clinical record included information to indicate RN #1 completed a modification to section O of this MDS on 12/10/25 at 9:15 a.m. Dialysis was now coded yes. On 12/10/25 at 3:30 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Regional Director of Clinical Services the issue with Resident #61's admission MDS not being coded for dialysis was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #69, the facility staff coded the residents Trulicity medication as insulin on a quarterly minimum data set (MDS) assessment. Trulicity belongs to the drug class of Glucagon-Like Peptide-1 (GLP-1) receptor agonists and is a multifaceted hormone. Resident 69's diagnoses included diabetes and dementia. Section C (cognitive patterns) of Resident #69's quarterly MDS assessment with an assessment reference date (ARD) of 10/24/25 included a brief interview for mental status (BIMS) score of 00. Indicating this resident was severely impaired in cognitive skills for daily decision making. Section N (medications) had been coded to indicate Resident #69 received insulin once in the last 7 days. Resident #69's clinical record included a provider order for Trulicity 1.5 mg subcutaneously one time a day every Wednesday for diabetes mellitus. On 12/09/25 at 3:55 p.m. Licensed Practical Nurse (LPN) #1 was asked about the coding of the Trulicity on the quarterly MDS assessment. On 12/09/25 at 4:05 p.m., LPN #1 stated the MDS was coded incorrectly, and she would be completing a modification of this MDS assessment. On 12/10/25 at 3:30 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Regional Director of Clinical Services the issue with Resident #69's quarterly MDS being miscoded regarding the Trulicity was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, and facility document review the facility staff failed to provide a safe, clean, comfortable environment for 1 of 3 units in the facilty. The findings included: During the initial tour of the facility on 12/9/25 several residents on the second floor complained of cold showers, which were fairly consistent for approximately two months. On 12/9/25 at 1:20 PM this surveyor interviewed resident #5. Resident #5 stated, Showers are sometimes cold and sometimes the water fluctuates, it'll be hot and then all of the sudden it goes really cold then it might get hot again. When asked if this was a recent or new issue they stated, No, it's been going on for a long time, a couple months probably. We just have to deal with it; we have to bathe.On 12/9/25 at 1:35 PM this surveyor interviewed resident #79. They stated, I enjoy showers but lately I've been getting bed baths because the water is too cold in the shower, I can't hardly stand that, and they give me good bed baths.On 12/19/25 at 1:45 PM this surveyor interviewed resident #3. They stated, It's hard to get a decent shower sometimes, the water temperature is cold, or I guess you'd call it tepid. I don't know how long it's been going on, a while I guess. They say they've worked on it, and I guess they have but it still isn't hot like it should be.On 12/9/25 at 2:18 PM this surveyor asked staff to unlock the shower room on the second floor Summit unit. This surveyor turned on the water in the shower stall. After 5 minutes the water was still cold on my hand. Licensed Practical Nurse (LPN) #4 stated, Let me see if they left the knob turned in the housekeeping closet. If they did, that is why it won't get hot. They returned and stated that it was the issue, I turned the knob back so if you wait and come back in 20 minutes or so the water should be warm then.On 12/9/25 at 3:30 PM this surveyor returned to the shower room and tried the water again. It was still not hot.At 3:37PM this surveyor interviewed Certified Nursing Assistant (CNA) #5. When asked to come in the shower room and show this surveyor how to get hot water to work they stated, That's about as warm as it gets to be honest. The water was less than lukewarm. When this surveyor asked CNA #5 if they would be comfortable bathing in water of that temperature they stated, I wouldn't take a shower in water that cold. I know that maintenance knows and has been working on it. It's a little warmer in the mornings usually. CNA #5 called maintenance to come to the shower room.At 3:45 PM other staff members #2 and #3 arrived at the shower room and stated they were the maintenance assistants. This surveyor asked if they were aware of low water temperatures and residents complained of cold showers. Other Staff Member #2 stated, We have had an ongoing problem, and we've been working on it through the process of elimination. To be honest, we thought it was fixed I haven't heard a word this week, so I thought we had it figured out. This surveyor asked them to get a water temperature in the shower stall. After approximately 8 minutes the water temperature never got above 84 degrees, it fluctuated between 80 and 84. The water temperature in the sink which was right beside the shower stall was 107 degrees right away with less than a minute of the faucet running. Other Staff Member #2 stated, It's an old building and the water has to travel a good distance through the pipes to get here so if the solenoid on the water heater is bad that could be the problem or there are spindles in there that may need to be replaced. We could turn up the mixing valve but with that we run the risk of the water getting too hot in other places like this sink. When asked if the company had considered calling in a contractor or professional plumber they stated, I will say that they are aware of the problem, that's all I know to say about that and like I said we have been going through and replacing parts kind of going through the process of elimination to find the problem and there are more spindles and a solenoid on order now.On 12/10/25 at 1:07 this surveyor asked the maintenance assistants to tour all of the facility shower rooms. The first floor Bathing room [ROOM NUMBER] water temperature was 90.1 degrees and felt comfortable for a shower. In bathing room [ROOM NUMBER] the water temperature read 92 degrees and felt comfortable. Other Staff Member #2 stated he had tried to calibrate the thermometer and is concerned it isn't accurate, he put it in ice, and stated the temperature only got down to 34 degrees. On the second floor in bathing room [ROOM NUMBER], the same one with the issues on 12/9/25, the water only got up to 78.1 and did not feel comfortable for bathing. In bathing room [ROOM NUMBER], the water temperature was 75 degrees, not comfortable for bathing. The maintenance assistant stated that this shower room is not used much. The sink water was hot in each area of these two bathing rooms. Other Staff Member #2 mentioned several times that they were unsure of the accuracy of the thermometer they were using. I asked how they would ensure the water is not too hot if the thermometer is not reading accurately. He stated they do routinely check water temps and adjust mixing valve as needed. On 12/10/25 at 1:40 PM this surveyor met with the administrator and informed them of the concern with cold showers and the concern of potential inaccurate thermometer readings per maintenance. The Administrator stated, We will get a new one today. The Administrator also provided a document called a Maintenance REQ that showed parts ordered on 10/22/25 for the shower room. On 12/11/25 8:15 AM this surveyor met with the Administrator and the Regional Director of Clinical [NAME] (RDCS). The Administrator stated that maintenance worked until 10:00 PM the night before on the water in the shower rooms and stated, It's better than it was, but not where it needs to be. The Administrator provided temperature logs and stated, We started these in October when we were first made aware of the issue. We have been working on it. On 12/11/25 at 9:00 AM this surveyor went on a tour with the two maintenance assistants to the 2nd floor bathing room [ROOM NUMBER]. They had a new temperature gun. After 7 minutes the temperature in the shower got up to 90 degrees. Other #2 stated they cleaned the spindles and checked the solenoid and earlier this morning it the temperature got up to 97 degrees. On 12/11/25 at 3:50 PM the Administrator came to surveyor and stated they have a corporate master plumber coming Monday 12/15/25 they stated, We recognize we still have issues, and the water is not where it needs to be. They stated they are showering residents on the first floor as needed until the issue is resolved. Administrator provided copy of email correspondence with their corporate office regarding the master plumber scheduled to come to the facility Monday 12/15/25. On 12/12/25 at 12:30 PM the survey team met with the Administrator Director of Nursing and the RDCS. This concern was discussed during this meeting. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to use appropriate alternatives prior to the installation of side bed rails for 1 of 35 residents, Resident #2. The findings included: For Resident #2, the facility staff failed to provide evidence of appropriate alternatives prior to the installation of bilateral half-side rails. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, muscle weakness, difficulty in walking, dementia, macular degeneration, legal blindness, restless leg syndrome, and history of falling. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 9/30/25 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. Section GG (Functional Abilities) coded the resident as being dependent on staff for the ability to roll from lying on back to left and right side and return to lying on back on the bed. On 12/9/25 at 2:11 PM, this surveyor observed Resident #2 lying in bed sleeping with bilateral 1/2 side rails observed upright on the resident's bed. A review of a medical provider orders disclosed an order with a start date of 10/17/25 which read in part, .1/2 side rails for bed mobility, self-positioning and self-support. A review of Resident #2's comprehensive person-centered care plan revealed a focus and intervention that read in part, .resident is at risk for pressure ulcers related to impaired mobility.1/2 upper SR (side rail) x 2 for bed mobility, self-repositioning and self-support. with a created date of 9/23/25. A review of a Bed Side Rail Tool dated 9/30/25 produced no evidence of alternatives being attempted prior to the use of side rails for the resident. On 12/11/25 at 11:35 AM, this surveyor spoke with regional director of clinical services (RDCS) and she informed surveyor Resident #2's BIMs was higher at the time the bed rails were implemented and the resident may have requested them. She agreed the assessment indicated no alternatives were attempted prior to the installation of the rails. This concern was discussed at the end of day meeting on 12/11/25 at 3:30 PM with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Device Assessment with an effective date of 1/29/24, which read in part, .All appropriate assessments.and documentation will be initiated. No further information was provided to the survey team prior to exit on 12/12/25.

Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to ensure the resident received the provider ordered amount of oxygen for 1 of 35 residents, Resident #61.Resident #61's Oxygen was observed to be set at 4 1/2 liters and 5 liters a minute. The provider order was for 2 liters a minute.Resident #61's clinical record included the diagnosis chronic obstructive pulmonary disease (COPD).Section C (cognitive patterns) of Resident #61's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/26/25 included a brief interview for mental status (BIMS) score of 7 out of a possible 15 points. Per the MDS manual a score of 7=severe impairment in cognitive skills for daily decision making. Resident #61's clinical record included a provider order for Oxygen at 2 liters per minute via nasal cannula as tolerated every shift for COPD/hypoxia. Date of order 12/05/25. On 02/10/25 at 8:25 a.m., the surveyor observed Resident #61's Oxygen to be set at 4 1/2 liters a minute. Resident #61 stated it's usually at 2 liters a minute, he wasn't sure who changed it, but it does help when he's lying down at night. On 12/10/25 at 1:10 p.m., the surveyor observed Resident #61's Oxygen to be set at 5 liters a minute. This was confirmed by Licensed Practical Nurse (LPN) #7. This staff checked the order and adjusted the Oxygen level. LPN #7 stated the resident would change it. Resident #61's comprehensive care plan included the focus area at risk for respiratory complications. Interventions included administer Oxygen as ordered. The surveyor did not find anything on this care plan indicating Resident #61 would change their Oxygen settings. On 12/10/25 at 3:30 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Regional Director of Clinical Services the issue with Resident #61's Oxygen was reviewed.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 35 sampled residents was free of significant medication errors, Resident #2. The findings included:For Resident #2, the facility staff failed to hold the medication Humalog for blood glucose levels less than (120) one-hundred twenty, as ordered by a medical provider. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, dementia, chronic kidney disease-stage 3, and muscle weakness. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 9/30/25 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. A review of a medical provider orders disclosed an order which read in part, .Humalog Solution 100 UNIT/ML (milliliters) (Insulin Lispro (Human)) Inject 2 unit subcutaneously (under the skin) before meals for diabetes Do not give if glucose < 120 (less than one-hundred twenty). A review of Resident #2's November and December 2025 MARs (medication administration records) indicated Humalog was administered on the following dates/times with BS (blood sugars) levels outside of the ordered parameter of holding the medication if BS <120: 11/16/25-BS 114 at 11:30 AM11/16/25-BS 102 at 16:30 (4:30 PM)11/26/25-BS 106 at 16:3011/29/25-BS 118 at 16:3012/9/25-BS 98 at 11:30 AM A review of Resident #2's comprehensive person-centered care plan included a focus area stating the resident had a diagnosis of type 2 diabetes mellitus with an intervention which read in part, .administer medications as ordered. This concern was discussed on 12/11/25 at 3:30 PM at the end of day meeting with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, General Guideline for Medication Administration which read in part, .Medications are administered as prescribed in accordance with good nursing principles and practices.II. Administration.2. Medications are administered in accordance with written orders of the prescriber.IV. Documentation (including electronic) 1.At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered. No further information regarding this concern was presented to the survey team prior to the exit conference on 12/12/25.

Based on observation, resident interview, staff interview and facility document review the facility staff failed to ensure a safe and functional environment for 4 of 85 resident rooms. The findings included: On 12/9/25 during the initial tour of the facility this surveyor identified four resident rooms on the second floor with package terminal air conditioners (PTACs) that were pulled loose from the wall causing safety concern, or with outdoors visible through the units and cold air coming in through and around the units. room [ROOM NUMBER] the PTAC was noted to be hanging crooked and loose from the wall. room [ROOM NUMBER], the surveyor could see daylight through the PTAC unit. room [ROOM NUMBER], the surveyor could see outdoors around the unit and the wall was crumbling around the unit. On 12/9/25 at 2:40 PM this surveyor interviewed resident #3. They stated, This whole room needs painting. I took my watercolors and tried to paint it right here, but it doesn't look too good. I thought it would match the other walls better. Resident #3 was talking about the area above the PTAC unit. This surveyor asked if the wall around the unit needed repair and the resident stated, There was rain blowing in through it before they fixed it. I can still feel some cool air coming in right here, (pointing to a hole in the wall on the right side of the unit) but I can't see through there and no rain is coming in anymore. This surveyor looked at the hole; there was no daylight visible through it but there was cool air coming in through it. Resident #3 denied being cold and stated, No, I'm not cold, I can't feel it unless I put my hand there. The whole wall needs patched and painted but they never came back to do it.On 12/11/25 at 12:15 PM this surveyor noted the PTAC unit in room [ROOM NUMBER] was crooked and pulled out and away from the wall causing a safety concern. There was an approximate 4-inch gap between the wall and the left edge of the unit.On 12/11/25 at 1:45 PM this surveyor met with the Administrator, Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) to review the allegations in this complaint. This surveyor discussed concerns with multiple PTAC's in the facility.According to the website http://thefurnaceoutlet.com, You should never be able to see directly outdoors through gaps around the main body of the PTAC unit or it's wall sleeve. PTAC units are installed within a wall sleeve that is designed to create a tight seal and proper insulation to block air leaks, water intrusion, and pests. The Administrator provided the policy entitled, HVAC Wall Units/PTAC with an effective date of 5/1/22 which read in part, Each through the wall heating and air conditioning unit will be inspected and serviced as scheduled to verify units are operational and safe. Under the heading Monthly, the document read in part, 1. Functionally inspect equipment to determine if repair/correction is needed. Check for proper operation and inspect belts and coils. 2. Initiate any necessary repairs or corrections immediately. On 12/12/25 at 12:30 the survey team met with the Administrator, Director of Nursing, and the Regional Director of Clinical Services (RDCS). This concern was discussed with them at this time.No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed to safeguard resident private information on 1 of 4 units, 2 front. The findings included: Facility staff failed to close the narcotic book or the computer screen when leaving the medication cart unattended on the hallway. 06/28/23 8:35 a.m., the surveyor observed a medication pass and pour observation with Licensed Practical Nurse (LPN) #1. Upon approaching the medication cart the surveyor observed LPN #1 to walk away from their medication cart and enter a residents room. LPN #1 left the computer screen up and running and the narcotic book was observed to be open exposing resident information. A male visitor and several staff were observed to be in the vicinity of the medication cart. LPN #1 returned to their medication cart and prepared a residents medication for administration. After preparing the medication LPN #1 again left their computer screen and the narcotic book open. Walked away from the cart and entered a residents room to administer the medications. Upon returning to the medication cart the surveyor observed that the computer screen and narcotic book remained open and in full view of anyone that walked by. 06/29/23 9:00 a.m., the Director of Nursing (DON) stated they were providing education in regard to privacy of residents information. 06/29/23 9:25 a.m., DON provided the survey team with their policy titled, Confidentiality of Patient Information/HIPAA. This policy read in part, .Employees are expected to protect the confidentiality of all patient and employee information .Employees are expected to protect documents and computer screens from inadvertent access by unauthorized parties . 06/30/23 11:50 a.m., this issue was reviewed with the Administrator, Assistant Administrator, DON, and Nurse Consultant. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, clinical record review, and staff interview, the facility staff failed to review and revise the residents Comprehensive Care Plan (CCP) for 1 of 39 residents, Resident #145. The findings included: The facility staff failed to review and revise the residents CCP when they fell and fractured their left distal fibula. Resident #145's diagnoses included, but were not limited to, fracture of the left distal fibula, muscle weakness and difficulty in walking. Section C (cognitive patterns) of Resident #145's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/06/23 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required minimal assistance of one person for transfers. Walk in room/corridor was coded to indicate the resident required extensive assistance of one person. Resident #145 was coded as using a walker for mobility. 06/27/23 1:10 p.m., Resident #145 stated their leg had given out when they were trying to get into their closet, they had fallen and broken their ankle. The clinical record included an X ray report dated 06/15/23 indicating Resident #145 had a Nondisplaced fracture distal fibula with mark associated soft tissue swelling. A review of Resident #145's CCP revealed that the CCP had not been revised to capture the fracture. 06/29/23 4:30 p.m., during an end of day meeting with the Administrator, Director of Nursing, and Nurse Consultant the issue with the missing CCP information regarding the fracture was reviewed. 06/30/23 10:05 a.m., Licensed Practical Nurse (LPN) #2 stated the CCP had been updated to reflect the fracture. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were two errors in 25 opportunities for a medication error rate of 8%. These errors effected Resident's #106 and #149. The findings included: For Resident #149, the facility nursing staff administered a whole tablet of Quetiapine (25 mg) when the order was for one half a tablet (12.5 mg) of Quetiapine. For Resident #106 the facility nursing staff failed to shake the residents liquid Carafate prior to administering. During a medication pass and pour observation on 06/28/23 8:35 a.m., the surveyor observed Licensed Practical Nurse (LPN) #1 prepare and administer Resident #149's medication. LPN #1 pulled a card of Quetiapine (Seroquel) from the medication cart and popped one full pill into the medication cup and handed the medication card to the surveyor. This card read, give 1 tablet by mouth at bedtime for delusional disorder. The surveyor stated to LPN #1 that the card read to administer at night. LPN #1 reviewed the medication card label and stated that sometimes the labels are incorrect. The surveyor reconciled the medication using Resident #149's clinical record. The clinical record included two orders for the medication Quetiapine. One that read, Quetiapine oral tablet 25 mg give 0.5 tablet by mouth one time a day. The time on the medication administration record (MAR) was documented as 9:00 a.m. The second order read Quetiapine 25 mg give 1 tablet by mouth at bedtime. The time on the MAR read 9:00 p.m. Both orders included the order date of 06/06/23. 06/28/23 9:45 a.m., LPN #1 pulled two cards of Quetiapine from the medication drawer one card contained a whole tab and read to administer at night. One medication card contained tablets that were cut in half and read to give 0.5 tablet by mouth one time a day. Indicating LPN #1 had administered the bedtime dosage in the morning. 06/28/23 8:50 a.m., the surveyor observed Registered Nurse (RN) #2 prepare and administer Resident #106's morning medications to include Carafate. RN #2 pulled the liquid Carafate from the medication drawer and poured 10 ml's into a clear medication cup. RN #2 did not shake this medication prior to pouring the medication into the medication cup. After the medication administration the surveyor and RN #2 checked the Carafate medication bottle this bottle read SHAKE WELL BEFORE USE. RN #2 was asked if they should have shaken the medication and stated most definitely, they should have. The facility staff provided the surveyor with a copy of their policy titled, Administration Procedures for All Medications. This policy read in part, .Check the MAR .for the order .Check the label against the order on the MAR .Note any supplemental labeling that applies (fractional tablet .shake well .etc.) . 06/28/23 4:15 p.m., during a meeting with the Director of Nursing (DON), Nurse Consultant, Administrator, and Assistant Administrator the issue regarding the medication errors were reviewed. The administrative staff were made aware that their medication error rate was 8%. 06/30/23 10:00 a.m., DON provided the surveyor with a copies of medication error/disciplinary action reports regarding these two medications. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observations, interviews, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure a functional environment for four (4) resident bathrooms. The facility staff failed to ensure four (4) resident bathrooms had functioning toilet paper holders. The findings include: Resident bathrooms were observed on 4/26/22. The resident bathroom shared by room 206 and room 208 was missing a toilet paper holder; two (2) rolls of toilet paper were noted to be tied to the handrail with what appeared to be plastic garbage bags. The following three (3) resident bathrooms were noted to have broken toilet paper holders: (a) room 218's bathroom, (b) the bathroom shared by room 209 and room 211; and (c) the bathroom shared by room 216 and room 214. The three (3) resident bathrooms with broken toilet paper holders had rolls of toilet paper placed on the handrails. On 4/27/22 at 8:11 a.m., the four (4) aforementioned resident bathrooms with broken and/or missing toilet paper holders were observed with the facility's Director of Rehabilitation. The following information was found in a facility policy titled Maintenance Service (with a revised date of December 2009): - Maintenance service shall be provided to all area of the building, grounds, and equipment. - Functions of maintenance personnel include, but are not limited to: . Maintaining the building in good repair . On 4/27/22 at 3:33 p.m., the observations of broken and/or missing toilet paper holders in the four (4) aforementioned resident bathrooms was discussed with the facility's Administrator, Director of Nursing, Interim Director of Nursing, and Director of Rehabilitation. This is a complaint investigation.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to ensure 1 of 5 residents was free from physical restraints, Resident #1. For Resident #1 the facility staff failed to ensure the resident was free from physical restraints. The findings included: Resident #1's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's admission minimum data set with an assessment reference date of 04/03/22 assigned the resident a brief interview for mental status score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section P, physical restraints, indicated that no type of restraints were being used. Resident #1's comprehensive care plan (CCP) was reviewed and contained care plans for . is at risk for [CONDITION(S)] r/t (related to) being inattentive with disorganized thinking d/t (due to) nontraumatic [CONDITION(S)] and Inappropriate (verbal/physical) sexual behavior verbal and touching related to unknown etiology. Resident #1's clinical record was reviewed on 04/26/22 and contained a nurse's progress note, which read in part Approached by (resident's adult child) . (name omitted). He/She brought to my attention that 'someone had tied dad/mom to the bed last night'. (Adult child) was extremely angry and voiced his/her concerns. While doing my round this am, I do not recall anything being tied to the bed. My student . (name omitted) did not recall anything as well. Pt was sitting up in wheelchair at front desk with mask on when we arrived for shift and voiced no concerns at all. Pt medication was administered at 0924. [Adult child] . had approached me previously asking for medication and did not voice the concern about the issue. Full skin assessment was completed by myself and . (certified nurse's aide [CNA] #1) and no bruising or open wounds were noted. While doing skin assessment resident stated 'no one had been mean to him/her last night'. Returned back to resident room to obtain blood pressure and (Adult child) . (name omitted) stated 'I don't understand how anyone could do this. We used to do this at (name omitted) back in the day before it was against the law'. Unit managers aware of current situation. Will continue to monitor. This note was signed by licensed practical nurse (LPN) #2. Surveyor spoke with CNA #1 on 04/26/22 at 1:05 pm. Surveyor asked CNA #1 if they recalled Resident #1 and the incident. CNA #1 stated they did not really much know about it, because it happened on night shift. CNA #1 stated resident was up in chair when they arrived for the start of their shift. Surveyor asked CNA #1 if they had observed a sheet tied to Resident #1's bed, and CNA #1 stated they observed a sheet tied to the bed frame and weaved through the side railing. Surveyor asked CNA #1 if the sheet was on the resident's bed and CNA #1 stated it was laying in the floor. Surveyor asked CNA #1 if they recalled what time this was, and CNA #1 stated, It was early, maybe 11:30 (am) or so. Surveyor spoke with LPN #2 on 04/27/22 at 9:10 am. Surveyor asked LPN #2 if he recalled the resident and the incident and LPN #2 stated they did. Surveyor asked LPN #2 what they could recall about it, and LPN #2 stated they had come in on days and relieved the night shift nurse. Stated they made rounds with the night shift nurse, and did not see anything unusual. Stated that Resident #1 was already up, dressed and seated at the nurse's station. Stated that the resident's family came in later in the morning and requested a breathing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked LPN #2 if they had observed the sheet tied to the bed at this time, and LPN #2 stated they had. Stated it was on the left side of the bed tied to the side rail. Surveyor asked LPN #2 what they did then, and LPN #2 stated they told the two unit managers (UM), who then reported to the director of nursing (DON). LPN #2 stated, Everyone came in. LPN #2 stated they did a full assessment of the resident, and identified no problems. Stated the resident said they were fine and no one had tied them up. LPN #2 stated this was their day to work until 7 pm, and when evening shift came it at 3 pm, they apprised the oncoming staff of the situation. Stated at this time, temporary nurse aide (TNA) #4 came to them, stating I need to tell you something, and stated (LPN #1) was in the room last night and did that. I should have reported it, but I was scared. LPN #2 stated they immediately reported this to the DON. Surveyor spoke with TNA #4 via telephone on 04/27/22 at 9:50 am. Surveyor asked TNA #4 what they recalled about Resident #1 and the incident. TNA #4 stated they were at the nurse's station, finishing their charting for the shift, when LPN #1 came out of Resident #1's room and hollered for one of the agency CNA's. TNA #4 stated they told LPN #1 that both CNA's were busy, and LPN #1 asked them for assistance. TNA #4 stated when they entered the room, they observed Resident #1 lying in the floor. TNA #4 stated they and LPN #1 picked (Resident #1) up and placed him/her back on the bed. TNA #4 stated that LPN #1 then took the flat sheet from the resident's bed, tied it in a knot under the bed, pulled it across the resident, tied it under the bed on the other side, then pulled the other bed covers up over the resident. TNA #4 stated that LPN #1 said, Don't tell anybody. Surveyor asked TNA #4 what time this happened, and TNA #4 stated, It was about 10:00 pm. Surveyor asked TNA #4 why they had waited until the next day to report the incident, and TNA #4 stated, I was scared. Surveyor asked TNA #4 if they know what a mandated reporter is, and TNA #4 stated, Well, I do now. Surveyor asked TNA #4 if they had received training on abuse prevention and reporting during their orientation, and TNA #4 stated that they did and that they have since received extra training on abuse/neglect and the reporting of such incidents. Surveyor spoke with LPN #3 and LPN #4, who are the unit managers, on 04/27/22 at 10:00 am. Surveyor asked them if they recalled Resident #1 and the incident, and LPN #4 stated that the resident's adult child had come to them and said there was a sheet tied to their parent's bed, and that it looked like an old-time restraint. LPN #4 stated they called the DON to report the allegation. Surveyor asked LPN #4 if they saw the sheet, and LPN #4 stated, It was tied through the bed frame, with a little knot right on the side rail, and then draped on the floor. Surveyor spoke with DON on 04/27/22 at 10:25 am. Surveyor asked DON to recall the incident, and DON stated that the unit managers (LPN #3 and LPN #4) called and said Resident #1 had a sheet tied to the side of the bed. Stated that the resident's adult child was very upset, and felt like that the resident had been restrained to the bed. DON stated that they and the unit managers went to the resident's room. DON stated they observed a sheet tied to the left side of the resident's bed, on the side rail, looped around the bed frame, and draped into the floor. DON stated they attempted to interview the resident, but they were not really with it and not oriented. DON stated that resident said no one had hurt them or tied them to the bed. DON stated they immediately started and investigation into the allegation of abuse. Surveyor asked the DON if the accused employee was still working at the facility, and DON stated that LPN #1, CNA #2, CNA #3 and TNA #4 were all suspended pending the investigation. Upon completion of the investigation, LPN #1, CNA #2 and CNA #3 had been terminated. DON stated that TNA #4 was provided re-education on abuse reporting and allowed to return to work. Surveyor was unable to speak with LPN #1, CNA #2 or CNA #3. Surveyor requested and was provided with the facility's investigation into the allegation of abuse. This investigation contained copies of the criminal background screening reports for LPN #1, CNA #2 and #3, written statements from LPN #1, LPN #2, TNA #4, CNA #2, and CNA #3. The investigation also contained interviews from Resident #1 and other residents of the facility regarding abuse. The investigation also contained a copy of an email sent to the Virginia Department of Health Professions complaint department, which read in part, Please see attached FRI (facility reported incident) from 4-6-22. At the start of the investigation we did not have a staff member that was accused. At the end of the investigation we have substantiated the allegation of abuse with . (LPN #1) as having tied a resident to the bed . Surveyor requested and was provide with facility policies entitled Abuse Prevention Program and Use of Restraints. The Abuse Prevention policy read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The restraint policy read in part, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Surveyor requested and was provided with a Plan of Correction, which read in part 1. The Administrator informed of allegation on 4/6/2022 regarding allegation of abuse with unvoluntary restraint of the resident on 4/5/2022. The identified resident had a psychosocial, physical, skin and pain assessment completed with no identified changes. MD/RP (medical doctor/responsible party), law enforcement, Ombudsman and APS (adult protective services) notified, and FRI sent of incident on 4/6/22. 2. All resident have the potential to be affected. An audit will be conducted by Social Services or designee on current residents 8 or above to include during interview psychosocial assessment, concerns or allegations with care or conduct. The DON or designee will conduct an audit on current residents to include skin assessments for residents with a BIMS (brief interview for mental status) of 7 or lower. If changes are identified, further intervention will be initiated with documentation and MD/RP notification. The administrator will be notified in person or via phone to determine if a Facility Report Incident and/or law enforcement is required. 3. In-services by the Facility Educator or designee for the facility staff on mandated abuse reporting by law, ethics, and policy to inform your department manager, a charge nurse or supervisor with escalation of report to the Administrator and/or DON on the day as soon as possible in person or via phone to initiate a Facility Reported Incident and investigation. A staff person with knowledge or witnessed abuse must do what is right and report as soon as possible to protect the resident from harm. An investigation will be initiated documentation. 4. An audit will be conducted by the DON or designee on residents with reports of abuse, signs of abuse such as; skin changes (bruising redness, skin tears, abrasion etc.) of unknown origin, If founded, verify the abuse process followed with reporting, intervention, implemented to prevent further actions, MD/RP notification with documentation, the Administrator notified in person or via phone to determine if a Facility Report Incident and law enforcement is required weekly x 4 then monthly x 2. The findings will be reviewed and revised as needed x 3 months. 5. Date of compliance: 4/20/2022. The concern of the facility not ensuring the resident was free of physical restraint was discussed with the administrator, DON, interim DON, and director of rehab services on 04/27/22 at 3:30 pm. No further information was provided prior to exit. This is a past noncompliance complaint deficiency.

Based on interviews and document reviews, it was determined the facility staff failed to investigate an injury of unknown origin for one of four sampled residents, Resident #1. For Resident #1, the facility staff failed to ensure a chest wall bruise was investigated. The findings include: Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/11/21, was signed as completed on 11/15/21. Resident #1 was assessed as usually being able to make self understood and as usually being able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) Summary Score was documented as a zero (0) out of 15 (indicating severe cognitive impairment). Resident #1 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following information was found in Resident #1's documentation from a hospital visit, in an Emergency Department (ED) provider note dated 12/28/21 at 4:51 p.m.: . Skin: . Findings: Bruising (Overlying right chest wall, yellowish discoloration, appears old and healing) present. A right rib x-ray was completed on 12/28/21 with the following results: There is anatomic alignment. There is age-related bone density. No acute fracture . No acute findings. On 1/26/22 at 8:17 a.m., the Director of Nursing (DON) was asked for information about Resident #1's yellow colored chest bruise the ED provider documented as being present on 12/28/21. No documentation of an assessment or investigation of a this bruise was found by or provided. During an interview on 1/26/22 at 10:00 a.m., Staff Member (SM) #11 was asked about Resident #1's care and condition. SM #11 reported remembering a yellow bruise somewhere on Resident #1. SM #11 reported it was possibly on the resident's hip. SM #11 stated they reported it to the nurse but could not remember which nurse. During an interview on 1/26/22 at 1:39 p.m., SM #16 reported seeing a yellow bruise on Resident #1's chest. SM #16 reported they notified the nurse of the bruise but was unsure which nurse they notified. SM #16 reported they had no way to document that they had notified the nurse of the bruise. The following information was found in a facility policy titled Resident Rights (with a revised date of December 2016): Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . be free from abuse, neglect, misappropriation of property, and exploitation . The following information was found in a facility policy titled Abuse Investigation and Reporting (with a revised date of July 2017): All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The failure of the facility staff to assess and investigate Resident #1's aforementioned bruise was discussed during a meeting with the facility's Administrator, Director of Nursing, and Director of Rehab on 1/27/22 at 3:15 p.m. No evidence of an investigation of this bruise was provided prior to exit.

Based on interviews, document reviews, and during the course of a complaint investigation, the facility staff failed to provide care and treatment to address the needs and/or assessment changes of one of four sampled residents, Resident #1. The facility staff failed ensure changes in Resident #1's condition was communicated to and addressed by a medical provider, and failed to complete post-fall neurocheck assessments as required by the facility's process. The findings include: Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/11/21, was signed as completed on 11/15/21. Resident #1 was assessed as usually being able to make self understood and as usually being able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) Summary Score was documented as a zero (0) out of 15 (indicating severe cognitive impairment). Resident #1 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The following information was documented in Resident #1's progress notes: On 12/20/21 (a Monday) at 6:28 a.m., resident was having diarrhea and vomiting episodes over the weekend. all [sic] night has been covering (their) mouth with (their) hand as if (they) would vomit but hasn't. resident [sic] hasn't voided in the last 12 hours. On 12/21/21 at 2:16 p.m., Loose watery diarrhea stools noted (twice) this shift. On 12/22/21 at 10:08 a.m., .12/19/21 developed vomiting and diarrhea. Vomiting resolved but still having diarrhea. On 12/23/21 at 6:46 a.m., Resident had loose watery stool (once) this shift. Will continue to monitor. The was no documentation found that Resident #1's physician was aware the resident was experiencing diarrhea or that any treatment was ordered. On 1/25/22 at 3:20 p.m., the absence of documentation of medical provider notification that Resident #1 was experiencing diarrhea was discussed with the facility's Administrator and Director of Nursing. The absence of a medical provider evaluation of Resident #1 related to the continued diarrhea was also discussed. During an interview on 1/27/22, the ADON reported they did not see treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . b. According to the clinical record, Resident #1 experienced a fall on 12/23/21 at 5:30 p.m. The following information was found as part of Resident #1's post-fall neurocheck assessments: On 12/23/21 at 5:30 p.m., 5:45 p.m., 6:01 p.m., 6:25 p.m, the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) able to verbalize appropriately. On 12/23/21 at 7:30 p.m., the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) changed to not able to verbalize appropriately. On 12/23/21 at 8:00 p.m., the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) continued to be unable to verbalize appropriately. On 12/23/21 at 9:30 p.m., the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) continued to be unable to verbalize appropriately. On 12/24/21 at 1:22 a.m., the resident was assessed as: (a) changed to not able to follow finger with eyes; (b) changed to not able to respond to simple commands; and (c) continued to be unable to verbalize appropriately. On1/27/22 at 11:15 a.m., the failure of the facility staff to notify Resident #1's medical provider and responsible party of a decline in resident being able to (a) follow a finger with their eyes, (b) respond to simple commands, and (c) verbalize appropriately was discussed with the facility's Administrator and Assistant Director of Nursing (ADON). The following information was found in a facility document titled Neurological Assessment (with a revised date of October 2010): The purpose of this procedure is to provide guidelines for a neurological assessment . when following an unwitnessed fall .Reporting . Notify the physician of any change in a resident's neurological status. The ADON reported that the neurocheck assessments were supposed to be completed as follows: (a) every 15 minutes for an hour; (b) every 30 minutes for four (4) hours; (c) every hour for two (2) hours; and (d) every shift for 72 hours. The ADON provided a facility document titled NEUROCHECKS (this document was not dated) which included the aforementioned neurocheck assessment schedule. During an interview on 1/27/22 at 11:10 a.m., the ADON reported one of Resident #1's every hour neurocheck assessments had not been completed and that Resident #1's every shift neurocheck assessments for 72 hours had not been completed. Review of Resident #1's clinical documentation from the local hospital indicated the Emergency Department (ED) provider documented the resident's mouth had dry mucous membranes. Laboratory test completed at the local hospital revealed the following elevated results: (a) a sodium level of 157 mmol/L; (b) a chloride level of 112 mmol/L; (c) a BUN level of 71 mg/dL; and (d) a Creatinine level of 228 mg/dL. The hospital discharge summary indicated the resident presented with altered mental status; the resident was found to have an elevated sodium, be profoundly dehydrated, and have a urinary tract infection ([CONDITION(S)]). The History and Physical (H&P) completed, at the hospital on 12/29/21 at 8:59 a.m., included the following information in the History of Present Illness section: Patient presents a [sic] skilled nursing facility with concerns for [CONDITION(S)] and [CONDITION(S)]. Per the SNF (skilled nursing facility) (blood pressure) was 70/40 and patient was poorly responsive. At the scene EMS (emergency medical services) (found the resident) to be normotensive but was hypoxic requiring approximately 5 (liters) (oxygen) and responsive only to noxious stimuli. Earlier in the day the patient received a bath and at that time the vital signs were normal. For the past week leading up to this event the patient had been affected by virus according to the family which has been present in the skilled nursing facility with symptoms including nausea, vomiting, diarrhea [sic]. (The resident's adult children) who visited (the resident) on Sunday denied any of these symptoms however they did notice the patient was more confused. The assessment/plan of the H&P indicated the resident had Acute Kidney Injury in the setting of solitary kidney . Suspect prerenal given (history) of diarrhea and dehydration. The ED provider documentation indicated the resident's history on arrival at the ED included nausea, vomiting, and diarrhea for four days, which had resolved. During a meeting with the facility's Administrator, ADON, and Director of Rehab, on 1/27/22 at 3:15 p.m., the above findings for Resident #1 were discussed. No further information was provided prior to exit. This is a complaint deficiency.

Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to ensure a provider ordered CMP (comprehensive metabolic panel) laboratory test was obtained for one of four residents in the sample, Resident #1. Findings include: Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/11/21, was signed as completed on 11/15/21. Resident #1 was assessed as usually being able to make self understood and as usually being able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) Summary Score was documented as a zero (0) out of 15 (indicating severe cognitive impairment). Resident #1 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's clinical documentation contained a provider order dated 12/15/21 for a Comprehensive Metabolic Panel (CMP) laboratory test to be obtained on 12/17/21. Review of Resident #1's December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the facility's Administrator and Assistant Director of Nursing (ADON), on 1/25/22 at 3:20 p.m., Resident #1's provider ordered Comprehensive Metabolic Panel (CMP) laboratory test was discussed. The ADON confirmed the CMP ordered on 12/15/21 to be completed on 12/17/21 had not been obtained. On 1/26/22 at 8:17 a.m., the facility's ADON confirmed the CMP had not been obtained but a staff member had documented it was completed on the MAR because the laboratory had the paperwork to do the CMP. During a meeting with the facility's Administrator, assistant director of nursing, and Director of Rehab, on 1/27/22 at 3:15 p.m., the failure to obtain a provider ordered CMP laboratory test was discussed. No further information was provided prior to exit.

Based on interviews, facility document reviews, and clinical record reviews, it was determined the facility staff failed to maintain complete and accurate clinical documentation for two of four sampled residents, Resident #1 and Resident #3. For Resident #1, the facility staff incorrectly documented the completion of a Comprehensive Metabolic Panel (CMP) laboratory test on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] For Resident #3, the facility staff failed to document assessment information after an unwitnessed fall. The findings include: 1. Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/11/21, was signed as completed on 11/15/21. Resident #1 was assessed as usually being able to make self understood and as usually being able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) Summary Score was documented as a zero (0) out of 15 (indicating severe cognitive impairment). Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's clinical documentation contained a provider order dated 12/15/21 for a Comprehensive Metabolic Panel (CMP) laboratory test to be obtained on 12/17/21. Review of Resident #1's December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the facility's Administrator and Assistant Director of Nursing (ADON), on 1/25/22 at 3:20 p.m., Resident #1's provider ordered Comprehensive Metabolic Panel (CMP) laboratory test was discussed. The ADON confirmed the CMP ordered on 12/15/21 to be completed on 12/17/21 had not been obtained. On 1/26/22 at 8:17 a.m., the facility's ADON confirmed the CMP had not been obtained but a staff member had documented it was completed on the MAR because the laboratory staff member had the paperwork to do the CMP. The incorrect documentation of Resident #1's CMP laboratory test being obtained was discussed during a meeting with the facility's Administrator, Director of Nursing, and Director of Rehab on 1/27/22 at 3:15 p.m. No further information was provided prior to exit. 2. Resident #3's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/10/21, was signed as completed on 12/13/21. Resident #3 was assessed as being able to make self understood and as being able to understand others. Resident #3's Brief Interview for Mental Status (BIMS) Summary Score was documented as a 13 out of 15 (indicating intact/borderline cognition). Resident #3 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's clinical documentation included an eINTERACT SBAR Summary for Providers note dated 1/23/22 at 10:30 a.m. This note indicated the resident had experienced a fall but did not include details about how the resident was found after the unwitnessed fall. This note indicated a medical provider was notified but did not detail what the provider was told or the provider's response. The note included a section titled Outcomes of Physical Assessment which indicated no change was observed with mental status evaluation. The area for Nursing observations, evaluations, and recommendations are: was left blank. The facility's Assistant Director of Nursing (ADON) was interviewed, about Resident #3's fall documentation, on 1/28/22 at 9:50 a.m. The ADON confirmed Resident #3's documentation did not include information about what Resident #3 was doing at the time of their 1/23/22 fall and did not include details of how the resident was found after the fall. On 1/28/22 at 9:57 a.m., Staff Member (SM) #4 (a unit manager) was interviewed about Resident #3's 1/23/22 fall. SM #4 confirmed details of the fall had not been documented. SM #4 reported the employee who had cared for Resident #3 at the time of the fall was being telephoned about the fall. On 1/28/22 at 9:59 a.m., SM #4 (after speaking to the staff member who cared for Resident #3 at the time of the fall) reported the resident was found sitting on the floor after taking themself to the bathroom. The following information was found in a facility document titled Guidelines for Charting and Documentation (dated as revised on April 2012): Purpose . The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care .General Rules for Charting and Documentation . 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. 2. Be concise, accurate, and complete and use objective terms . 8. All entries must reflect the date, the time and the signature and title of the person recording the data . 12. Miscellaneous Documentation . Documentation should also include: a. Any time the physician or family is called about the resident and their response . On 1/28/22 at 11:00 a.m., Resident #3's aforementioned incomplete documentation was discussed with the facility's Administrator and DON. No further information was provided prior to exit.

Based on staff interviews, document review and clinical record review, the facility staff failed to notify the physician of changes in condition for one of four sampled residents, Resident #1. The facility staff failed to notify the physician of Resident #1's post-fall neurocheck assessment changes with decreased level of responsiveness; and episodes of diarrhea. The findings include: Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/11/21, was signed as completed on 11/15/21. Resident #1 was assessed as usually being able to make self understood and as usually being able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) Summary Score was documented as a zero (0) out of 15 (indicating severe cognitive impairment). Resident #1 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. According to the clinical record, Resident #1 experienced a fall on 12/23/21 at 5:30 p.m. The following information was found as part of Resident #1's post-fall neurocheck assessments: On 12/23/21 at 5:30 p.m., 5:45 p.m., 6:01 p.m., 6:25 p.m, the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) able to verbalize appropriately. On 12/23/21 at 7:30 p.m., the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) changed to not able to verbalize appropriately. On 12/23/21 at 8:00 p.m., the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) continued to be unable to verbalize appropriately. On 12/23/21 at 9:30 p.m., the resident was assessed as: (a) able to follow finger with eyes; (b) able to respond to simple commands; and (c) continued to be unable to verbalize appropriately. On 12/24/21 at 1:22 a.m., the resident was assessed as: (a) changed to not able to follow finger with eyes; (b) changed to not able to respond to simple commands; and (c) continued to be unable to verbalize appropriately. On 1/26/22 at 9:50 p.m., Staff Member (SM) #10 was interviewed about a visit by two (2) of Resident #1's adult children. SM #10 reported they remembered a visit where one of the resident's adult children reported the resident would not respond a lot. SM #10 reported they did not notify a medical a medical provider about the family's report. SM #10 stated the family member did not request a medical provider be notified. Resident #1's clinical record did not include documentation of this interaction between SM #10 and the resident's adult child; Resident #1's child reported this occurred on 12/26/21. There was no documentation in the clinical record to evidence the facility had notified the physician of the post-fall neurocheck assessment changes. On 1 /27/22 at 11:15 a.m., the failure of the facility staff to notify Resident #1's medical provider of a decline in resident being able to follow a finger with their eyes, respond to simple commands, and verbalize appropriately was discussed with the facility's Administrator and Assistant Director of Nursing (ADON). b. The following information was documented in Resident #1's progress notes: On 12/20/21 (a Monday) at 6:28 a.m., resident was having diarrhea and vomiting episodes over the weekend. all [sic] night has been covering (their) mouth with (their) hand as if (they) would vomit but hasn't. resident [sic] hasn't voided in the last 12 hours. On 12/21/21 at 2:16 p.m., Loose watery diarrhea stools noted (twice) this shift. On 12/22/21 at 10:08 a.m., . 12/19/21 developed vomiting and diarrhea. Vomiting resolved but still having diarrhea. On 12/23/21 at 6:46 a.m., Resident had loose watery stool (once) this shift. Will continue to monitor. On 1/25/22 at 3:20 p.m., the absence of documentation of a medical provider notification of Resident #1 experiencing diarrhea was discussed with the facility's Administrator and Director of Nursing (DON). On 1/26/22 at 8:17 a.m., the DON reported the only evidence of provider notification of the vomiting and diarrhea was the documentation of a [MEDICATION(S)] order received on 12/18/21 at 10:45 p.m. The following information was found in a facility document titled Guidelines for Notifying Physicians of Clinical Problems (with a revised date of September 2017): These guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and that 2) all significant changes in resident / patient status are assessed and documented in the medical record The following symptoms, signs, and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. These situations include: . 2. Rapid decline or continued instability (for example, markedly fluctuating vital signs), unless the individual is receiving palliative care and has declined workup or treatment. 3. The following symptoms: a. Sudden in onset OR a marked change (for example, much more severe or frequent) compared to usual (baseline) status . The following information was found in a facility policy and/or procedure titled Change in a Resident's Condition or Status (with a revised date of May 2017): Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payment, resident rights, etc.) . The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . significant change in the resident's physical/emotional/mental condition . The failure of the facility staff to assure a medical provider was notified of the aforementioned changes in condition was discussed during a meeting with the facility's Administrator, Director of Nursing, and Director of Rehab on 1/27/22 at 3:15 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation it was determined that the facility staff failed to implement facility policy and procedures in regards to reporting and investigating incidents for 10 of 30 Residents, Residents #72, #111, #108, #131, #28, #26, #140, #53, #134, and #115. The findings included: 1. For Resident #72 the facility staff failed to implement facility policy in regards to reporting/investigating resident to resident altercations Resident #72's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15. This indicates that the resident is cognitively intact. Resident #72's comprehensive care plan was reviewed and contained a care plan for Inappropriate behavior at times, history of verbal/physical agitation/aggression towards other residents related to Cognitive impairment, [CONDITION(S)]. The goal for this care plan is to decrease/minimize episodes of verbal/physical abuse. Resident #72's clinical record was reviewed and contained nurse's progress notes, which read in part 09/19/2020 15:24 CNA (certified nurse's aide) observed this resident slap her roommate because she was 'using her sink'. this resident turned the water off at the cutoff so other resident couldn't use it. Reminded this resident that roommate can use sink and other areas of the room as well, 09/20/2020 14:57 CNA reported to nurse that this resident 'slammed' another resident in to a chair. Reminded resident she shouldn't be putting her hands on other people, 09/20/2020 15:26 this resident hit another resident on the right side of the face. separated residents, 09/20/2020 15:34 Notified DON (director of nursing) of resident's behavior. Explained to resident that the police can be called if she hits anyone else. Room change to 323 B, 09/23/2020 18:20 Second floor staff called to tell this nurse that they observed . (Resident #72) place her hand over another resident's face and nose. She then hit the other resident, 10/04/2020 18:52 Rsd (resident) found in room with curtain pulled hitting roommate. Writer was informed of what staff had observed. Will continue to observe., 10/06/2020 11:04 Residents were up at nurse's station watching TV and talking. This resident smacked the resident beside her in the head for no apparent reason. The residents were separated and unit manager notified, 4/7/2021 10:10 this nurse entered activity room, this resident walked over to another resident and smacked her twice to right side of face to point you heard the second slap. resident that was slapped was sitting in chair in corner with a drink in her hands. no injury noted. resident removed from area. when asked why she slapped other resident she stated 'she was staring at me'. MD and RP (responsible party) notified and 4/9/2021 16:43 the nurses aides ([names omitted]) relayed to me that the resident pushed another resident ([name omitted]) three times. resident did not sustain any injury or fall. (name omitted) stated 'He was going to hit her if she did not quit'. the two were separated, no further issues at this time. Will continue to monitor. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not implementing their policy for reporting/investigating incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 2. For Resident #111 the facility staff failed to implement facility policy in regards to report a resident to resident altercation. Resident #111's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/13/21 assigned the resident a BIMS (brief interview for mental status) score of 11 out of 15 in section C, cognitive patterns. This indicates the resident is cognitively intact. Resident #111's comprehensive care plan was reviewed and contained a care plan for At risk for behavior symptoms related to Alzheimer's disease/dementia, [CONDITION(S)]; Resident will approach residents/others to hug and kiss in face, makes repetitive statements demanding pudding/food and hugs. Resident #111's clinical record was reviewed and contained nurse's progress notes, which read in part 9/23/2020 18:20 This nurse received a phone call from 2nd flood staff stating that staff saw another resident place her hand over . (Resident #111) mouth and nose, and then hit . (Resident #111). Unit manager and DON (director of nursing) notified, residents were separated and will be monitored, 10/4/2020 19:13 Rsd (resident) has been hit by roommate. Writer has completed head to toe assessment and no injuries noted at this time. Family and MD have been notified no new orders. Rsd is safe sitting at nurses station. Will continue to observe, and 4/7/2021 12:08 this nurse entered the activity room, when another resident walked over to this resident and smacked her twice to right side of face to point you heard the second slap. this resident was sitting in chair in corner with a drink in her hands when smacked. no injury noted. other resident removed from area. rp (responsible party) and md notified. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not implementing their policy for reporting/investigating incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 3. For Resident #108 the facility staff failed to implement facility policy in regards to reporting resident to resident altercations. Resident #108's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/12/21 assigned the resident a BIMS (brief interview for mental status) score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #108's comprehensive care plan was reviewed and contained a care plan for Verbal/physical agitation/aggression related to Change in routine, Cognitive impairment, Communication disorder/visual impairment, sensory overload. Goal for this care plan is Will not harm self or others Resident #108's clinical record was reviewed and contained nurse's progress notes, which read in part 3/21/2021 20:34 Resident in hall cursing, another resident came out of his room and told resident to 'shut up'. The residents then locked their hands together and began pushing and pulling each other back and forth, resident received two skin tears to left fingers. Resident became aggressive and hit a staff member several times in the back, resident then hit this nurse and other female resident in the face. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not implementing their policy for reporting/investigating incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 4. For Resident #131 the facility staff failed to implement facility policy in regards to reporting a resident to resident altercation. Resident #131's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/23/21 assigned the resident a BIMS (brief interview for mental status score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #131's comprehensive care plan was reviewed and contained a care plan for Verbal/physical agitation/aggression related to dementia. Goals for this care plan are Will not harm self or others. Resident #131's clinical record was reviewed and contained a nurse's progress note, which read in part 2/18/201 01:41 On rounds, other nurse called this to resident's room. Resident was seen hitting roommate with a knotted sock by other nurse. When this nurse entered the room, resident was in a rage, screaming loudly, swinging and hitting this nurse and other nurse. Resident threatened to 'beat the[OBSCENITY]out of her', speaking of roommate. Resident attempted multiple times to go back over to roommate and hit roommate. Other nurse and this nurse intervened and separated resident. Resident attempted multiple times to shut the door on this nurse and other nurse while separating residents. Resident continued to hit, scratch, and pinch this nurse and other nurse. Resident tied a knot in her sheet and swung and hit this nurse with it. This nurse was able to take sheet and attempted to redirect resident by lying down and rubbing shoulders. Resident continued to be in a rage, refused to lie down. Supervisor notified. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not implementing their policy for reporting/investigating incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 5. For Resident #28, the facility staff failed to implement facility policy regarding reporting and investigating a resident to resident altercation occurring on 3/15/21. Resident #28's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #28's clinical record revealed the following documentation: A SBAR (Situation, Background, Appearance, Review) Communication Form dated 3/15/21 at 11:43 am states in part, Resident standing at nurses desk with walker, another resident came and shoved resident in the back. Resident fell , hitting right cheek on nurses desk as went down into the floor. Landed on (his/her) buttocks. Assessed from head to toe with red slightly raised area noted on right cheek. No other complaints voiced. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI report for the aforementioned incident involving Resident #28 occurring on 3/15/21. The following day at 10:52 am, surveyor spoke with the DON who stated the incident was reported to them and they then reported it to the administrator but could not find an FRI for the incident. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing), surveyor discussed the concern of the facility not implementing facility policy regarding an incident of a resident to resident altercation involving Resident #28. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 6. For Resident #26 and #134, the facility staff failed to implement facility policy regarding reporting a resident to resident altercation occurring on 6/03/21 to Adult Protective Services. Resident #26's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/22/21 assigned the resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, Cognitive Patterns. Resident #134's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #134's most recent quarterly MDS with an ARD of 5/24/21 assigned the resident a BIMS score of 15 out of 15 in section C, Cognitive Patterns. On 6/08/21 at 1:55 pm during initial rounds, surveyor observed Resident #26 with redness under the left eye and bruising to the left side of the face from the left eye down to the cheek area. Surveyor asked the resident what caused the bruising and the resident stated they hit their face on the door and then stated they must have fallen. At 2:08 pm, surveyor spoke with TCNA (temporary certified nursing assistant) #1 concerning the cause of the bruising and TCNA #1 stated it was reported to them that Resident #134 punched this resident. Surveyor spoke with the administrator and DON (director of nursing) on 6/09/21 at 11:42 am concerning the bruising on Resident #26's face and the DON stated a FRI (facility reported incident) was completed and they are working on the final report now. At 12:30 pm, the DON provided the initial and final FRI report to the surveyor. The follow-up to the FRI dated 6/04/21 for the incident date of 6/03/21 involving Resident #26 and #134 states in part, Reported by staff that the residents mentioned above had a resident-to-resident altercation. It was reported that (Resident #26) wheeled (his/her) self into (Resident #134's) room and started going through (his/her) personal belongings. (Resident #134) asked (him/her) to leave (his/her) 'stuff' alone, (Resident #134) also asked (Resident #26) to leave (his/her) room due to this being (his/her) room and not (his/hers). (Resident #134) was unable to redirect (Resident #26) from (his/her) personal belongings. (Resident #134) stated, '(he/she) started cussing me and I hit (him/her)'. (Resident #26) was assessed, and staff observed a red area on the left side of the forehead. I, (name omitted), DON, upon entering the facility the next morning assessed (Resident #26) and I observed a discolored area to the left side of the forehead, staff was verbally instructed to continue to monitor for [NAME] [sp] and symptoms of any distress. The FRI report did not include the date that APS (adult protective services) was notified of the resident to resident altercation. On 6/10/21 at 11:45 am, surveyor spoke with the DON and asked if APS was notified of the resident to resident altercation between Resident #26 and #134, the DON stated no because there was no injury. At 11:52 am, surveyor spoke with the administrator who stated APS was not notified and it was a team decision. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not implementing facility policy regarding reporting an incident of a resident to resident altercation involving Resident #26 and Resident #134 to APS. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 7. For Resident #140, the facility staff failed to implement facility policy regarding reporting resident to resident altercations occurring on 3/21/21 and 4/05/21. Resident # 140's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/25/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. A review of Resident #140's clinical record revealed the following documentation: A nursing progress note dated 3/21/21 19:55 (7:55 pm) states This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. A 4/05/21 09:45 (9:45 am) eINTERACT SBAR Summary for Providers note states in part, resident entered another residents room and hit resident, denies pain no injuries noted staff immediately intervened and ensured both residents safety staff witnessed and stated 'As I entered the room another Resident was in this residents room hitting this resident, staff immediately moved both residents to safety. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI reports for the aforementioned incidents involving Resident #140. On 6/09/21 at 12:30 pm, the DON provided the surveyor with a risk management form, Incident #827 for Resident #140. Incident #827 form states in part, This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. In the section Resident Description, it is documented I told (him/her) to shut up and quit cussing. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later th [TRUNCATED]

Based on staff interview, facility document review, clinical record review and in the course of a complaint survey it was determined that the facility staff failed to report incidents for 10 of 30 Residents, Residents #72, #111, #108, #131, #28, #26, #140, #53, #134, and #115. The findings included: 1. For Resident #72 the facility staff failed to report incidents of resident to resident altercations. Resident #72's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15. This indicates that the resident is cognitively intact. Resident #72's comprehensive care plan was reviewed and contained a care plan for Inappropriate behavior at times, history of verbal/physical agitation/aggression towards other residents related to Cognitive impairment, [CONDITION(S)]. The goal for this care plan is to decrease/minimize episodes of verbal/physical abuse. Resident #72's clinical record was reviewed and contained nurse's progress notes, which read in part 09/19/2020 15:24 CNA (certified nurse's aide) observed this resident slap her roommate because she was 'using her sink'. this resident turned the water off at the cutoff so other resident couldn't use it. Reminded this resident that roommate can use sink and other areas of the room as well, 09/20/2020 14:57 CNA reported to nurse that this resident 'slammed' another resident in to a chair. Reminded resident she shouldn't be putting her hands on other people, 09/20/2020 15:26 this resident hit another resident on the right side of the face. separated residents, 09/20/2020 15:34 Notified DON (director of nursing) of resident's behavior. Explained to resident that the police can be called if she hits anyone else. Room change to 323 B, 09/23/2020 18:20 Second floor staff called to tell this nurse that they observed . (Resident #72) place her hand over another resident's face and nose. She then hit the other resident, 10/04/2020 18:52 Rsd (resident) found in room with curtain pulled hitting roommate. Writer was informed of what staff had observed. Will continue to observe., 10/06/2020 11:04 Residents were up at nurse's station watching TV and talking. This resident smacked the resident beside her in the head for no apparent reason. The resident were separated and unit manager notified, 4/7/2021 10:10 this nurse entered activity room, this resident walked over to another resident and smacked her twice to right side of face to point you heard the second slap. resident was slapped was sitting in chair in corner with a drink in her hands. no injury noted. resident removed from area. when asked why she slapped other resident she stated 'she was staring at me'. MD and RP (responsible party) notified and 4/9/2021 16:43 the nurses aides ([names omitted]) relayed to me that the resident pushed another resident ([name omitted]) three times. resident did not sustain any injury or fall. (name omitted) stated 'He was going to hit her if she did not quit'. the two were separated, no further issues at this time. Will continue to monitor. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor asked the DON if the incidents should have been reported and DON stated, They should have been documented and reported to me. We will do education on that and do what needs to be done. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not reporting incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 2. For Resident #111 the facility staff failed to report an incident of resident to resident altercation. Resident #111's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/13/21 assigned the resident a BIMS (brief interview for mental status) score of 11 out of 15 in section C, cognitive patterns. This indicates the resident is cognitively intact. Resident #111's comprehensive care plan was reviewed and contained a care plan for At risk for behavior symptoms related to Alzheimer's disease/dementia, [CONDITION(S)]; Resident will approach residents/others to hug and kiss in face, makes repetitive statements demanding pudding/food and hugs. Resident #111's clinical record was reviewed and contained nurse's progress notes, which read in part 9/23/2020 18:20 This nurse received a phone call from 2nd flood staff stating that staff saw another resident place her hand over . (Resident #111) mouth and nose, and then hit . (Resident #111). Unit manager and DON (director of nursing) notified, residents were separated and will be monitored, 10/4/2020 19:13 Rsd (resident) has been hit by roommate. Writer has completed head to toe assessment and no injuries noted at this time. Family and MD have been notified no new orders. Rsd is safe sitting at nurses station. Will continue to observe, and 4/7/2021 12:08 this nurse entered the activity room, when another resident walked over to this resident and smacked her twice to right side of face to point you heard the second slap. this resident was sitting in chair in corner with a drink in her hands when smacked. no injury noted. other resident removed from area. rp (responsible party) and md notified. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor asked the DON if the incidents should have been reported and DON stated, They should have been documented and reported to me. We will do education on that and do what needs to be done. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator , or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not reporting incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 3. For Resident #108 the facility staff failed to report an incident of resident to resident altercations. Resident #108's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/12/21 assigned the resident a BIMS (brief interview for mental status) score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #108's comprehensive care plan was reviewed and contained a care plan for Verbal/physical agitation/aggression related to Change in routine, Cognitive impairment, Communication disorder/visual impairment, sensory overload. Goal for this care plan is Will not harm self or others Resident #108's clinical record was reviewed and contained nurse's progress notes, which read in part 3/21/2021 20:34 Resident in hall cursing, another resident came out of his room and told resident to shut up. The residents then locked their hands together and began pushing and pulling each other back and forth, resident received two skin tears to left fingers. Resident became aggressive and hit a staff member several times in the back, resident then hit this nurse and other female resident in the face. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor asked the DON if the incidents should have been reported and DON stated, They should have been documented and reported to me. We will do education on that and do what needs to be done. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator , or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not reporting incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 4. For Resident #131 the facility staff failed to report an incident of resident to resident altercation. Resident #131's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/23/21 assigned the resident a BIMS (brief interview for mental status score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #131's comprehensive care plan was reviewed and contained a care plan for Verbal/physical agitation/aggression related to dementia. Goals for this care plan are Will not harm self or others. Resident #131's clinical record was reviewed and contained a nurse's progress note, which read in part 2/18/201 01:41 On rounds, other nurse called this to resident's room. Resident was seen hitting roommate with a knotted sock by other nurse. When this nurse entered the room, resident was in a rage, screaming loudly, swinging and hitting this nurse and other nurse. Resident threatened to 'beat the[OBSCENITY]out of her', speaking of roommate. Resident attempted multiple times to go back over to roommate and hit roommate. Other nurse and this nurse intervened and separated resident. Resident attempted multiple times to shut the door on this nurse and other nurse while separating residents. Resident continued to hit, scratch, and pinch this nurse and other nurse. Resident tied a knot in her sheet and swung and hit this nurse with it. This nurse was able to take sheet and attempted to redirect resident by lying down and rubbing shoulders. Resident continued to be in a rage, refused to lie down. Supervisor notified. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor asked the DON if the incidents should have been reported and DON stated, They should have been documented and reported to me. We will do education on that and do what needs to be done. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator , or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not reporting incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 5. For Resident #28, the facility staff failed to report a resident to resident altercation occurring on 3/15/21. Resident #28's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #28's clinical record revealed the following documentation: A SBAR (Situation, Background, Appearance, Review) Communication Form dated 3/15/21 at 11:43 am states in part, Resident standing at nurses desk with walker, another resident came and shoved resident in the back. Resident fell , hitting right cheek on nurses desk as went down into the floor. Landed on (his/her) buttocks. Assessed from head to toe with red slightly raised area noted on right cheek. No other complaints voiced. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI report for the aforementioned incident involving Resident #28 occurring on 3/15/21. The following day at 10:52 am, surveyor spoke with the DON who stated the incident was reported to them and they then reported it to the administrator but could not find an FRI for the incident. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing), surveyor discussed the concern of the facility not reporting an incident of a resident to resident altercation involving Resident #28. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 6. For Resident #26 and #134, the facility staff failed to report a resident to resident altercation occurring on 6/03/21 to Adult Protective Services. Resident #26's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/22/21 assigned the resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, Cognitive Patterns. Resident #134's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #134's most recent quarterly MDS with an ARD of 5/24/21 assigned the resident a BIMS score of 15 out of 15 in section C, Cognitive Patterns. On 6/08/21 at 1:55 pm during initial rounds, surveyor observed Resident #26 with redness under the left eye and bruising to the left side of the face from the left eye down to the cheek area. Surveyor asked the resident what caused the bruising and the resident stated they hit their face on the door and then stated they must have fallen. At 2:08 pm, surveyor spoke with TCNA (temporary certified nursing assistant) #1 concerning the cause of the bruising and TCNA #1 stated it was reported to them that Resident #134 punched this resident. Surveyor spoke with the administrator and DON (director of nursing) on 6/09/21 at 11:42 am concerning the bruising on Resident #26's face and the DON stated a FRI (facility reported incident) was completed and they are working on the final report now. At 12:30 pm, the DON provided the initial and final FRI report to the surveyor. The follow-up to the FRI dated 6/04/21 for the incident date of 6/03/21 involving Resident #26 and #134 states in part, Reported by staff that the residents mentioned above had a resident-to-resident altercation. It was reported that (Resident #26) wheeled (his/her) self into (Resident #134's) room and started going through (his/her) personal belongings. (Resident #134) asked (him/her) to leave (his/her) 'stuff' alone, (Resident #134) also asked (Resident #26) to leave (his/her) room due to this being (his/her) room and not (his/hers). (Resident #134) was unable to redirect (Resident #26) from (his/her) personal belongings. (Resident #134) stated, '(he/she) started cussing me and I hit (him/her)'. (Resident #26) was assessed, and staff observed a red area on the left side of the forehead. I, (name omitted), DON, upon entering the facility the next morning assessed (Resident #26) and I observed a discolored area to the left side of the forehead, staff was verbally instructed to continue to monitor for [NAME] [sp] and symptoms of any distress. The FRI report did not include the date that APS (adult protective services) was notified of the resident to resident altercation. On 6/10/21 at 11:45 am, surveyor spoke with the DON and asked if APS was notified of the resident to resident altercation between Resident #26 and #134, the DON stated no because there was no injury. At 11:52 am, surveyor spoke with the administrator who stated APS was not notified and it was a team decision. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not reporting an incident of a resident to resident altercation involving Resident #26 and Resident #134 to APS. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 7. For Resident #140, the facility staff failed to report resident to resident altercations occurring on 3/21/21 and 4/05/21. Resident # 140's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/25/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. A review of Resident #140's clinical record revealed the following documentation: A nursing progress note dated 3/21/21 19:55 (7:55 pm) states This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. A 4/05/21 09:45 (9:45 am) eINTERACT SBAR Summary for Providers note states in part, resident entered another residents room and hit resident, denies pain no injuries noted staff immediately intervened and ensured both residents safety staff witnessed and stated 'As I entered the room another Resident was in this residents room hitting this resident, staff immediately moved both residents to safety. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI reports for the aforementioned incidents involving Resident #140. On 6/09/21 at 12:30 pm, the DON provided the surveyor with a risk management form, Incident #827 for Resident #140. Incident #827 form states in part, This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. In the section Resident Description, it is documented I told (him/her) to shut up and quit cussing. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misap [TRUNCATED]