Every finding on record at Veterans Victory House

Based on observation, interview, and facility policy review, the facility failed to ensure all items in the freezer and dry storage were sealed, labeled, and dated. The facility also failed to ensure hair coverings were used properly and dishes were clean and allowed to dry before stacking. These failures had the potential to affect all 181 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's undated policy titled, Employee Sanitary Practices, revealed .Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food . Review of the facility's policy titled, Cleaning Dishes/Dish Machine, undated, revealed, .Allow the dishes to air dry on the dish racks. Do not dry with towels . Review of the facility's policy titled, Dry Storage Areas, undated, revealed, Dry storage areas will be kept in a condition which protects stored foods from infestation .Refrigerated and frozen foods are dated upon delivery. Foods with expiration dates are used prior to the date on the package . The following observations on 02/19/25 at 8:30 AM in the kitchen were made with and verified by the Assistant Director of Dietary (Asst. DOD) and the Director of Dietary (DOD). 1. The walk-in freezer contained one bag each of okra, celery, squash, and country fried steak that were not sealed shut. 2. The dry storage room contained the following items that had been opened with no use-by-dates: cherry gelatin, green split peas, fettuccini, 64 oz jar of peanut butter, and one bag of grits. One bag of breadcrumbs was not sealed shut. 3. A metal bin of sugar was not labeled and had no use-by-date. A metal bin of rice and flour had no use-by-dates. 4. The large industrial food slicer had dried food on it that could be scraped off. 5. Three large baking sheets were stacked wet and had dried food particles on them. Twenty-five wet plates were stacked in the plate warmer. Four plastic lid coverings that were covering the plates in the plate warmer had dried food particles on them. Six bowls and the rack storing the bowls had dried food particles in them that looked like dried egg. 6. The Eco Lab Dishwasher was dirty on the outside with dried food all over it. Interview with the (DOD) on 02/21/25 at 9:48 AM revealed My expectation of the kitchen is to be in compliance across the board. For all kitchen employees to know basic food safety and train, train, train. On 02/21/25 at 11:55 AM, interview with the Administrator revealed My expectation of the kitchen is to prepare nutritious meals in a safe and sanitary environment that meets the needs of the residents. Meals need to be palatable and served in a timely manner.

Based on the facility policy titled, Catheter Care (Male), observations and interview, the facility failed to ensure a procedure was followed during Foley catheter care for Resident (R)76, to aid in the prevention of infection. Findings include: Review of the facility policy titled, Catheter Care (Male), states under the procedure: 3. Wash or sanitize your hands. 4. Gather materials (pre-moistened wipes). 5. Set up supplies on barrier. 6. Position the resident for care. 7. Wash or sanitize your hands and apply gloves. 8. Hold shaft of penis (retract foreskin if uncircumcised). 9. Cleanse around one side of the of meatus in a circular motion. Dispose of wipe. 10. Cleanse other side with a new wipe in a circular motion. Dispose of wipe. 11. Anchor catheter, hold securely and cleanse tubing from the urethral opening downward. Dispose of wipe. 12. Return the foreskin over the end of the penis if circumcised. 13. Remove gloves and wash or sanitize your hands. 14. Reposition resident's clothing and cover. 15. Wash or sanitize your hands. 16. Discard trash and linen. 17 Wash or sanitize your hands. The facility admitted R76 with diagnoses including, but not limited to, urinary retention, obstructive and reflux uropathy and chronic pain. An observation on 01/17/2024 at 03:45 PM of Foley catheter care revealed Certified Nursing Assistant (CNA)1 explained the procedure, and privacy was provided. CNA1, washed her hands, and in the process of applying gloves, one tore so she went back to the box on the wall at the door and retrieved another pair and applied the clean gloves. CNA1 moved the over bed table closer to the bed, went to a drawer at the foot of the bed and retrieved a clean towel and wipes, She placed the towel on the over bed table, along with the package of wipes. The CNA then opened the wipes and took out the first wipe and threw it away. Using her foot, she moved the trash can over to the bed for easy access. CNA1 then pulled the bed covers down and unfastened the resident's brief, using the same gloved hand she removed a wipe from the opened package of wipes, and wiped around the outside of the penis and using the same wipe and wiped up the tubing from about 2 inches toward the insertion site. She did not fold the wipe to use a clean area, or retrieve a clean wipe. She took another wipe and wiped around the penis again, and then using the same wipe and the same gloved hands, she wiped down the tubing. The CNA removed her gloves and cleaned her hands with hand sanitizer. With ungloved hands, she then fastened the R76's brief, and took the covers in hand and covered him and made him comfortable. She used the hand sanitizer to clean her hands, bagged the trash and the towel she had used on the table as a drape, then brought the trash and the soiled linen to the soiled utility room and washed her hands. During an interview on 01/17/2024 at 4:10 PM, CNA1 stated that she should have wiped around the penis with one wipe and then discarded the wipe and then get another one before wiping the tubing. She stated, I know I should have washed my hands and then applied gloves prior to starting the actual catheter care.

Based on the facility policy titled, Hand Hygiene, observations and interview, the facility failed to ensure proper hand hygiene during catheter care for Resident (R)76 for 1 of 3 residents reviewed with catheters. Findings include: Review of the facility policy titled, Hand Hygiene, on 01/18/2024 at 02:20 PM revealed, It is the policy of this facility that staff will perform hand hygiene to aide in the prevention of the transmission of infections. Infection Control: Standard Precautions. The facility admitted R76 with diagnoses including, but not limited to, urinary retention, obstructive and reflux uropathy and chronic pain. An observation on 01/17/2024 at 03:45 PM of Foley catheter care revealed Certified Nursing Assistant (CNA)1 explained the procedure, and privacy was provided. CNA1, washed her hands, and in the process of applying gloves, one tore so she went back to the box on the wall at the door and retrieved another pair and applied the clean gloves. CNA1 moved the over bed table closer to the bed, went to a drawer at the foot of the bed and retrieved a clean towel and wipes, She placed the towel on the over bed table, along with the package of wipes. The CNA then opened the wipes and took out the first wipe and threw it away. Using her foot, she moved the trash can over to the bed for easy access. CNA1 then pulled the bed covers down and unfastened the resident's brief, using the same gloved hand she removed a wipe from the opened package of wipes, and wiped around the outside of the penis and using the same wipe and wiped up the tubing from about 2 inches toward the insertion site. She did not fold the wipe to use a clean area, or retrieve a clean wipe. She took another wipe and wiped around the penis again, and then using the same wipe and the same gloved hands, she wiped down the tubing. The CNA removed her gloves and cleaned her hands with hand sanitizer. With ungloved hands, she then fastened the R76's brief, and took the covers in hand and covered him and made him comfortable. She used the hand sanitizer to clean her hands, bagged the trash and the towel she had used on the table as a drape, then brought the trash and the soiled linen to the soiled utility room and washed her hands. During an interview on 01/17/2024 at 4:10 PM, CNA1 stated that she should have wiped around the penis with one wipe and then discarded the wipe and then get another one before wiping the tubing. She stated, I know I should have washed my hands and then applied gloves prior to starting the actual catheter care.

Based on observations, record reviews, and interviews, the facility failed to assure that a medication was administered to Resident (R)242, according to physician orders resulting into significant medication errors for 1 of 3 residents reviewed for respiratory care. Findings included: R242 had been admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive disease and dependence on supplemental oxygen. On 1/17/24 at approximately 10:50 AM during medication pass for R242, Registered Nurse (RN)1 stated that Fluticasone 250 mcg (micrograms) - salmeterol 50 mcg/dose was not available and that she needed to notify pharmacy. On 1/17/24 at approximately 12:40 PM during medication reconciliation, a review of the Physician Orders List for R242 revealed an order dated 1/15/24 at 2:23 PM for fluticasone 250 mcg (micrograms) - Salmeterol 50 mcg/dose blistr powdr [sic] for inhalation: Inhale 1 puff(s) by mouth twice daily Every Day. Further review of the facility's MAR (Medication Administration Record) revealed that this physician's order had been entered to be given at 9:00 AM and 9:00 PM with the medication charted as administered on 1/15/24 at 9:00 PM and on 1/16/24 at 9:00 PM. On 1/16/24 and 1/17/24 at 9:00 AM, the MAR stated N (not administered) by RN1. On 1/17/24 at approximately 1:50 PM during an interview, RN1 acknowledged that she had talked with pharmacy, that the medication had been dispensed by Pharmacy on 1/15/24 and that she had failed to realize it was in the medication cart for the 9:00 AM doses on 1/16/24 and 1/17/24. The Surveyor confirmed that the medication was in the cart and had been dispensed on 1/15/24. On 1/17/24, the Facility's Pharmacist stated that the medication had dispensed on 1/15/24, that 9:00 PM doses had been administered on 1/15/24 and 1/16/24, but had not been administered at 9:00 AM on 1/15/24 and 1/16/24.

Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from abuse for one Resident (R) 155 of four reviewed for abuse in a total sample of 35 residents. Additionally, the facility failed to ensure physician services to provide orders for immediate care and needs for one (R)356 of three reviewed for injuries of unknown origin in a total sample of 35 residents, as evidenced by failing to assess and identify the cause of increased pain and swelling after an unwitnessed fall. R356 sustained an unwitnessed fall on 10/06/21 resulting in increasing pain and [CONDITION(S)] to the right leg and the facility medical director (R356's attending physician) failed to obtain an x-ray for six days after receiving negative doppler (ultrasonography used to evaluate the direction and pattern of blood flow) results ruling out a [CONDITION(S)] (DVT; type of blood clot). The failure to ensure the resident received proper and adequate care resulted in harm. R155 Findings include: Review of the facility's policy titled Abuse dated 11/2019 indicated, .each resident has the right to be free from abuse .abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy defined physical abuse as, includes but is not limited to: hitting, slapping, pinching, and kicking. The definition of verbal abuse included, the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. The Summary Report of Facility Investigation from the 12/20/21 Five Day Follow Up DHEC Report noted the Director of Nursing (DON) received a report from a Certified Nurse Aide (CNA)22 that alleged CNA21 used profanity in front of R155. R155 reported he was upset, cursed at CNA21, and she cursed back at him. CNA21 denied swearing at R155 but did admit to refusing to change his shirt when asked. The facility provided a folder containing their investigation which included an Investigative Statement/Interview from CNA22 dated 12/20/21. Review of the interview with CNA22, who reported the abuse, indicated the following regarding CNA21 and R155: CNA21 requested assistance with providing care for R155, because he was complaining about 1st shift not changing him. When we went into the room, resident was agitated that he was not changed earlier. I usually let the resident vent and then change them. [CNA21] came in and pointed her finger in his face and said, I'm your tech note [sic] her. Then stated that I'm picking and like to pick with the resident while they are mad. [CNA21] said three times, do you want to sit in your[OBSCENITY] I don't think the resident understood what she was saying. Then she said do you want to sit in your BM [bowel movement]. The resident balled up his fist at [CNA21] and then [CNA21] balled her fist and put it in his face. I got between them and told her to be quiet. She continued to instigate the resident. She said I'm not going to hit him; I am just picking. At one time, [CNA21] shoved him on his arm. I was on the other side of the bed and caught him. [While assisting to change the resident following an episode of incontinence] She was digging in his butt and he told her that is was hurting him. Resident told her you are being a [OBSCENITY] . [CNA21] said no you are being a [OBSCENITY] . After we finished changing the resident, he asked to have his shirt changed. [CNA21] said no I'm not going to change or do anything else for you. CNA22 found another staff member and they assisted R155 to change his shirt. CNA22 then reported the incident to a charge nurse. A staff member then approached her and asked questions about what had occurred. CNA22 also reported that the resident told CNA21 if I had legs, I would kick your ass. She said, haha I have legs and you don't. [sic] Review of an Investigative Statement/Interview included in the facility-provided investigation folder, taken by Unit Lead (UL) 2 on 12/20/21 after the alleged incident indicated R155 said CNA21, told him she didn't want to hear that[OBSCENITY] When asked what else CNA21 said R155 said, never mind. Review of an interview, included in the facility's investigation, with R155 conducted by the DON on 12/20/21 indicated R155 said, the tech that looks like [NAME] Mouse came in here and got into my face. We had words .I think she called me a dumb ass, but I don't remember .Yes, she changed my brief. At one time she was rubbing so hard that it hurt. I told her that it hurt. The DON asked R155 if CNA21 stopped rubbing him when he said it hurt and he could not remember. Review of R155's undated Face Sheet found in the electronic medical record (EMR) under the Face Sheet tab, revealed R155 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/21 indicated a Brief Interview of Mental Status (BIMS) score of 10 out of 15 which meant R155 had moderate cognitive impairment. The assessment documented R155 required extensive physical assistance from one staff member for bed mobility, dressing, and personal hygiene, and R155 was totally dependent on staff assistance for transfers and toilet use. The MDS also documented R155 had no behaviors. Review of R155's Care Plan dated 09/30/21 located in the EMR under the Care Plan tab indicated he had numerous mood and behavior problems (i.e. verbal abuse, combativeness, anxiety, cursing etc.) secondary to Dementia. R155's interventions included, but were not limited to, approach resident in calm, reassuring manner. Observe for episode of inappropriate behavior and redirect .Provide for safety of resident and those near resident during periods of combativeness. Additionally, R155's care plan dated 07/13/21 indicated he was non-factual in relating happenings and situations between self and other residents/staff and conversations. Interventions included, assure resident of staff concern .encourage resident to be factual when relating situations and redirect resident when not. During an interview on 01/10/22 at 2:47 PM, R155 said he recalled an incident with a female CNA and thought she cussed at him but could not recall the words. He said he told UL2 about the incident and she, straightened it all out. He said he had not seen the CNA since he talked to UL2. R155 could not recall the CNA's name and had not seen her since. He said he felt safe in the facility and was not concerned about anyone hurting him. During an interview on 01/11/22 at 3:03 PM, UL2 said CNA22 reported to her that CNA21 had cursed at R155. UL2 said she spoke with the resident, and he did not go into many details but said CNA21 cursed. UL2 said R155 did not mention any physical abuse. UL2 said she was unaware of any issues between CNA21 and CNA22. UL2 also said she had no complaints regarding the accused, CNA21, in the past. UL2 said R155 did have confusion and his reports could be misleading at times. UL2 said it was CNA22 who initially reported the abuse, not the resident. During an interview on 01/11/22 at 3:10 PM, the DON said she was notified by UL2 that CNA21 was rough with R155 and said some curse words in front of him. The DON said CNA21 was suspended pending the investigation and then terminated for her unprofessional conduct. The DON said when she interviewed R155 he could not remember exactly what happened. She said CNA21 and CNA22 gave different accounts of the incident. The DON acknowledged R155 told two staff on separate occasions that CNA21 used curse words at him or in front of him. The DON also confirmed R155 said CNA21 hurt him while rubbing too hard during incontinence care. She said she felt it was one CNA's word versus the other. The DON said because there were variations in R155's account of the incident, as well as the involved CNAs, she was unable to prove the abuse occurred as reported, but the end result was to terminate CNA21 to protect the residents. The DON acknowledged it was not R155 who made the allegation of abuse against CNA21. During an interview on 01/12/22 at 10:28 AM, the Administrator said CNA22 was an agency staff who made an allegation of abuse against CNA21 regarding R155. She said R155 was not a good historian and often confabulates stories. The Administrator said from what she understood of the investigation, R155 could not remember the accused CNA swearing at him. The Administrator said CNA21 admitted to behaving unprofessionally so they terminated her. She said the facility did not terminate CNA21 for abuse because of varying stories from the staff and resident made it difficult to determine what actually occurred. The Administrator said R155 did not have a history of making false accusations of abuse and she confirmed it was not R155 who made this allegation against CNA21. Although the Administrator acknowledged R155's two different statements regarding CNA21 cursing at him and one statement regarding hurting him during incontinence care, she said R155 did not convince me it happened exactly the way it was reported. The Administrator said there was no indication of any issues between the two CNAs that would cause one to make a false accusation against the other. The Administrator said regardless of whether abuse was substantiated or not, the outcome was the same, CNA21 was terminated. R356 Findings include: Review of electronic medical record (EMR) revealed, under tab, Face Sheet, revealed R356 was admitted to facility on 07/10/19 with multiples diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/21 located in the EMR MDS tab revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. The assessment documented R356 required extensive assistance from two or more staff members for bed mobility and was totally dependent on staff for transfers, dressing, toilet use, and personal hygiene. Review of the facility-provided document titled, Care Plan with a revision date of 10/06/21 revealed a Problem/Need of, At risk for injury/falls related to Dementia, L3 Spinal cord injury, [CONDITION(S)], vitamin D deficiency, [CONDITION(S)] med [medication] use, bowel incontinence .incontinence of bladder .resident places self on floor and refuses to allow staff to assist him up. Throws his legs over side of bed . Approaches listed on the care plan included but were not limited to observe routinely, offer time out of bed, bed in low position, fall mat to bedside, monitor for behaviors including placing self on floor, ensure resident is positioned in middle of bed, offer snack, encourage to call for assistance, offer early morning get up, bed alarm, check placement and function of bed alarm every shift, keep personal items in reach, and offer weighted blanket. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/06/21 documented R356 sustained an unwitnessed fall and was assessed by the nurse. R356 was sitting on the floor with his back against the bed. When asked how he got on the floor he reported he wanted to get off the bed. Neurological assessments were initiated and within normal limits. The note documented, PROM [passive range of motion] completed to BLE [bilateral lower extremities] and no complaints of pain or deformities noted. Res [resident] able to move both arms WNL [within normal limits]. Resident offered to get in the chair but stated he wanted to go back to bed. MD [Medical Director (R356's attending physician)] notified. Weighted blanket applied. The facility-provided paper document titled PHYSICIAN'S TELEPHONE ORDERS, dated 10/07/21, revealed [MEDICATION(S)] [narcotic [MEDICATION(S)]] 50 mg po [by mouth] TID [three times a day] prn (pain) .venous us [ultrasound] RLE [right lower extremity] (rule out DVT) [deep vein thrombus] swelling. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/07/21 which documented R356's right leg was observed to be swollen. An order was received for a doppler to right leg and to begin [MEDICATION(S)] (type of pain medication). The note documented [MEDICATION(S)] was effective to control R356's pain. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/08/21 which documented a new order transport R356 to obtain the doppler due to the mobile radiology company not available at this time. A follow up note dated 10/08/21 revealed when transportation arrived to the facility the resident refused to go. The note stated, RN [Registered Nurse] was on floor and attempted to convince him, but he would not be swayed. RN and this nurse compared bilat [bilateral] lower legs; determined there was no color or size difference. No fever to Right lower leg [sic]. RN called Admin [facility administrator] and it was determined risk of xport [sic; transport] would outweigh benefit at this time . The original order for the mobile radiology group to come to facility and obtain ordered doppler was still scheduled. The physician was notified. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/12/21 revealed R356 reported his leg was extremely painful. The note also documented [CONDITION(S)] was noted from the knee up and his skin was described as shiny and tight from the ankle up .The resident did not eat his dinner, stated his stomach would not let him. Review of the facility-provided document titled, DOPPLER REPORT dated 10/12/21 revealed, Conclusion: No evidence of right lower extremity deep venous [CONDITION(S)] [DVT], and was electronically signed by the by the interpreting physician at 5:37 PM. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/13/21 which documented the physician was notified of the doppler results and no new orders were received. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/14/21 which documented R356 was displaying behaviors of attempting to hang his legs off the side of the bed, was yelling and screaming, refused to allow staff to complete a body audit, and staff were unsuccessful in repositioning him even after several attempts. The nurse notified the supervisor. The notes lacked evidence of any additional orders provided by the physician. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/15/21 which documented R356 had increased pain and [CONDITION(S)] to his right leg. The hospice Certified Nursing Aide (CNA) reported difficulty completing activities of daily living with the resident due to his pain. The resident did not eat the breakfast or lunch meal. A new order was received to change R356's pain medication. The note lacked evidence that R356 was assessed by the physician due to the increase pain and swelling and no evidence that any new diagnostic orders were received. The facility-provided paper document titled NURSE'S MEDICATION NOTES, revealed PRN [MEDICATION(S)] was administered to R356 eight times from 10/07/21-10/15/21 with effective results. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/17/21 which documented R356 was making multiple attempts to throw his legs over the side of the bed. The note also documented his right leg [CONDITION(S)] continued and staff identified the right leg was warmer than the left with a reddened area. The note documented the physician was notified but lacked evidence that the physician completed an assessment or provided any new orders. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/18/21 at 12:00 PM which showed a new order to obtain a stat x-ray of R356's right leg was received due to right leg swelling. A note dated 10/18/21 at 2:00 PM documented R356 continued to complain of pain. A note dated 10/18/21 at 3:36 PM revealed the ordered x-ray was completed and were reviewed by the physician. The note documented new orders were received but did not indicate what the order stated. A note date 10/18/21 at 4:04 PM documented R356 was transported to the hospital. A note dated 10/18/21 at 8:47 PM documented, LE [late entry]: 4:15pm X-ray results of right pelvis and right femur received: Results of right pelvis: right hip [CONDITION(S)] changes. No acute osseous [bone] abnormality. Results right femur - acute distal femur fracture. MD notified. [sic] The facility-provided paper document titled NURSE'S MEDICATION NOTES, revealed PRN [MEDICATION(S)] was administered to R356 six times from 10/15/21-10/18/21 with effective results. During an interview that was conducted on 01/11/22 at 4:45 PM, DON (Director of Nursing) confirmed R356 sustained an unwitnessed fall on 10/06/21. She confirmed a doppler was obtained on 10/12/21 with negative results for a DVT, the resident continued to display pain and swelling, and an x-ray was not ordered until 10/18/21. During an interview that was conducted on 01/12/22 at 10:25 AM, CNA15 reported she worked with R356 in October 2021. She recalled that his leg was swollen, he complained of pain, and he had a decline in his ability to assist with bed mobility prior to transferring to the hospital. CNA15 also recalled he was eating less during that time and nursing staff was aware of the [CONDITION(S)] in his leg. An interview was conducted on 1/12/22 at 11:30 AM with a family member of R356's. They confirmed they were notified he had an unwitnessed fall in early October 2021 and that he passed away at the hospital shortly after going there stating, his organs shut down because of blood loss. During an interview on 01/12/22 at 01:09 PM Licensed Practical Nurse (LPN)7 reported staff were aware of R356's right leg [CONDITION(S)] that developed following his fall on 10/06/21. She confirmed the physician was made aware of the resident's increased pain and [CONDITION(S)]. An interview was conducted on 01/12/22 at 1:48 PM, Unit Leader (UL)3 verified a diagnostic X-ray would be indicated for a resident with complaints of right leg pain and signs of swelling following an unwitnessed fall. UL3 confirmed diagnosis/treatment (x-ray) conducted/performed eleven days after a resident complained of pain and swelling following an unwitnessed fall would be considered a delay in diagnosis/treatment. An interview was conducted on 01/12/22 at 2:40 PM with the Medical Director (R356's attending physician). The MD did not recall being notified by facility staff of R356's increased pain following the 10/06/21 unwitnessed fall and said she reviewed this case multiple times. The MD reported the facility's nursing documentation was inconsistent. The MD said the resident received a surgery that she would not have recommended which she felt lead to his decline. She said she had not expected the x-ray would reveal a fracture and felt it was possible the fracture was caused by one of his numerous previous falls or possibly a hairline fracture worsened over time. During a follow-up interview on 01/12/22 at 3:47 PM the MD confirmed a doppler of the right leg was completed on 10/12/21, showed negative results, and the x-ray was not ordered until 10/18/21. The MD reported that she assessed R356 on the unit but did not complete a progress note every time. She said she was never given the impression by the nursing staff that something was horribly wrong with the resident. She further stated that when she looked at the whole scenario, she suspected that R356 had a hairline fracture that may not have been seen on a previous x-ray and that the [CONDITION(S)] she saw during this timeframe was not impressively different. When asked why there was a delay in ordering an x-ray after receiving the negative doppler results she said, You treat the symptoms. She further explained that R356's [CONDITION(S)] continued so that is why she ordered the x-ray, however, a DVT could be caused by a broken bone and immobility. The MD felt R356 sustained a more significant fall on 09/28/21 for which an x-ray was completed of his knee and showed no fracture. She went on to say that she was not informed R356 was having extreme pain because if she were, she would have examined him. The MD felt one could speculate about the cause of the fracture, but she could not know for sure. She said for someone to break the strongest bone in the body it would have to be some sort of fall and she believed the more likely cause of the fracture was his history of multiple falls. A phone interview was conducted on 01/13/22 at 10:57 AM with the MD. She reported she ordered the doppler on 10/07/21 because R356's leg was edematous and wanted to rule out a DVT. The MD confirmed the doppler was negative for a DVT and the resident still had swelling. She explained there was no underlying cause for the swelling but that swelling can be caused by soft tissue injuries as well. The MD said she got an x-ray of his knee after he fell on [DATE], which did show the top of the femur without any fracture. Copies of any physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and facility policy review, the facility failed to follow food safety requirements by not labeling and dating food items, keeping the refrigerator clean and removing items from the refrigerator by their use by date. This practice had the possibility of negatively affecting all residents in the facility. Findings include: Review of the facility's policy titled, Food Storage dated 2006 stated, Policy: Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination .14. All refrigerator units are kept clean .at all times. 15. Refrigeration: .e. All foods should be covered, labeled and dated . During observation of the kitchen on 01/10/22 at 9:15 AM with the Director of Dietary (DD) present, revealed the walk-in cooler contained a rolling cart with 14 pitchers of tea which lacked a label and date. When the DD removed the rolling cart, a puddle of a reddish/pink tinted clear liquid was revealed on the floor under a storage rack full of paper boxes containing food. Upon further inspection, one of the boxes closest to the reddish/pink tinted clear liquid contained thawing turkeys. The DD confirmed there was a reddish/pinkish tinted clear liquid on the floor. The DD stated staff should have placed a pan under the turkeys to keep the juice contained. Continued observation of the kitchen with the DD present revealed the smaller walk-in cooler (cooler #3) contained seven pre-made sandwich halves wrapped in plastic wrap sitting in a black bin on a storage shelf. The sandwiches included three ham sandwiches with a use by date of 01/09/22 and four turkey sandwiches with a use by date of 01/04/22. The DD confirmed the sandwiches were out of date and removed them from the refrigerator. Also, on the storage shelf, was a Ziploc plastic bag dated 01/06/22, which contained half an egg salad sandwich wrapped in plastic wrap, two packaged snacks, and a bottled water. The DD stated the bag was used as a snack for residents going to [CONDITION(S)] and the bagged items (sandwich) had a three-day use period. The DD removed the Ziploc bag from the refrigerator. During an interview on 01/12/22 at 10:45 AM with the DD, she stated her kitchen staff were aware of and had received education regarding labeling/dating of items in the refrigerator, removing out of date items from the refrigerator, and proper containment of juices of thawing meat.

Based on record review, observation, interview, and review of Resident Council Minutes the facility failed to provide meals of an appetizing temperature for the residents receiving room trays on three of four units per complaints received through resident council and five of five (Resident (R)6, R155, R35, R110, R147) reviewed for food in a total sample of 35 residents. Findings include: 1. Review of Resident Council minutes dated 10/12/21 revealed in part, Residents asked if both food tray carts must be on the unit before trays can be distributed? Council members suggest that trays be distributed from the first cart to arrive while the kitchen is finishing up trays on the second cart. This way, food trays would be served sooner as they leave the kitchen. Right now, residents report that staff wait until both carts are on the unit and then begin passing all the trays. Council advised the matter would be discussed with the Dietary Manager and the unit nursing managers for follow up. The form lacked documentation of a response from facility staff related to the food concerns voiced by the residents. 2. Review of the electronic medical record (EMR) under the face sheet tab revealed R35 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)]. Review of phys [physician] order tab of the EMR revealed an order dated 07/18/19 showing R35 received a regular diet, utilized built-up utensils for meals, and directed staff to avoid providing R35 with rice and peanuts. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/21 revealed R35 required setup help only for meals. The MDS further revealed resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating resident was cognitively intact. During an interview with R35 on 01/11/22 at 10:16 AM revealed R35 was the President of Resident Council. R35 reported one of the major complaints during Resident Council meetings was half the time they serve food, the food is cold, especially when you're eating in your room .staff tell Resident Council that they are addressing issues, but nothing ever changes .major complaint is food, either too soft or too cold. 3. Review of the EMR under the Face Sheet tab revealed R6 was admitted to the facility on [DATE] with the diagnoses of [CONDITION(S)], drug induced [CONDITION(S)] secondary to parkinsonism, [CONDITION(S)], post-traumatic stress disorder ([CONDITION(S)]), and major depressive disorder. Review of R6's EMR under the Physician's Orders tab indicated an order for regular diet dated 06/25/19. Review of R6's quarterly MDS with an ARD of 10/09/21 indicated the resident was cognitively intact as evidenced by a BIMS score of 15 out of 15. During an interview on 01/11/22 at 9:22 AM, R6 stated by the time his food tray was delivered to his room the food was cold. R6 said that he must go to the dining room to eat if he wanted hot food. R6 stated when the facility delivered meals in Styrofoam food containers they placed a clear plastic top over the container, but the food still arrived cold. R6 said the blue plate covers currently used by the facility did not keep the food warm. R6 stated being served cold food had been occurring for years and it was not something that started due to issues related to the Coronavirus Disease 2019 (COVID-19) epidemic. R6 confirmed he had brought this issue to the attention of facility management. 4. Review of the EMR face sheet tab revealed R110 was admitted to the facility on [DATE]. Review of diet order in the EMR, under phys order tab, revealed R110 had an order for regular diet with allergy to oysters and clams. Review of quarterly MDS with ARD date 12/04/21, revealed R110 was able to eat independently with no help or staff oversight required. The MDS further revealed resident had a BIMS score of 15 indicating resident was cognitively intact. During an interview on 01/10/22 at approximately 10:00 AM, R110 reported, food is terrible .for the past one to two years unfit for human consumption .poor quality, getting second and third cuts on meats .frequently undercooked and breakfast served room temperature. 5. Review of R147's EMR under the Dx [diagnosis] tab indicated he was admitted on [DATE] with diagnoses including [CONDITION(S)] and stage 4 kidney disease. Review of R147's quarterly MDS with an ARD of 12/25/21 revealed R147 had a BIMS score of seven out of 15, which indicated severe cognitive impairment. During an interview on 01/10/22 at 10:48 AM R147 said the food served at the facility did not taste very good. He also said it was not served hot and was rarely served warm. R147 said he ate his meals in his room. 6. Review of R155's EMR under the Dx [diagnosis] tab indicated he was admitted on [DATE] with diagnoses including type II diabetes and double below the knee amputations. Review of R155's quarterly MDS with an ARD of 12/25/21 revealed R155 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. During an interview on 01/10/22 at 2:51 PM R155 said, the food is horrible, and the food temperature is always cold. R155 said the meal trays on B hall were always cold and not on time. 7. Observation of meal service temping of the steam table completed by Dietary Staff 24 in the kitchen on 01/11/22 at 5:00 PM revealed results were as follows: beef hamburger patty equaled (=)178 degrees Fahrenheit; tater tots = 145 degrees Fahrenheit; vegetables = 174 degrees Fahrenheit; mechanical chopped beef = 168 degrees Fahrenheit; pureed meat = 184 degrees Fahrenheit; pureed potatoes = 168 degrees Fahrenheit; pureed vegetables = 167 degrees Fahrenheit; alternative starch, rice = 167 degrees Fahrenheit; alternative vegetable, carrots = 173 degrees Fahrenheit; alternative meat, chicken = 143 degrees Fahrenheit; and gravy = 160 degrees Fahrenheit. The number of kitchen staff working on the dinner food line were: four employees on the tray line and two employees serving. The blue plate holders (top and bottom covers for each plate) were being used but were not being heated. Carafes of coffee and pitchers of tea were placed on top of the carts for delivery. Test trays for A, B and D Halls were requested. During an observation on 01/11/22 at 5:35 PM a tray cart came on Hall A and two Certified Nurse Aides (CNAs) began passing trays to resident rooms. At 6:35 PM the trays were passed to all the residents and Unit Clerk (UC) 1 brought a test tray to the nurses' station. The test tray consisted of a burger patty with cheese served on white bread, a mixture of bell peppers and onions and tater tots. The food items were tasted by UC1, and she said the burger was lukewarm and could be warmer. She also said the peppers and onions were too cool and the tater tots were too hard. This tray was also tested by a surveyor who confirmed UC1's conclusion that the burger patty, onion and peppers, and tater tots were not at an appetizing temperature. Observation on 01/11/22 at 5:35 PM, revealed meal trays started being served to Hall B at by CNA19 and CNA16. The last tray on the cart was provided to the surveyor as a test tray, at approximately 6:25 PM. The test tray included two slices of bread with a hamburger patty, one slice of cheese, green pepper and onion mixture, tater tots, and bowl of pears on the side. The hamburger, cheese, and bread were cool to the touch; the green peppers and onion mixture was lukewarm and overcooked; and the tater tots were hard and room temperature. Registered Nurse (RN)20 was present at 6:25 PM and confirmed the bread, meat and cheese were served cool to touch, vegetable was lukewarm and overcooked, tater tots were room temperature and hard. Observation on 01/11/22 at 5:55 PM in the kitchen revealed the first insulated food cart for the Hall D was loaded by 5:55 PM and the second cart by 6:02 PM, with both carts arriving to the Hall at 6:04 PM. Observation on Hall D at 6:05 PM revealed two CNAs began delivering trays and were then assisted by two nurses. The last tray was delivered at 6:25 PM. Immediately following the last resident tray being delivered, a test tray from the cart was carried to the nurses' station (located in the center of Hall D) and the temperatures of the food items were taken. Temperature results were as follows: Beef hamburger patty = 128 degrees Fahrenheit; tater tots = 99 degrees Fahrenheit; and vegetables = 107 degrees Fahrenheit. The food items were then tasted by a surveyor, which revealed the hamburger patty was warm, the vegetables were cool, and the tater tots were cold. An interview was conducted during dinner service on 01/12/22 at 5:50 PM with the Director of Dietary. When asked why the blue plate holders were not being heated, the DD stated the heating element stopped working on 01/10/22 (Monday) and she submitted a work order to have it repaired on the same day. The DD provided one of the China plates off the line so the surveyor could feel that it was warm to the touch. The DD stated serving a patty melt sandwich for this meal slowed down the meal service process due to there being a couple of extra steps to plate each sandwich. The DD explained on 12/10/21 the facility management made the decision all meals would be served on China plates only (no Styrofoam containers except for the COVID-19 hall) in an attempt for the meals to be warmer by the time they reach the residents. The DD confirmed the kitchen staff delivered the food carts to the resident halls but did not assist with tray delivery. During an interview on 1/13/22 at 10:45 AM with the Administrator, she stated she was aware of residents' complaints of the food being cold by the time it reached their rooms. The Administrator stated due to COVID-19 infection control issues there were periods of time when meals were delivered in Styrofoam containers which made it difficult to keep the food hot. The Administrator stated another issue that forced the use of Styrofoam containers, was the dish machine began working intermittently during August of 2020. The Administrator said after much back and forth between several agencies and numerous repairs the dish machine was replaced during October 2020. The Administrator explained the facility had tried several solutions to resolve the cold meals issue: Encouraging residents to eat their meals in the small dining rooms on their hall (most residents refused), Changing the order meal trays were delivered in (those residents that need more assistance with eating versus those that are independent), Purchasing smaller meal delivery carts (found to be cost prohibitive), Using clear plastic covers over the Styrofoam containers (was not effective), and Re-opening the large dining room for communal dining (seating one resident per a four person table). The Administrator stated the cold meal issue had been addressed in Quality Assessment Performance Improvement (QAPI). The Administrator stated a company was at the facility this morning to repair the Temp-Rite (the machine that heats the blue plate holders) and the repair company determined several of the heating elements were not functioning. During an interview on 01/13/22 at 12:05 PM with the Director of Nursing (DON), who is over the QAPI program, she stated the cold meal issue was not included in the current QAPI plan. On 01/13/22 at 11:00 AM the Surveyor requested, from the Administrator, a facility policy regarding meal delivery/temperature, but one was not received prior to exit. -

Based on review of facility policy, record review, and interviews, the facility failed to ensure one resident (R) 155 was treated with respect and dignity by facility staff. Findings include: Review of the facility's policy titled Abuse dated 11/2019 indicated, .each resident has the right to be free from abuse .abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy defined physical abuse as, includes but is not limited to: hitting, slapping, pinching, and kicking. The definition of verbal abuse included, the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. The Summary Report of Facility Investigation from the 12/20/21 Five Day Follow Up DHEC Report noted the Director of Nursing (DON) received a report from a Certified Nurse Aide (CNA)22 that alleged CNA21 used profanity in front of R155. R155 reported he was upset, cursed at CNA21, and she cursed back at him. CNA21 denied swearing at R155 but did admit to refusing to change his shirt when asked. The facility provided a folder containing their investigation which included an Investigative Statement/Interview from CNA22 dated 12/20/21. Review of the interview with CNA22, who reported the abuse, indicated the following regarding CNA21 and R155: CNA21 requested assistance with providing care for R155, because he was complaining about 1st shift not changing him. When we went into the room, resident was agitated that he was not changed earlier. I usually let the resident vent and then change them. [CNA21] came in and pointed her finger in his face and said, I'm your tech note [sic] her. Then stated that I'm picking and like to pick with the resident while they are mad. [CNA21] said three times, do you want to sit in your[OBSCENITY] I don't think the resident understood what she was saying. Then she said do you want to sit in your BM [bowel movement]. The resident balled up his fist at [CNA21] and then [CNA21] balled her fist and put it in his face. I got between them and told her to be quiet. She continued to instigate the resident. She said I'm not going to hit him; I am just picking. At one time, [CNA21] shoved him on his arm. I was on the other side of the bed and caught him. [While assisting to change the resident following an episode of incontinence] She was digging in his butt and he told her that is was hurting him. Resident told her you are being a [OBSCENITY] . [CNA21] said no you are being a [OBSCENITY] . After we finished changing the resident, he asked to have his shirt changed. [CNA21] said no I'm not going to change or do anything else for you. CNA22 found another staff member and they assisted R155 to change his shirt. CNA22 then reported the incident to a charge nurse. A staff member then approached her and asked questions about what had occurred. CNA22 also reported that the resident told CNA21 if I had legs, I would kick your ass. She said, haha I have legs and you don't. [sic] Review of an Investigative Statement/Interview included in the facility-provided investigation folder, taken by Unit Lead (UL) 2 on 12/20/21 after the alleged incident indicated R155 said CNA21, told him she didn't want to hear that[OBSCENITY] When asked what else CNA21 said R155 said, never mind. Review of an interview, included in the facility's investigation, with R155 conducted by the DON on 12/20/21 indicated R155 said, the tech that looks like [NAME] Mouse came in here and got into my face. We had words .I think she called me a dumb ass, but I don't remember .Yes, she changed my brief. At one time she was rubbing so hard that it hurt. I told her that it hurt. The DON asked R155 if CNA21 stopped rubbing him when he said it hurt and he could not remember. Review of R155's undated Face Sheet found in the electronic medical record (EMR) under the Face Sheet tab, revealed R155 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/21 indicated a Brief Interview of Mental Status (BIMS) score of 10 out of 15 which meant R155 had moderate cognitive impairment. The assessment documented R155 required extensive physical assistance from one staff member for bed mobility, dressing, and personal hygiene, and R155 was totally dependent on staff assistance for transfers and toilet use. The MDS also documented R155 had no behaviors. Review of R155's Care Plan dated 09/30/21 located in the EMR under the Care Plan tab indicated he had numerous mood and behavior problems (i.e. verbal abuse, combativeness, anxiety, cursing etc.) secondary to Dementia. R155's interventions included, but were not limited to, approach resident in calm, reassuring manner. Observe for episode of inappropriate behavior and redirect .Provide for safety of resident and those near resident during periods of combativeness. Additionally, R155's care plan dated 07/13/21 indicated he was non-factual in relating happenings and situations between self and other residents/staff and conversations. Interventions included, assure resident of staff concern .encourage resident to be factual when relating situations and redirect resident when not. During an interview on 01/10/22 at 2:47 PM, R155 said he recalled an incident with a female CNA and thought she cussed at him but could not recall the words. He said he told UL2 about the incident and she, straightened it all out. He said he had not seen the CNA since he talked to UL2. R155 could not recall the CNA's name and had not seen her since. He said he felt safe in the facility and was not concerned about anyone hurting him. During an interview on 01/11/22 at 3:03 PM, UL2 said CNA22 reported to her that CNA21 had cursed at R155. UL2 said she spoke with the resident, and he did not go into many details but said CNA21 cursed. UL2 said R155 did not mention any physical abuse. UL2 said she was unaware of any issues between CNA21 and CNA22. UL2 also said she had no complaints regarding the accused, CNA21, in the past. UL2 said R155 did have confusion and his reports could be misleading at times. UL2 said it was CNA22 who initially reported the abuse, not the resident. During an interview on 01/11/22 at 3:10 PM, the DON said she was notified by UL2 that CNA21 was rough with R155 and said some curse words in front of him. The DON said CNA21 was suspended pending the investigation and then terminated for her unprofessional conduct. The DON said when she interviewed R155 he could not remember exactly what happened. She said CNA21 and CNA22 gave different accounts of the incident. The DON acknowledged R155 told two staff on separate occasions that CNA21 used curse words at him or in front of him. The DON also confirmed R155 said CNA21 hurt him while rubbing too hard during incontinence care. She said she felt it was one CNA's word versus the other. The DON said because there were variations in R155's account of the incident, as well as the involved CNAs, she was unable to prove the abuse occurred as reported, but the end result was to terminate CNA21 to protect the residents. The DON acknowledged it was not R155 who made the allegation of abuse against CNA21. During an interview on 01/12/22 at 10:28 AM, the Administrator said CNA22 was an agency staff who made an allegation of abuse against CNA21 regarding R155. She said R155 was not a good historian and often confabulates stories. The Administrator said from what she understood of the investigation, R155 could not remember the accused CNA swearing at him. The Administrator said CNA21 admitted to behaving unprofessionally so they terminated her. She said the facility did not terminate CNA21 for abuse because of varying stories from the staff and resident made it difficult to determine what actually occurred. The Administrator said R155 did not have a history of making false accusations of abuse and she confirmed it was not R155 who made this allegation against CNA21. Although the Administrator acknowledged R155's two different statements regarding CNA21 cursing at him and one statement regarding hurting him during incontinence care, she said R155 did not convince me it happened exactly the way it was reported. The Administrator said there was no indication of any issues between the two CNAs that would cause one to make a false accusation against the other. The Administrator said regardless of whether abuse was substantiated or not, the outcome was the same, CNA21 was terminated.

Based on observations, interviews, record review, and facility policy review, the facility failed to accurately transcribe a physician telephone order regarding a medication for one Resident (R)25 of eight residents observed during medication administration. The sample included 35 residents. Findings include: Review of the Pharmacy Policy and Procedure Manual - Pharmacy Services, with an effective date of 07/01/2017, revealed new orders may be received verbally by the nurse on duty for transcription. If verbally received, the nurse writes down the complete order and then reads the information back to the prescriber for confirmation. The order is transcribed onto the Resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of medication administration on Hallway D with Registered Nurse (RN)6, on 01/12/22 at 7:50 AM, revealed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN6 confirmed this information was missing. RN6 reported medication orders should be accurately transcribed from the physician's medication order to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R25's paper chart located in the chart room on the D Hallway revealed a physician's telephone order behind the physicians order tab dated 01/11/22 for [MEDICATION(S)] 875 milligrams (mg) one tablet by mouth (po) twice daily (BID) for five days for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/12/22 at 2:15 PM, RN5 stated a medication order should be transcribed to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Unit Leader (UL)3 of the D Hallway on 01/12/22 at 10:00 AM revealed it was her expectation that nursing staff accurately transcribe all physician medication orders to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . UL3 continued to relate all the orders were double checked by the nurse on the evening shift. UL3 confirmed the order for R25's [MEDICATION(S)] was not accurately transcribed on the MAR. An interview with the Director of Nursing (DON) on 01/12/22 at 2:21 PM revealed it was her expectation that nursing staff accurately transcribe all physician orders, especially medication orders, to include the name of the medication, the dosage, and the route of the medication. The DON related it was her understanding each unit had a backup system where the evening nurse checked all the new orders written on the day shift to ensure accuracy. The DON confirmed the evening nurse did not identify the medication transcription error on R25's MAR. An interview with the Administrator on 01/12/22 at 4:23 PM revealed it was her expectation that nursing staff follow the expected guidelines regarding the transcription of medication orders. She continued to relate that the facility had built in checks and balances in the system to catch medication transcription errors. The administrator confirmed the order for R25's antibiotic failed to include the dosage when transcribed to the MAR.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents receive assistance with hearing aids to maintain hearing abilities for one (Resident (R)70) of three reviewed for communication/sensory in a total sample of 35 residents. Findings include: Review of the facility policy titled, Hearing Aid, with a revision date of October 2012, revealed, A resident requiring a hearing aid will be assisted in the placement, maintenance, care and storage of the hearing aid .Purpose: To maintain the resident's hearing and enhance the quality of life .Procedure: Placement: 1. Check the battery . During an interview on 01/11/22, at 10:10 AM, R70 revealed a concern regarding the care and maintenance of his hearing aid equipment. The interview was challenging to conduct due to the resident not being able to hear accurately with out the use of hearing aids. The resident related the batteries had not been working for several weeks and the resident had asked the staff for assistance and new hearing aid batteries, however the resident had not received new batteries. The resident stated being without the use of hearing aids for several weeks had affected the ability to communicate and interact with family, peers, and staff at the facility. Review of R70's Face Sheet located in the paper chart kept in the chart room on the D Hallway revealed an admitted [DATE]. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/21 revealed R70 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment also documented R70 had minimal hearing difficulties with the use of hearing aids. An interview conducted with Registered Nurse (RN)5 on 01/12/22 at 2:15 PM revealed the facility did take care of R70's hearing aids and the batteries should have been checked and replaced. An interview conducted with Unit Leader (UL)3 on 01/10/22 at 10:30 AM, revealed it was the policy of the facility to assist the resident with the care of their hearing aids. An interview with the Director of Nursing (DON) on 01/12/22 at 2:21 PM revealed it was her expectation that all the nursing staff follow the Hearing Aid policy and assist the residents with the care of their hearing aids. An interview with the Administrator on 01/12/22 at 4:23 PM revealed that it was her expectation that the facility followed their policy regarding the care of the resident hearing aids. She reported she was aware of the importance of properly functioning hearing aids to improve the quality of life for the residents.

Based on interview and record review, the facility failed to report an allegation of verbal abuse within the required timeframe for 1 of 2 residents reviewed for abuse. The findings include: Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set indicated s/he had a Brief Interview of Mental Status (BIMS) score of 99. During an interview with Resident #2 on 7/14/2021 at 10:30 AM, s/he revealed an allegation of verbal abuse. Resident #2 stated that last month (June 2, 2021) the Administrator and Assistant Administrator (AA) were serving food in the cafeteria without a hairnet. Resident #2 explained to the Administrator and AA that this was a DHEC violation and that s/he was going to report them (to DHEC). At that time, the Administrator rolled him/her out of the cafeteria into the dining room and told him/her Don't ever embarrass me like that again or I will make the rest of your time here miserable. Resident #2 expressed there were two staff witnesses that saw the Administrator tell me that but they got fired for knowing too much the week after that happened to me, but they used to work in Activities. A record review on 7/14/2021 at 10:45 am revealed that the facility reported the alleged verbal abuse on 6/8/2021 to DHEC after the alleged verbal abuse, which took place on 6/2/2021 according to the Grievance report. An interview with the Director of Nursing (D.O.N.) on 7/14/21 at 3:30 PM revealed that the facility reported the incident on 6/8/21 however, the incident happened the week prior on 6/2/21. During the investigation the Administrator was placed on leave for the investigation and was re-educated on abuse and neglect by the Regional Vice President and Nurse Consultant and a training about reducing interactions with Resident #2 and when interactions are necessary, to have another staff member present. A record review of the facility policy titled Abuse on 7/14/21 at 3:45 PM All allegations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property will be reported immediately to the employee's direct supervisor and or Administrator or Director of Nursing. The facility will have a process in place to report allegations of abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation if resident property to the required agencies immediately or no later than two (2) hours after the allegation for allegation involving abuse or result in serious bodily injury is made or twenty-four (24) hours if the allegation don't involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to implement the Abuse policy in timeliness of reporting alleged abuse to the State Agency (DHEC) for 1 of 2 residents reviewed for abuse. The findings include: Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set indicated s/he had a Brief Interview of Mental Status (BIMS) score of 99. During an interview with Resident #2 on 7/14/2021 at 10:30 AM, s/he revealed an allegation of verbal abuse. Resident #2 stated that last month (June 2, 2021) the Administrator and Assistant Administrator (AA) were serving food in the cafeteria without a hairnet. Resident #2 explained to the Administrator and AA that this was a DHEC violation and that s/he was going to report them (to DHEC). At that time, the Administrator rolled him/her out of the cafeteria into the dining room and told him/her Don't ever embarrass me like that again or I will make the rest of your time here miserable. Resident #2 expressed there were two staff witnesses that saw the Administrator tell me that but they got fired for knowing too much the week after that happened to me, but they used to work in Activities. A record review on 7/14/2021 at 10:45 am revealed that the facility reported the alleged verbal abuse on 6/8/2021 to DHEC after the alleged verbal abuse, which took place on 6/2/2021 according to the Grievance report. An interview with the Director of Nursing (D.O.N.) on 7/14/21 at 3:30 PM revealed that the facility reported the incident on 6/8/21 however, the incident happened the week prior on 6/2/21. During the investigation the Administrator was placed on leave for the investigation and was re-educated on abuse and neglect by the Regional Vice President and Nurse Consultant and a training about reducing interactions with Resident #2 and when interactions are necessary, to have another staff member present. A record review of the facility policy titled Abuse on 7/14/21 at 3:45 PM revealed all allegations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property will be reported immediately to the employee's direct supervisor and or Administrator or Director of Nursing. The facility will have a process in place to report allegations of abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation if resident property to the required agencies immediately or no later than two (2) hours after the allegation for allegation involving abuse or result in serious bodily injury is made or twenty-four (24) hours if the allegation don't involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to prevent verbal abuse for Resident #2 by a staff member for 1 of 2 residents reviewed for abuse. The findings include: Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set indicated s/he had a Brief Interview of Mental Status (BIMS) score of 99. During an interview with Resident #2 on 7/14/2021 at 10:30 AM, s/he revealed an allegation of verbal abuse. Resident #2 stated that last month (June 2, 2021) the Administrator and Assistant Administrator (AA) were serving food in the cafeteria without a hairnet. Resident #2 explained to the Administrator and AA that this was a DHEC violation and that s/he was going to report them (to DHEC). At that time, the Administrator rolled him/her out of the cafeteria into the dining room and told him/her Don't ever embarrass me like that again or I will make the rest of your time here miserable. Resident #2 expressed there were two staff witnesses that saw the Administrator tell me that but they got fired for knowing too much the week after that happened to me, but they used to work in Activities. Resident #2 filed a grievance with the facility on 6/2/2021, the date of the alleged verbal abuse, and was able to show the Survey team their copy of the grievance. The Grievance stated Please answer my question with a yes or no, food services department states all must wear a hair at all times. Attached to the Grievance regarding a Food Policy stating All meal services staff shall wear clean clothes, maintain personal cleanliness, and conform to hygienic practices while on duty. Shoes worn by meal service staff shall be closed-toed. Only authorized persons be allowed in the kitchen. A record review on 7/14/2021 at 10:45 am revealed that the facility reported the alleged verbal abuse on 6/8/2021 to DHEC after the alleged verbal abuse, which took place on 6/2/2021 according to the Grievance report. A phone interview with Activities Staff #1 on 7/14/2021 at 11:00 AM revealed that they confirmed their witness statement from 6/9/2021. The witness statement stated Do you know anything about an incident with the Administrator and Resident #2? Yes, the Administrator and Assistant Administrator were in the kitchen when Resident #2 rolled into the kitchen and stated you guys don't have a hairnet on and you guys didn't wash your hands loudly. The Assistant Administrator stated to Resident #2 to get out of the kitchen and we will talk about this later in very respectful manner. Resident #2 was still yelling on the way out and the Administrator went out behind him, I heard the Administrator say don't disrespect me like that again, I can make your time here very uncomfortable. An interview with the Administrator on 7/14/2021 at 2:30 PM revealed that s/he confirmed their witness statement of the alleged verbal abuse on 6/8/21. The witness statement from the Administrator stated Since we have resumed socially distance communal dining in the Trulluck Dining Room, I try to be present, in the dining room for lunch most days. Sometimes I serve the veterans at their tables, sometimes I bus the tables and scrape the plates. At times, I serve behind the steam table as the dietary employees are in the back of the kitchen preparing meal trays for the dayroom and room service. We do not have a designated dietary employee to serve employee lunches at the front cafeteria line. I am usually in the dining room around 11:15 or 11:30, after the Activity Department employees have taken resident orders and served drinks, and I stay until lunch service is over around 12 noon. On the day in question, I came to the dining room later than usual. The residents had all been served, only employees were purchasing lunch at this time. The AA was standing at the side of the serving/steam table against the wall, not far from the hand washing sink. When I came in, the AA mentioned that Resident #2 had been yelling at them about not wearing a hairnet. The AA stated that they were not behind the serving line and was not serving food. Shortly after I walked in the cafeteria line area, Resident #2 wheeled into that area very agitated and began yelling loudly and aggressively waving their arms/ pointing towards me and the AA saying something about the requirements for wearing hairnets. I replied that individuals serving food are required to wear a hair net and neither the AA nor I were behind the line serving food at this time. Resident #2 continued to talk loudly, interrupting me and gesturing. Resident #2 was very disruptive and there were several people in the area, I asked him to leave the area twice. Resident #2 turned their wheelchair to leave the cafeteria area, I approached them directly outside the double doors exiting the cafeteria leading into the main dining room. I told Resident #2 Don't ever speak to me like that again. I have never spoken to you disrespectfully and I don't expect you to talk to me that way. Then I walked away and left the dining room, I have not spoken to Resident #2 since that interaction. Resident #2 submitted a grievance either that day or the next, stating it was a requirement that employees wear hairnets in the kitchen. I responded in writing to Resident #2 grievance and provided them a copy of the SC Nursing Home Licensure regulations pertaining to Dietary employee requirements. When asked by the Surveyor to the Administrator, did you ever tell Resident #2 I will make your time here miserable or anything else verbally abusive the Administrator replied no. During an interview with the AA on 7/14/21 at 3:15 PM, s/he confirmed their witness statement regarding the alleged verbal abuse with Resident #2. They stated that Resident #2 came into cafeteria and was yelling loudly about at me about not wearing a hairnet because it is CDC and DHEC guidelines to wear one while serving food. I explained to him/her that we could talk about it later. When the Administrator came in 5 minutes later to help serve, that is when Resident #2 wheeled back in and began yelling again about DHEC violations. The Administrator told Resident #2 to leave so we could to finish serving the residents. Resident #2 continued to yell the same things loudly. At that time, the Administrator started walking towards Resident #2 and they started to back out of the serving room. The Administrator told Resident #2 that I don't speak to you in a disrespectful way, so I do not expect you to speak to me in this manner. Resident #2 then went back to their table and had no other concerns. An interview with the Director of Nursing (D.O.N.) on 7/14/21 at 3:30 PM revealed that the facility reported the incident on 6/8/21 however, the incident happened the week prior on 6/2/21. During the investigation the Administrator was placed on leave for the investigation and was re-educated on abuse and neglect by the Regional Vice President and Nurse Consultant and a training about reducing interactions with Resident #2 and when interactions are necessary, to have another staff member present. A record review of the facility policy titled Abuse on 7/14/21 at 3:45 PM revealed each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Verbal abuse - the use of oral, written, or gestured language that is willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

This requirement was not met as evidenced by: Based on interviews, record reviews and observations the facility failed to accurately assess and document a back/shoulder abscess on one of one resident (Resident #386) investigated for skin condition. Findings include: A record review revealed Resident #386 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the Isolation unit per Covid- 19 protocol. During the initial interview with Resident #386, s/he stated s/he had pain in his/her left upper leg and his/her calf, s/he also complained of pain on his/her upper back. S/he then pulled down his/her shirt to expose a quarter size scabbed sore on his/her right back/shoulder area. S/he stated the sore had been present for several days and was painful and no one has looked at it yet. When questioned if s/he had seen a physician at the facility Resident #386 stated, No. I keep asking to see the doctor, but no one has come down to see me. During an interview on 11/16/2020 at approximately 12:15 PM with RN #3, s/he stated the facility physician had been in to see Resident #386 within 24 hours of admission, but due to the physician being in full PPE with mask, gown and face shield per COVID protocol, the resident probably didn't realize it was the doctor. RN #3 denied knowledge of the sore on Resident #386's back/shoulder area. S/he stated the resident had not complained about a painful area but stated s/he would look into it. Record review on 11/16/2020 at 3 PM of nursing notes from 11/9/2020 - 11/16/2020 revealed no mention of the back/shoulder sore on Resident #386. Care plan dated 11/9/2020 reviewed for potential for skin breakdown due to co-morbidities. Care plan included recommendation for pressure relieving mattress pad for bed and wheelchair and routine body audits. Record review also revealed MDS not yet completed, admitted [DATE]. Interview on 11/17/20 at 01:30 PM with Resident #386 who, again, showed the surveyor a quarter size scabbed wound on his/her right back/shoulder, and multiple small healing areas (which appeared to look like small surgical incisions), on his/her left knee and upper leg, s/he stated no clinical staff have been in to see the areas. On 11/17/20 at 03:33 PM a record review of the body audits for Resident #386, revealed the initial audit, dated 11/09/2020 completed by RN #4 stated scar to right lower back. The body audit dated 11/16/2020 completed by LPN #1, documented age spots, scabs, scars, and [MEDICAL CONDITION] on left lower leg. Interview with the Director of Nursing (DON) on 11/17/2020 at 3:45 PM, s/he verified the body audits should indicate the sore on the resident's back/shoulder. S/He stated s/he would have the wound nurse look at Resident #386 to assess the area. During an interview on 11/18/2020 at 09:10 AM with Resident #386, s/he verified the wound nurse (RN #4) and then the physician came to his/her room the previous afternoon, inspected and then opened and drained the wound on his right back/shoulder. S/He stated the doctor drained a lot of pus out of it. S/He also stated the area feels so much better. In an interview with the facility physician on 11/18/20 at approximately 3:07 PM s/he stated the resident's wound was brought to his/her attention on 11/17 /2020 in the afternoon by the Wound nurse RN #4. The physician stated s/he entered the resident's room to examine the resident and assessed the quarter size wound on his/her right back/shoulder, the area had developed a ring of [DIAGNOSES REDACTED] and redness around it. The central area had fluctuance and a small dark scab over it. S/He elevated the corner of the scab and immediately had purulent drainage discharged from the wound. Slight pressure was applied, and multiple clumps of white cheesy material was removed. S/He stated the resident stated the area felt much better. The physician placed the resident on antibiotics and packed the wound with [MEDICATION NAME] gauze. When asked what, in his/her professional opinion, caused the wound, s/he stated s/he would classify it as a sebaceous cyst that developed into an abscess. When asked how long s/he thought the resident had the wound, based on his/her clinical assessment, s/he stated, looking at the scab, it has probably been there for several days. A phone interview on 11/18/20 at 3:29 PM with LPN #1 confirmed during the body audit on Resident #386 s/he pulled resident's shirt up to his/her shoulders and did not observe a sore on the resident's back/shoulder area. S/he confirmed s/he did not take the resident's shirt off or look under the shirt. S/he stated the resident never complained of pain or voiced concerns about the wound.

Based on observation and interview, the facility failed to properly store and label food items in both the walk-in coolers. During initial tour of the kitchen with the assistant to the Assistant Dietary Director on 11/16/2020 at approximately 11:00 am, observation of the walk-in cooler revealed an opened gallon of milk without a date indicating when it was opened. The tour also identified five (5) sandwiches without a label to identify the type of sandwich or the date and time the sandwiches were prepared. Various packs of meats opened without a date or time it was opened were also observed. The facility's policy on Food Storage in Refrigerated Food Storage states: 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. (Also see policy on Use of Leftovers in this section.) Check state regulations for more detail. 14(f). All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. An interview and follow-up visit with the Assistant Dietary Director on 11/17/20 at approximately 11:15 am, revealed various packs of meats opened without a date or time it was opened.

Based on observations and interviews, the facility failed to ensure a resident was provided with privacy when making a telephone call for 1 of 1 sampled resident observed. Resident #21 was observed making a personal telephone in a staff members' office and at the nursing station. The findings included The facility admitted Resident #21 with [DIAGNOSES REDACTED]. A random observation on 11/16/20 at approximately 12:56 PM revealed Resident #21 asking to use the telephone to speak with his/her spouse. At approximately 12:57 PM, the Social Social Director (SSD) took the Resident #21 to his/her office to use the telephone. With the door opened the SSD was observed in the office holding the telephone while the resident was on the telephone receiver engaged in conversation. An interview on 11/16/20 at approximately 1:02 PM with the SSD confirmed the observation revealed he/she often let resident use the telephone in his/office to talk with his/her spouse. The SSD further stated his/her telephone provided access to Telecommunications Device for the Deaf (TDD). An observation on 11/17/20 at approximately 12:25 PM revealed Resident #21 in front of dining room asking to use the telephone. A staff member immediately offered the use of the nursing station telephone for the Resident's use. There were three staff members present and a random resident walking past the nurses' station while the resident was on the telephone. An interview on 11/17/20 at 12:32 PM with Licensed Practical Nurse (LPN) #2 confirmed the observation and revealed there was a telephone for the residents in the day area but it got broken since the pandemic and that's why the resident use the telephone at the nurses' station.

Based on observation and interview, the facility failed to serve food under sanitary conditions for 1 of 4 units, 1 of 1 kitchens, and 2 of 2 steam tables reviewed with the potential to affect 212 of 212 residents with ordered diets as evidenced by failing to remove expired food, calibrate temping probe, and plate food sanitarily. In addition, in the nourishment room on the(NAME)Unit, the refrigerator was observed with orange/yellow spillage and the microwave was observed with dried food particles on the ceiling of the microwave for 1 of 4 nourishment rooms. The findings included: On [DATE] at approximately 10:55 AM, an initial tour of the main kitchen with the Certified Dietary Manager (CDM) revealed in the walk in refrigerator two expired 5 gallon, 25 pound containers of hard boiled eggs; one with an expiration date of [DATE], and the other with an expiration date of [DATE]. In an interview following the observation, the CDM verified the eggs were expired and indicated they should have been removed from storage. On [DATE] at approximately 11:10 AM, an observation of the back line steam table lunch meal temping revealed Cook #1 had a Fahrenheit (F) temping probe placed in ice water that read 40 degrees (F). Cook #1 then removed the probe and attempted to take food temperatures. The surveyor asked the cook, what should a Fahrenheit temping probe be calibrated to in ice water. Cook #1 stated, 60 degrees. On [DATE] at approximately 11:50 AM, an observation of the front line steam table lunch plating with the CDM revealed Dietary Aide #1 donned gloves and touched multiple items away from the line on the shelf of the stove, then returned to the plating line and plated salad and buns with his/her hands without sanitizing hands or changing gloves. In an interview following the observation, the CDM verified Dietary Aide #1 touched multiple items away from the plating table and returned without sanitizing or replacing gloves and proceeded to touch food items with his/her hands and put them on the plates to be served to residents. On [DATE] at 12:30 PM, during an observation on the B-Unit dining room, one Certified Nursing Assistant (CNA) was observed removing bread from a plastic bag with his/her bare hand and placing the bread onto the residents plate. On [DATE] at 11:40 AM, observation of the(NAME)(B) Unit kitchenette revealed food particles on the ceiling of the microwave. Observation of the refrigerator in the kitchenette revealed spillage on the back wall of the refrigerator and discoloration/staining on the back and left wall of the refrigerator. On [DATE] at 10:40 AM, a second observation was made with CNA #1. CNA #1 confirmed the above findings of particles in the microwave, and spillage and staining/discoloration on the back and side wall of the refrigerator. Information related to deep cleaning provided by the facility for the(NAME)Hall revealed each Sunday housekeeping was scheduled to deep clean the nursing station and side rooms. No other information was provided to the facility related to cleaning the kitchenettes.

Based on observations, interview, and review of the facility's policy, the facility failed to dispose of garbage and refuse properly for 3 of 3 refuse containers reviewed for garbage disposal. Trash and grease were not contained in the refuse containers leaving food and debris visible. The findings included: On 5/28/19 at approximately 11:40 AM, an observation of the trash disposal area outside the main kitchen with the Certified Dietary Manager (CDM) revealed one dumpster that was full of garbage and was missing a door exposing the trash inside. Also, the compactor door was open exposing the trash and food debris inside. Furthermore, the grease trap had grease and food debris pooled on the top, spilling down the front and was draining onto the pavement and under the compactor. The CDM verified the trash, food debris and grease were not being contained in their receptacles.

Based on review of facility files, observation, interview, and review of the facility policy titled, Abuse, the facility failed to ensure each resident remained free from abuse. Observation of video of a resident to resident altercation between Resident #31 and Resident #33 revealed staff did not intervene to protect residents from abuse. Staff were noted to intervene and stand between the two residents when Resident #33 was observed to swing at Resident #31 with a utensil. The staff member then walked away and left the residents sitting next to each other unattended and Resident #33 threw coffee on Resident #31. One of thirteen reportable incidents reviewed for resident to resident abuse. The facility failed to ensure Resident #4 was not physically abused by Resident #36 and further failed to ensure Resident #26 was not physically abused by Resident #23 for 4 of 28 residents reviewed for resident to resident abuse and 2 of the 4 residents with multiple allegations of resident to resident abuse. The findings included: The facility reported an allegation of resident to resident abuse involving Resident #31 and Resident #33 to the State Agency on 2/27/19. The facility admitted Resident #33 on 9/26/18 with [DIAGNOSES REDACTED]. The facility admitted Resident #31 on 1/2/19 with [DIAGNOSES REDACTED]. Review of the facility's Five-Day Follow-Up dated 3/1/19 indicated during the breakfast meal Resident #33 was observed suddenly swinging in an attempt to hit Resident #31. Resident #33 did not make contact with Resident #31. Resident #33 simultaneously grabbed a cup of coffee and threw it at Resident #31. The two residents were immediately separated and redirected from incident by staff. The coffee was not hot and no injuries were noted to either resident. Registered Nurse assessments and body audits completed. Resident #33 received an as needed medication for behaviors. Residents will not be seated at the same table for meals. The surveyor requested to view the video of the dining room at the time of the incident. The surveyor viewed the video and noted concerns with staff response to the incident between Resident #33 and Resident #31. The video clip began with Resident #33 sitting in a chair beside Resident #31 and a Certified Nurse Aide (CNA) delivering Resident #33's meal tray to the table. Resident #31 is eating breakfast. The CNA leaves the table and an empty chair pulled up next to Resident #31 is noted. At 8:07 AM Resident #33 drinks his/her glass of juice and places the empty glass on Resident #31's meal tray. Resident #31 continues to eat his/her meal. At 8:08 AM Resident #33 picks up Resident #31's coffee mug and pours the contents onto Resident #31's plate of food. No sound can be heard on the video, but Resident #31 is noted to appear to say something to Resident #33. Resident #33 jabs his/her utensil at Resident #31's right arm. Resident #31 looks down at his/her arm and then around the dining room. Resident #31 picks up his/her coffee mug and lifts it and Resident #33 holds his/her arms up. Two CNAs in the dining room look at the residents at this time. Resident #33 held his/her utensil up aimed at Resident #31 and CNA #17 is noted to approach the table. CNA # 17 is noted to stand between Resident #31 and Resident #33 while the CNA is noted to be eating. CNA #17 then removes Resident #31's plate and walks away to the other side of the dining room leaving the residents unattended. Resident #33 then lifts his/her coffee mug to drink and then throws coffee onto Resident #31. Resident #31 swings at Resident #33 who stands up holding their coffee mug. At this point staff intervene with the residents. The surveyor noted other staff in the dining room passing meal trays during the video. The surveyor noted that the events of Resident #33 swinging to hit Resident #31 and throwing coffee on the resident were not simultaneous. The surveyor did not observe CNA #17 remove a utensil from Resident #33 as stated in an interview with CNA #14. LPN #7's facility-obtained statement dated 2/27/19 indicated s/he was at the medication cart at the door of the dining room. LPN #7 saw Resident #33 swing at Resident #31 that was sitting beside him/her at the dining room table, no words were exchanged. Then Resident #33 grabbed a coffee cup and threw coffee on resident, which landed on Resident #31's chest. Coffee was not hot. Residents were separated. CNA #17's facility-obtained statement dated 2/27/19 indicated Resident #31 was sitting down having his/her breakfast and Resident #33 was sitting next to him/her. Resident #33 was saying something to Resident #31 and Resident #33 swung at Resident #31. Then CNA #17 was standing there in the middle between the two residents. Resident #31 wanted another slice of bread, so CNA #17 went to the food cart to get the bread. When CNA #17 turned around s/he saw Resident #33 throw his/her cup of coffee on Resident #31, so s/he went and parted the two. CNA #14's facility-obtained statement dated 2/27/19 indicated Resident #31 and Resident #33 were sitting at the table eating breakfast. CNA #14 was at another table setting a resident up for breakfast when s/he heard another CNA yell oh no, s/he turned around and saw the CNA getting Resident #31 because Resident #33 threw his/her coffee at Resident #31. CNA #14 and another CNA separated the residents and Resident #33 stepped back and swung his/her fist at CNA #14 when s/he asked him/her to please sit down. In an interview with the surveyor on 3/20/19 at approximately 4:40 PM, CNA #17 stated s/he works on the (Name of Unit). CNA #17 stated Resident #31 likes to get up, doesn't like anyone to get in his/her space. Resident #31 likes to try to fix things, will take things apart and put back together. CNA #17 stated s/he was in the back-dining room and was passing out trays. CNA #17 stated s/he was 1:1 with Resident #31 and s/he was passing out trays. Resident #31 was trying to eat and wanted another piece of toast. Resident #33 was saying something to Resident #31, CNA #17 could not hear what the resident said. Resident #31 was reaching over touching Resident #33's tray. CNA #17 went to get another piece of bread from the food cart, and as s/he was returning to the table Resident #33 threw his/her coffee on Resident #31. The surveyor asked CNA #17 and s/he confirmed the statement that s/he left the residents and went to the food cart to get the bread. In an interview with the surveyor on 3/20/19 at approximately 4:55 PM, CNA #14 stated s/he was in the dining room feeding another resident, behind the table where Resident #33 was sitting. Resident #33 sometimes gets upset, believes that this is his/her building. Resident #33 feels s/he can tell residents where they can sit, if they can sit at his/her table. Resident #31 was sitting at the table with Resident #33 and both residents were eating breakfast. CNA #14 stated s/he did not know what made Resident #33 flip, first Resident #33 tried to poke Resident #31 with a fork and CNA #17 stopped him/her. Everything was fine and then they had another incident. CNA #14 is not sure what happened, s/he heard a CNA yell oh no so everyone jumped up and went to the table. Resident #33 was trying to get at Resident #31, CNA #14 got between both of them and Resident #33 swung at him/her. CNA #17 took Resident #33's fork away and told him/her to eat with a spoon after the resident tried to poke Resident #31. CNA #17 was coming up to the residents when s/he turned around. Resident #33 has his/her days, the resident will set on somebody on some days and focus on them. In an interview with the surveyor on 3/21/19 at approximately 4:20 PM, the Interim DON stated 1:1 is a person assigned to provide attention to the resident, so they are available to meet and anticipate the resident's needs. They don't have to be within arms' reach but are accountable for them throughout the shift. The Interim DON stated Resident #31 has been on 1:1 since admission, when Resident #31 was admitted s/he displayed behaviors that would be a trigger for others. The Interim DON stated there had never been an issue between Resident #31 and Resident #33 before. Resident #33 left the building two days after the incident and went out for a psychiatric evaluation. Resident #33 hit a staff member who was assigned 1:1 to the resident because Resident #33 said s/he didn't like someone following him/her around all the time. In an interview with the surveyor on 3/22/19 at approximately 10:20 AM, Social Worker #2 stated s/he has only heard of a couple of incidents involving Resident #33. Resident #33 threw water and coffee on residents. Resident #33 is not on 1:1. Resident was put on 1:1 on (MONTH) 27th at 7:30 PM after a second incident with another resident. On (MONTH) 28th the resident was having a really bad, Resident #33 was agitated with the 1:1 staring at him/her. The following day is when Resident #33 went after the 1:1 staff member. Resident #33 pushed the staff member against the door, punched him/her in the stomach, and attempted to stab him/her with a pen. Resident #33 was sent out to the hospital and then sent to (Name of Hospital) for an IOP assessment. Resident #33 has been okay since s/he returned from the hospital. They have given Resident #33 different activities to do and s/he is doing better with that. They did a lot of medication changes when Resident #33 came back from the hospital. In an interview with the surveyor on 3/21/19 at approximately 3:15 PM, the facility Administrator stated s/he had not started working at the facility at the time of the incident between Resident #31 and Resident #33 on 2/27/19. The administrator viewed the video of the incident with the surveyor. When asked if staff should have intervened and separated residents when they witnessed Resident #33 attempt to hit Resident #31 with his/her fork, the administrator stated s/he felt staff had responded appropriately to the situation. The administrator felt the CNA who stood between the residents and left with Resident #31's meal was just trying to get the resident a new one. When asked if the CNA should have summoned another staff member to assist with replacing the resident's meal, the administrator responded s/he could have but again the administrator felt staff responded appropriately to the situation. When asked if the CNA who was assigned 1:1 to Resident #31 should have been with the resident, the administrator stated s/he could not answer that. The administrator stated, staff were doing the right thing, but the timing was wrong to witness the interactions between the two residents. The facility admitted Resident #4 on 11/3/2017 with [DIAGNOSES REDACTED]. Review on 3/20/2019 at approximately 3:34 PM of the medical record for Resident #4 revealed multiple resident to resident altercations that he/she was involved with no new interventions to prevent resident to resident altercations. Further review on 3/20/2019 at approximately 3:34 PM of the medical record for Resident #4 revealed a resident to resident altercation between Resident #4 and Resident #36. The facility admitted Resident #36 on 1/20/2015 with [DIAGNOSES REDACTED]. Review on 3/20/2019 at approximately 3:40 PM of the medical record for Resident #36 revealed an altercation with Resident #4 in which Resident #36 hit Resident #4 on the back of his/her left hand with a marker and Resident #4 obtained a skin tear. Review on 3/20/2019 at approximately 3:45 PM of the Summary Report of the Facility Investigation, states, Resident #4 has a Brief Interview of Mental Status (BIMS) of 6 out of 15. Resident #4 was sitting in the day room and went to leave from where he/she was sitting. Resident #36 with a BIMS of 15 out of 15, was in the pathway of Resident #4. Both residents began yelling at one another. Resident #4, using a rollator tried to go past Resident #36 who was in a wheel chair, Resident #36 grabbed onto Resident #4's rollator and they were pushing it back and forth. Resident #4 began swinging at Resident #36 who also swung back. Resident #4 did not make contact but Resident #36, while holding a marker with a closed hand, hit Resident #4 on the top of his/her left hand. Resident #4 obtained a 1-centimeter (cm) x 1 cm skin tear to the back of his/her left hand. Both residents were separated and redirected by staff. The Registered Nurse completed an assessment on both residents. Both residents refused complete body audits, but nursing staff was able to visualize the small skin tear to Resident #4's left hand. Resident #4 did allow staff to initiate a treatment to the skin tear on his/her left hand. The physician, director of nursing, the administrator and the personal representative were made aware. Local law enforcement were notified. Following a thorough investigation, to include staff interviews, the facility substantiates a resident to resident altercation witnessed by staff. An interview on 3/21/2019 at approximately 11:30 AM with Certified Nursing Assistant (CNA) #1, a Unit Secretary, and Licensed Practical Nurse #1 and #2 confirmed witness of the altercation. The CNA, Unit Secretary, and Licensed Practical Nurse #1 and #2 verified that Resident #36 hit Resident #4 with a marker and caused a skin tear to his/her left hand following an argument between both residents. The facility admitted Resident #15 on 9/15/2017 with [DIAGNOSES REDACTED]. The facility admitted Resident #26 on 10/2/2017 with [DIAGNOSES REDACTED]. Review on 3/21/2019 at approximately 1:35 PM of the medical record for Resident #15 and Resident #26 revealed a resident to resident altercation in which Resident #15 approached Resident #26 and deliberately stepped on his/her right foot. No injuries were documented. Residents were immediately separated and redirected by staff. It was determined that Resident #15 believed that Resident #26 was wearing his/her clothes. Resident #15 was documented as initiating and or involved in multiple resident to resident altercations with no new interventions to prevent resident to resident altercations. Review on 3/21/2019 at approximately 1:45 PM of the statements from CNA #2 and LPN #3 confirmed the altercation and no injuries. Review on 3/21/2019 at approximately 2:08 PM of the facility policy titled, Abuse, and under Purpose states, To identify, Prohibit and prevent resident abuse. Under Procedure number 1. states, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Number 2. states, Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, resident representatives, friends and other individuals. Number 3 states, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidations, or punishment with resulting physical harm, pain or mental anguish. Willful: The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on review of facility files, observation, and interview, the facility failed to implement a comprehensive person-centered care plan for each resident. Review of Resident #31's care plan for behavior problems revealed interventions included 1:1 staff observations. The facility failed to ensure 1:1 staff observation was maintained. Resident #31 was involved in resident to resident physical abuse with Resident #33 and there was no staff member maintaining 1:1 observation of the resident at the time of the incident. One of twenty-six residents care plans reviewed for behaviors. The facility failed to ensure a Comprehensive Plan of Care was followed for Resident #25 related to a physician's orders [REDACTED]. The findings included: The facility reported an allegation of resident to resident abuse involving Resident #31 and Resident #33 to the State Agency on 2/27/19. The facility admitted Resident #33 on 9/26/18 with [DIAGNOSES REDACTED]. The facility admitted Resident #31 on 1/2/19 with [DIAGNOSES REDACTED]. Review of Resident #31's Smart Chart Tasks revealed 1:1 observation with a problem onset date of 1/2/19. Review of Resident #31's Care Plan revealed resident is at risk for exhibiting numerous mood and behavior problems (verbal abuse, combativeness, anxiety, intrusiveness, puts items in mouth, etc.) secondary to Alzheimer's and [MEDICAL CONDITION] with a problem onset dated of 1/2/19. On 1/10/19 it was noted the resident was on the Behavior Management Program and resident to be on 1:1 staff observations. The surveyor requested to view the video of the dining room at the time of the incident. The surveyor viewed the video and noted concerns with staff response to the incident between Resident #33 and Resident #31. The video clip began with Resident #33 sitting in a chair beside Resident #31 and a Certified Nurse Aide (CNA) delivering Resident #33's meal tray to the table. Resident #31 is eating breakfast. The CNA leaves the table and an empty chair pulled up next to Resident #31 is noted. At 8:07 AM Resident #33 drinks his/her glass of juice and places the empty glass on Resident #31's meal tray. Resident #31 continues to eat his/her meal. At 8:08 AM Resident #33 picks up Resident #31's coffee mug and pours the contents onto Resident #31's plate of food. No sound can be heard on the video, but Resident #31 is noted to appear to say something to Resident #33. Resident #33 jabs his/her utensil at Resident #31's right arm. Resident #31 looks down at his/her arm and then around the dining room. Resident #31 picks up his/her coffee mug and lifts it and Resident #33 holds his/her arms up. Two CNAs in the dining room look at the residents at this time. Resident #33 held his/her utensil up aimed at Resident #31 and CNA #17 is noted to approach the table. CNA # 17 is noted to stand between Resident #31 and Resident #33 while the CNA is noted to be eating. CNA #17 then removes Resident #31's plate and walks away to the other side of the dining room leaving the residents unattended. Resident #33 then lifts his/her coffee mug to drink and then throws coffee onto Resident #31. Resident #31 swings at Resident #33 who stands up holding their coffee mug. At this point staff intervene with the residents. The surveyor noted other staff in the dining room passing meal trays during the video. The surveyor noted that the events of Resident #33 swinging to hit Resident #31 and throwing coffee on the resident were not simultaneous. The surveyor did not observe CNA #17 remove a utensil from Resident #33 as stated in an interview with CNA #14. In an interview with the surveyor on 3/20/19 at approximately 4:40 PM, CNA #17 stated s/he was in the back-dining room and was passing out trays at the time of the incident. CNA #17 stated s/he was 1:1 with Resident #31 and s/he was passing out trays. Resident #31 was trying to eat and wanted another piece of toast. Resident #33 was saying something to Resident #31, CNA #17 could not hear what the resident said. Resident #31 was reaching over touching Resident #33's tray. CNA #17 went to get another piece of bread from the food cart, and as s/he was returning to the table Resident #33 threw his/her coffee on Resident #31. The surveyor asked CNA #17 and s/he confirmed the statement that s/he left the residents and went to the food cart to get the bread. In an interview with surveyor on 3/21/19 at approximately 3:55 PM, the Unit Manager on (Name of Unit) stated that Resident #31 is on 1:1 because s/he is so compulsive. Resident #31 does not understand respecting other people's personal space. CNAs on 1:1 are not to help with other task, they are to stay with the resident at all times. CNAs should be no more than an arms' length away from a resident on 1:1. The Unit Manager stated Resident #31 has to be watched closely especially in common areas like the dayroom. The facility admitted Resident #25 on 12/3/2015 with [DIAGNOSES REDACTED]. An observation on 3/18/2019 at approximately 3:00 PM of the metal bed rails on Resident #25's bed revealed no padding but use of a scoop mattress. Resident #25 was documented as turning on to his/her left side and hugging the metal bed rail. A second observation on 3/19/2019 at approximately 10:00 AM revealed no padded side rails on the bed of Resident #25. During an interview on 3/19/2019 at approximately 10:05 AM with Licensed Practical Nurse (LPN) #4 s/he confirmed that no padding was affixed to the metal side rails of Resident #25's bed and had not been used on his/her bed even though they were ordered by the physician on 1/17/2019. This surveyor asked LPN #4, why padded side rails were not used on the metal side rails for Resident #25 LPN #4 stated, I guess they never thought about it. Review on 3/19/2019 at approximately 10:30 AM of the physician's orders [REDACTED]. The padding was never applied to the side rails as ordered. Review on 3/19/2019 at approximately 2:39 PM of the Comprehensive Plan of Care for Resident #25 included a Problem Onset dated 5/21/2017 which states, At risk for skin tears and/or bruising related to resident has thin fragile skin. A problem onset of 1/16/2019 states, Resident has left side chest area bruising. The goal states, Resident will not have complications from skin tears and/or bruising through next review date. An approach/intervention was added on 1/17/2019 and stated, Padded side rails as ordered. An observation on 3/20/2019 at approximately 1:15 PM revealed padded side rails in use on the bed of Resident #25. An interview on 3/20/2019 at approximately 1:15 PM with CNA #3 confirmed that the padding for the side rails was applied on 3/20/2019 and was not applied before 3/20/2019.

Based on review of facility files, observation, and interview, the facility failed to ensure each resident received adequate supervision to prevent accidents. Resident #31 was assigned a 1:1 staff member related to resident behaviors. The resident was involved in a resident to resident abuse incident on 2/27/19 and no staff was maintaining 1:1 observation of the resident. The facility did not have policies or education for staff related expectation of 1:1 observation of residents. One of one resident reviewed for 1:1 observation. The findings included: The facility reported an allegation of resident to resident abuse involving Resident #31 and Resident #33 to the State Agency on 2/27/19. Review of the Staff Assignment Sheet for 2/27/19 revealed Resident #31 was assigned a 1:1 CNA. Review of Resident #31's Smart Chart Tasks revealed 1:1 observation with a problem onset date of 1/2/19. Review of Resident #31's Care Plan revealed resident is at risk for exhibiting numerous mood and behavior problems (verbal abuse, combativeness, anxiety, intrusiveness, puts items in mouth, etc.) secondary to Alzheimer's and [MEDICAL CONDITION] with a problem onset dated of 1/2/19. On 1/10/19 it was noted the resident was on the Behavior Management Program and resident to be on 1:1 staff observation. The surveyor requested to view the video of the dining room at the time of the incident. The video was provided on 3/21/19 at 2:37 PM. The surveyor viewed the video and noted concerns with staff response to the incident between Resident #33 and Resident #31. The video clip began with Resident #33 sitting in a chair beside Resident #31 and a Certified Nurse Aide (CNA) delivering Resident #33's meal tray to the table. Resident #31 is eating breakfast. The CNA leaves the table and an empty chair pulled up next to Resident #31 is noted. At 8:07 AM Resident #33 drinks his/her glass of juice and places the empty glass on Resident #31's meal tray. Resident #31 continues to eat his/her meal. At 8:08 AM Resident #33 picks up Resident #31's coffee mug and pours the contents onto Resident #31's plate of food. No sound can be heard on the video, but Resident #31 is noted to appear to say something to Resident #33. Resident #33 jabs his/her utensil at Resident #31's right arm. Resident #31 looks down at his/her arm and then around the dining room. Resident #31 picks up his/her coffee mug and lifts it and Resident #33 holds his/her arms up. Two CNAs in the dining room look at the residents at this time. Resident #33 hold his/her utensil up aimed at Resident #31 and CNA #17 is noted to approach the table. CNA #17 is noted to stand between Resident #31 and Resident #33 while the CNA is noted to be eating. CNA #17 then removes Resident #31's plate and walks away to the other side of the dining room leaving the residents unattended. Resident #33 then lifts his/her coffee mug to drink and then throws coffee onto Resident #31. Resident #31 swings at Resident #33 who stands up holding their coffee mug. At this point staff intervene with the residents. The surveyor noted other staff in the dining room passing meal trays. In an interview with the surveyor on 3/20/19 at approximately 4:40 PM, CNA #17's stated s/he was in the back-dining room and was passing out trays at the time of the incident. CNA #17 stated s/he was 1:1 with Resident #31 and s/he was passing out trays. CNA #17 went to get another piece of bread from the food cart, and as s/he was returning to the table Resident #33 threw his/her coffee on Resident #31. The surveyor asked CNA #17 and s/he confirmed the statement that s/he left the residents and went to the food cart to get the bread. In an interview with the surveyor on 3/20/19 at approximately 4:55 PM, CNA #14 stated s/he was in the dining room feeding another resident, behind the table where Resident #33 was sitting. CNA #14 stated Resident #33 first tried to poke Resident #31 with a fork and CNA #17 stopped him/her. Everything was fine and then they had another incident. CNA #14 is not sure what happened, s/he heard a CNA yell oh no so everyone jumped up and went to the table. Resident #33 was trying to get at Resident #31, CNA #14 got between both of them and Resident #33 swung at him/her. CNA #17 took Resident #33's fork away and told him/her to eat with a spoon after the resident tried to poke Resident #31. CNA #17 was coming up to the residents when s/he turned around. In an interview with the surveyor on 3/21/19 at approximately 4:20 PM, the Interim DON stated 1:1 is a person assigned to provide attention to the resident, so they are available to meet and anticipate the resident's needs. They don't have to be within arms' reach but are accountable for them throughout the shift. The Interim DON stated Resident #31 has been on 1:1 since admission, when s/he was admitted s/he displayed behaviors that would be a trigger for others. Resident #31 is very intrusive, very fidgety, s/he is very mobile. They wanted to make sure they could keep Resident #31 occupied. In an interview with the surveyor on 3/21/19 at approximately 5:15 PM, CNA #12 stated 1:1 is to make sure the residents don't harm themselves or others. They keep the residents occupied so they don't get in confrontations with other residents. CNA #12 stated staff have to be in arm's reach from resident at all times. In an interview with the surveyor on 3/21/19 at approximately 5:25 PM, the facility administrator stated they do not have a policy on 1:1 or any staff training. 1:1 can mean different things depending on the resident. The surveyor asked where that information would be documented so staff would know what it means for the resident assigned 1:1 and s/he stated, it isn't documented anywhere. In an interview with the surveyor on 3/21/19 at approximately 3:15 PM, the facility Administrator stated s/he had not started working at the facility at the time of the incident between Resident #31 and Resident #33 on 2/27/19. When asked if the CNA who was assigned 1:1 to Resident #31 should have been with the resident, the administrator stated s/he could not answer that. The administrator stated, staff were doing the right thing but the timing was wrong to witness the interactions between the two residents. In an interview with surveyor on 3/21/19 at approximately 3:55 PM, the Unit Manager on (Name of Unit) stated that Resident #31 is on 1:1 because s/he is so compulsive. Resident #31 does not understand respecting other people's personal space. CNAs on 1:1 are not to help with other task, they are to stay with the resident at all times. CNAs should be no more than an arms' length away from a resident on 1:1. The Unit Manager stated Resident #31 has to be watched closely especially in common areas like the dayroom.

Based on review of facility files and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the survey, surveyors reviewed 16 reportable incidents. Review of the facility's investigative files for those incidents revealed the incidents were not thoroughly investigated. The findings included: Cross refer to CMS 2567 F0607, F0610 and F0842 related to concerns identified related to the facility not thoroughly investigating allegations of abuse. Review of facility investigative files revealed that allegations were not thoroughly investigated. There were allegations that did not contain staff statements that were assigned to the unit at the time of incident and may have knowledge of the incident. Staff statements that were obtained did not contain enough information to know what happened for incidents that were witnessed by staff. The investigation summaries and notes within the medical records do not contain an accurate representation of the actual experiences of the resident and resident outcomes. During an interview with the facility Administrator on 12/13/18 at approximately 6:15 PM, the Administrator stated the facility staff have been taught that anything they document needs to be factual. The Administrator stated the Staff should be objective in documentation, some words could be subjective. The Administrator stated that Punch would be subjective, slap would be subjective. The administrator stated that If you have an open hand and make contact that is more descriptive than strike or slap. The administrator stated s/he generally reviews every 24 hour report and 5 day. During the interview the surveyor asked the Administrator how do you know when touch is documented if it is a friendly touch or a slap which is defined as abuse in the facility abuse policy? The Administrator stated that if staff witnesses an event, if they document touch or contact s/he would not clarify the velocity with witch that touch was made. The Administrator stated that the velocity of the touch would vary based on how fast the resident's hand/closed hand came in contact with the other resident. The facility policy on abuse stated, Physical abuse-- Includes but is not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. On (MONTH) 12, (YEAR) at approximately 10:40 AM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0835 at a scope and severity of [MI] The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on (MONTH) 25, (YEAR) and is ongoing.

Based on review of facility files and interviews, the facility failed to have a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. Review of 16 reportable incidents revealed allegations of abuse were not thoroughly investigated. Review of staff statements related to the incidents did not provide detail about the incidents. The findings included: Cross refer to CMS 2567 F0607, F0610 and F0842 related to concerns identified related to the facility not thoroughly investigating allegations of abuse. Also, cross refer to CMS 2567 F 835 related to administration of the facility regarding documentation of incidents that occurred at the facility. Review of Registered Nurse (RN) #1's employee file revealed a One on One In-Service education sheet dated 7/12/18 by Instructor RN #2 related to Nursing Documentation. Under the topic to discussed section see attached was indicated. The attachment titled Nursing Documentation revealed Nurse's notes are not the place to put a summary of your thoughts, opinions, or judgements of a resident and their medical status or condition. You should not be placing recommendations for care in the nurse's notes. Nurse's notes should capture what you actually saw, what you did, and the resident's response. Notes should not include hard words such as hit, punched, shoved, etc. They should include soft words such as touched or made contact with. Please understand that while your opinions and observations may be helpful in providing care to our residents and we would like to be made aware of your findings, the nurse's notes are not the appropriate place to communicate this type of information. Notification via phone call to the nursing supervisor or by listing it on the 24 hour report is sufficient. Review of the facility's Abuse Policy revealed physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. In an interview with the surveyor on 12/13/18 at approximately 10:55 AM, RN #1 stated the facility wants staff to do soft documentation. During a telephone interview on 12/14/18 at approximately 10:25 AM RN #2 stated s/he is an RN Supervisor, s/he just changed to that role in (MONTH) (YEAR). RN #2 was the Quality Assurance/Infection Control nurse in (MONTH) (YEAR) when s/he completed the education with RN #1. RN #2 was assisting with the ADON (Assistant Director of Nursing), their DON (Director of Nursing) left and the ADON was filling in and RN #2 was helping. RN #2 was providing education to help at the time. RN #2 stated the information related to how to document came from the acting DON who is now the DON. RN #2 stated it was a corporate thing. Corporate wanted RN #1 educated because his/her documentation gave a lot of opinions. RN #1 would document why residents were having behaviors, that type of thing. Corporate asked the current DON to educate RN #1 on his/her documentation and the DON asked RN #2 if s/he would do it. The DON asked RN #2 to type something up on appropriate documentation. RN #2 stated it was explained to RN #1 that documentation should not be subjective, s/he may interpret it as a slap but someone else may not. RN #2 stated that when they talk with families they don't want to mislead them. They inform them that contact was made. It could be hard slap or a light touch, they don't want it to be misconstrued. They describe how the hand was, not that it was a punch. They can't describe if something is hard or soft. They are instructed to use made contact with and where the contact was made. RN #2 stated the DON is who talked with him/her about that and that it came down from corporate. RN #2 stated Corporate told them they need to document using that language. RN #2 stated s/he knows since (MONTH) (YEAR). S/he started in (MONTH) (YEAR) and it started sometime after that. RN #2 stated when s/he notifies a family about an incident s/he uses the same language that the resident was touched or came in contact with someone. During an interview on 12/12/18 at approximately 2:10 PM, the Administrator, Nurse Consultant, and DON were all present for interview. They stated that the statements in the investigative files that were provided to the surveyors are all the statements they have related to the investigated incidents. The Nurse Consultant stated s/he does not understand what is wrong with the investigations. The surveyor provided the investigative file information on one of the reportable incidents. When asked to review and describe what happened based on the information provided, the Nurse Consultant stated s/he would have to talk to the nurse to see what actually happened related to the incident. The Nurse Consultant stated s/he could not say what type of contact was made based on the information provided in the investigative file. During the interview the Nurse Consultant stated the Vice President of Clinical was the person responsible for the wording used in staff statements describing incidents. The surveyor asked about the reference to using soft language and not hard language in the education provided to RN #1. The Nurse Consultant stated the Vice President of Clinical provided the instruction on what language to use in statements and nurses' notes. During an interview on 12/13/18 at approximately 5:10 PM, the DON stated s/he has been DON for almost 6 months. The DON stated s/he is responsible for the [MEDICATION NAME], once there is an allegation of abuse the nurse supervisors call and notify him/her immediately. If an incident occurs during the week, they discuss it in clinical rounds the next morning. If an incident occurs on a weekend, the DON comes in and the nurse supervisors bring him/her the statements, incident reports, everything they have collected and s/he does the 24 hour report. The DON stated that they have 5 days to complete the investigations - on the 5th day the DON reviews everything they have and completes documentation for certification and licensure reports. The DON stated the nurse supervisors obtain the statements at the time of the incident. The DON stated they have supervisor meetings and annual training on abuse and reporting. The DON stated s/he reviews the statements, the incident report, and anything in the nurses' notes, that way s/he has some idea of what went on. The DON stated that if s/he has a question, if something was not clear, s/he would talk to the staff member or supervisor for additional information. The DON stated the 24 hour reports contain the same documentation as what is provided in statements, nurses' notes, and incident reports. The DON stated when a reportable event occurs the nurse supervisors contact both the DON and the Administrator. The DON stated staff are trained to document what they see and what they hear. The DON stated they are instructed on how to document at orientation. The DON stated s/he has never talked with the nurses about using soft documentation. The DON stated s/he knew RN #1 was educated to document using soft language in documentation. The DON then stated RN #1 was instructed to use soft language because s/he was not documenting the way they were instructed. RN #1 was using words that s/he should not use, s/he wrote profanity in the chart if that is the language a resident used. The DON stated s/he could say someone touched someone and it not be a slap. The DON stated s/he could say someone touched someone with a closed hand and it not be a punch. The DON stated s/he feels that the words punch and slap are opinions. The DON stated opinions should not be documented. The surveyor asked about hitting and kicking as described as physical behaviors in the resident's Minimum Data Set information, and why they are not documented that way in the nurses' notes. The DON stated they are trained to use words such as touch, lay hands on during orientation. During an interview on 12/13/18 at approximately 5:40 PM, the Nurse Consultant stated s/he would have to ask the DON about how staff are instructed to document. The Nurse Consultant stated s/he reviews some [MEDICATION NAME] when s/he visits the facility. The Nurse Consultant stated s/he would instruct staff to document what they see. The Nurse Consultant stated that s/he feels that the word slap would be an opinion and not fact. The Nurse Consultant stated that staff are instructed to document facts and not opinions. On (MONTH) 12, (YEAR) at approximately 10:40 AM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0837 at a scope and severity of [MI] The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on (MONTH) 25, (YEAR) and is ongoing.

Based on record review, review of facility files and interviews, the facility failed to maintain medical records that were complete and accurately documented. Medical Record Documentation was misleading and unclear for 18 of 18 medical records reviewed for reportable incidents. Physical contact was described in incidents as touched, came in contact with, open hand or closed hand. The investigation summaries and notes within the medical records did not contain complete and accurate representation of the actual experiences of the residents. Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17 and #18. The findings included: The facility admitted Resident #14 on 2/13/18 with [DIAGNOSES REDACTED]. Review of the Facility Investigation for Resident #14 dated 9/27/18 revealed Resident reported to staff a Certified Nursing Assistant (CNA) had touched him/her with closed hands in his/her stomach. Resident with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Review of the 5 day report for Resident #14 revealed the Resident's statement dated 9/27/18 stated, Resident stated that on Monday, 9/24/18, after midnight, girl (meaning CNA) came in her/his room and tried to take her/his clothes off. S/He said that s/he told her (CNA) to leave her/him alone because s/he had already had a shower and her/his clothes were clean. S/He said, that girl got mad and hit her/him in the stomach. Girl then went to check on her/his roommate and that was the last time s/he saw her that night. S/He then said the same girl gave her/him a shower today. Licensed Practical Nurse (LPN) #4 wrote a statement dated 9/27/18 which stated Resident #14 told her/him, the CNA hit the resident all over her/his body. The nurse looked her/him over and found no discolorations or marks on the resident. The investigation did not include who the CNA was who had been suspended. The 5 day Report Form stated the alleged perpetrator was CNA #4. CNA #4 had given a statement dated 9/27/18. CNA #4 stated s/he did not work on 9/24/18 on the 11/7 shift. S/he worked on the 7-3 shift on another unit and had no knowledge of the alleged accusation. The facility investigation for Resident #14 failed to show time cards or staff assignments to show who had worked at the time of the alleged incident in order to determine if abuse actually accrued. Review of the facility investigation for Resident #14 dated 10/27/18 revealed Resident #14 with a BIMS score of 3 stated to nurse that one of the CNAs beat up her/his roommate last night then came over and hit her/him. Resident #14 reports s/he does not know the name and is scared to get anyone in trouble. RN (Registered Nurse) assessment completed. Resident interviewed by RN supervisor and reports that s/he heard a large female getting rough with her/his roommate. Resident reports s/he saw the CNA tossing the roommate around and when s/he said something to the CNA, s/he pushed on Resident #14's stomach region with an open hand. Completion of investigation was unsubstantiated. The CNA in question was providing incontinent care to the roommate per staff statements when the resident went into the room. The report failed to identify the CNA in question. Statements were obtained from nurses and CNAs. LPN (Licensed Practical Nurse) #5 gave a statement dated 10/27/18. .S/He (Resident #14) said to me one of the CNA's beat up my roommate last night then came over and hit me. S/He started to cry. I am scared I will get into trouble . The CNAs stated they were unaware of any incident. There was no statement from a CNA which stated the roommate was being provided incontinent care. The facility investigation for Resident #14 failed to identify the CNA assigned to the resident or her/his roommate. In addition, the facility investigation failed to show time cards or staff assignments to show who had worked at the time of the alleged incident in order to determine if abuse actually accrued. Review of Resident #14's Departmental Notes from 8/1/18 through 11/29/18 revealed the facility failed to document resident #14's complaints of being hit or roommate beat up by CNA. Review of the facility investigation for Resident #16 and Resident #15 dated 9/26/18 revealed a summary report of the facility's investigation. Staff alerted to room ___ by a loud noise. Staff observed Resident #15 making contact with Resident #16's neck with an open hand and contact with her/his chest with a closed hand Resident #16 was noted to have red marks on her/his neck. Upon completion of facility investigation no intent to harm was found related to cognitive impairment of both residents Staff will continue to intervene as needed. Review of witness statements revealed a statement from LPN #6 dated 9/26/18. Heard yelling coming out of room___, this nurse ran into room and observed Resident #15 with a closed hand around another resident (resident #16) throat and s/he was on top of her/him in Resident #16's bed. Had to call resident's name several times before we could separate them. A statement was obtained from CNA #5, dated 9/26/18. The CNA stated s/he had heard yelling in resident room. CNA entered resident room and saw Resident #15 standing beside bed of Resident #16 while Resident #16 was lying in the bed. Resident #15 had open hand to Resident #16's neck and closed hand in contact with the chest. CNA separated residents and alerted nurse. The facility admitted Resident #16 on 5/7/18 with [DIAGNOSES REDACTED]. Review of Departmental Notes from 8/2/18 through 12/8/18 for Resident #16 revealed: 9/26/18 Around 8:15 pm yelling was heard coming from resident's room, went in to see what was going on and observed a resident on top of this resident holding her/him with a closed hand around her/his neck. Took several minutes to separate residents. Got other resident out of room. Assessed this resident for injuries, s/he did have some redness noted to his/her neck on the right side. No more injuries noted. The facility admitted resident #15 on 4/12/16 with [DIAGNOSES REDACTED]. Review of Resident #15's Departmental Notes from 8/1/18 through 12/10/18 revealed: 9/26/18: Around 8:15 PM nurse heard yelling coming from room ___. Nurse went in to see what was going on and observed resident on top of another resident, holding her/him with a closed hand around resident's neck. Tried for several minutes to separate residents. Once separated, got resident out of room and assessed him/her for injuries, none found. 11:52 PM (late entry of supervisor) Resident was unable to state what happened due to baseline dementia. Body assessment completed, no apparent injuries noted. 9/27/18: Pharmacy Note: Resident had altercation with another resident last night. Unclear if something triggered this. Resident is not prone to behaviors and none have been documented for several months. Will review him/her in PMT for 4 weeks. No irregularities noted on MRR. No recommendations. 11/7/18: Notified by CNA that resident had been verbally and physically approached by another resident. Per witness this resident in return made contact to other resident, altercation not witnessed by this nurse. 11/17/18 Another resident became agitated in the dayroom. Resident became more aggressive making physical contact with open hands to nursing staff. Resident #15 noted physical contact and intervened by asking other resident to stop and then made contact with open hands causing other resident to fall to floor. Resident easily redirected. The Facility Investigation for Resident #16 and Resident #15 failed to contain an accurate representation of the incident dated 9/26/18. The facility report stated no harm was intended, but witness statements contained in the report stated that Resident #15 had hand over throat and was on top of Resident #16 in the bed. The facility investigation for Resident #16 and Resident #15 failed to provide evidence that Resident #15 had been removed from the room by the CNA and then returned for the nurse to find Resident #15 on top of Resident #16. The facility investigation did not clarify whether the resident was being choked, or held down by the throat nor if the resident was pressing against the resident's chest with a closed hand or if the resident was being punched in the chest with a fist. Review of the facility investigation for Resident #18 for injury of unknown origin revealed on 8/27/18 at time of x-ray results. PT (Physical Therapy) alerted staff that resident was unable to bear weight during her/his restorative program, RN assessment and body audit were completed. Resident had pain with ROM (range of motion). X-ray of right hip revealed acute right femoral fracture. Bedrest, pain meds. Statements obtained. CNA #6's interview dated 8/27/18 revealed I noticed the resident was in pain. I assisted in helping x-ray technician get x-ray of hip and then was informed to leave in bed. Resident did resist a little during x-ray and brief change. CNA # 7 statement dated 8/27/18 revealed I took care of the resident two days prior. S/He was guarding her/his right hip during ADL care. I informed the nurse that the resident was not acting right. During an interview on 12/13/18 at 9:30 AM CNA # 6 stated that on 8/27/18 After I came back from a 2 day break I noted Resident #18 was in pain. I reported to the nurse. I assisted tech to get x-ray. S/He resisted the x-ray. S/He could not communicate. It was a facial expression and grunting. I just said s/he seemed to be in pain. I didn't know it was coming from her/his hip. Additional information provided included Incident Report of 8/27/18. Narrative: Alerted by PT staff that resident unable to bear weight to right leg. Upon ROM assessment, resident screamed in agony. Hip x-ray in place, bed fast and pain med prn. Will monitor. Review of Resident #18's Departmental Notes from 8/1/18 through 9/29/18 revealed. On 8/4/18 resident was noted on the floor on his/her left side with wheelchair turned over on side. Resident denied acute pain. Assisted back to wheelchair by staff. No moaning or grimacing noted. 12:26 PM. Resident fought during body audit. No notable skin changes. 8/7/18 No distress noted. Active in seat of chair. Propelling self with feet, neurochecks wnl (within normal limits). 8/27/18 2:20 PM Was informed by PT that resident was having difficulty bearing weight to Right leg today. Upon assessment noted resident in gerichair in room resting. When performing Range of Motion (ROM) resident guarded R (right) leg and moaned. Dr. aware and x-ray ordered to right hip to r/o (rule out) fracture. 6:17 PM Late Entry for 1701 on 8/27/18. Dr. telephoned and stated saw x-ray and appears to have a possible R [MEDICAL CONDITION]. New orders received for bedrest and pain management. 6:19 PM Alerted by PT staff that resident unable to bear weight to right leg upon ROM assessment res. (resident) screamed in agony, hip x-ray taken [MEDICATION NAME] 50 mg (milligrams) po (by mouth) tid (three times a day) prn (as needed). There was no evidence that the facility investigation was completed as to how Resident #18 may have obtained the fracture. The facility investigation did not include any further investigation into CNA #7's statement of the resident guarding his/her hip 2 days prior to the identified incident, and reported to nurse. In addition, the facility investigation failed to identify the nurse that CNA #7 reported to and failed to include any statements from that nurse related to the incident. Additional information provided by the facility to the surveyor related to the facility's investigation did not include Resident #18's x-ray report. Review of the facility investigation for Resident #17 for injury of unknown origin dated 8/25/18 revealed Resident with laceration to left side of nose. Resident sent to hospital for treatment and evaluation. X-ray report revealed non-displaced fracture of nose. Padded siderails were added to bed. Resident's nails were trimmed and filed. Neurochecks and O2 sats initiated. Pain management. Care Plan updated. Resident with BIMS of 5 and able to reposition self in bed. Padded siderails added to bed for protection when repositioning in the bed. Care Plan updated. 5 statements obtained, dated 8/25/18. All with no knowledge of any incident. Review of Resident #17's Departmental notes from 8/1/18 to 10/26/18. On 8/22/18 9:54 AM Late Entry 7AM notified that resident was found sitting on the floor. No noted injuries. On 8/25/18 at 2:45 am this resident was noted to have a nose bleed, when assessed closer to find a laceration on the left side of the nose near the center. Area cleansed with normal saline (NS). Skin prep applied to surrounding area, then steri-strips, applied, Supervisor notified. Will continue to monitor. 5:06 AM Supervisor informed by floor nurse that this resident was noted with a small laceration to her/his left nostril. Resident is unable to state how laceration was obtained due to baseline dementia, Resident denies pain, body assessment complete. No other injuries notes. 10:11 AM Upon walking into dayroom this am noted steristrip to nose saturated with blood, steri strips removed for assessment and noted deep laceration/split to left nostril with swelling and redness noted to bridge of nose. Physician informed for need of sutures and possible x-ray and order received to send to Emergency Department (ED) for treatment. 10:34 AM Transferred to ED 8/25/18 2:52 PM: 1346 resident returned from ED with [DIAGNOSES REDACTED]. Left nare laceration was treated with dermabond. 2:52 PM Notified by CNA, that resident had a skin tear. Observed a skin tear 3.5 cm long to his left, posterior wrist. Area was cleansed with NS and wound was approximated w steri strips- resident tolerated the procedure well. 4:10 PM, new order for padded side rails to bed. 4:10 PM New order received to pad siderails Last fall documented was on 8/22/18. Resident found on floor in front of nurse's desk. Review of Resident #17's physician progress notes [REDACTED]. Had recent fall and laceration to nose that required dermabond in ER. Has frequent falls. Up in broda chair when out of bed. Review of Resident #17's ED Report of 8/25/18 revealed Patient was reported by nursing home staff to a fall 10 hours ago. The day nurse put steri strips on it and sent him/her here for x-ray and a couple of stitches. The facility was unable to provided additional information/evidence to the surveyor that any assessment as to the cause of injury for Resident #17 was documented. The facility documented on the incident report resident hit siderail and to pad siderail. The facility investigation failed to provide evidence that Resident #17 hit the side rail. The facility investigation failed to provide documentation that Resident #17 had restlessness in bed, no indication of any movement which would cause a nasal fracture or laceration. The facility investigation failed to provide documentation/evidence that Resident #17 was being injured from the siderails or that the resident had a fall since 8/22/18. Documentation of the fall on 8/22/18 stated there was no injury. Review of the facility investigation for Resident #11 and Resident #10 dated 10/25/18 revealed On 10/26/18 Resident #11 noted with a change in neuro status and continued complaints of pain to the right eye. Resident sent to ER for evaluation. X-ray obtained and reveals a right orbital fracture. No surgical intervention needed. Witness statement of CNA #13 of 10/25/18: Heard residents yelling out of room ___. When entering room both residents was in contact with one another. Residents #10 and Resident #11 was both on the floor. Removed Resident #10 out of the room and the two other CNAs went and picked up Resident #11 off the floor. Notify the nurse that was duty. Review of Resident #11's Departmental Notes from 10/3/18 through 12/10/18: 10/26/18 2:34 AM Upon entering room, resident on floor, roommate standing up. CNA states made contact with roommate. Skin tear to left forearm, discoloration to right face. Supervisor notified, Attempted to call Responsible Party (RP), message (msg) left. Resident stated, S/He got me pretty well. Separated from roommate. 10/26/18 4:36 AM-late entry for 10/25/18 11:15 PM, informed by floor nurse that resident was noted lying on floor of bedroom and making physical contact with roommate. Resident had change in neuro checks. Resident is lying in bed, bruising noted to right eye. Left pupil reactive to light, right pupil non-reactive. Hand grasps equal. Follows instruction. MD notified to send to ER for evaluation. 10:38 AM Resident will change from room. 3:24 PM diagnosed with [REDACTED]. Resident being monitored and on behavior management. CNA #14 gave a witness statement, Heard resident yelling Help out of room ---. The assigned CNA entered the room and asked for help. Upon entering the room, I saw Resident #11 on the floor with discoloration under his/her right eye. CNA #13 took Resident #10 out of the room while me and another CNA helped the nurse get resident #11 back to her/his bed. During an interview on 12/13/18 at 3:10 PM CNA #5 stated s/he Heard yelling coming from Resident #11's room, when I came in Resident #15 had 1 (one) hand around neck 1 (one) hand touching chest, wasn't choking was hitting, wasn't pushing down just had her/his hands on her/him, it was a surprise because they always walk around together, talked to her/him and s/he stopped touching resident, calmed her/him down. Resident #11 was lying in bed when I got in room. The two residents were yelling at each other. Review of Resident #10's Departmental Progress Notes from 8/1/18 through 12/11/18 revealed 10/26/18: Resident noted on bedroom floor making physical contact with roommate. Residents separated and redirected. Resident unable to state what happened. 10:53 AM: Resident will be getting a new roommate. Added to Behavior management program. Review of the facility investigation for Resident #12 and Resident #10 of incident dated 9/12/18 revealed. Staff observed Resident #10 make contact with resident #12's arms with open hands. RN assessments and body audits were completed. Resident #12 was observed with red discolorations to the right inner arm measuring 2 cm x 2 cm and left outer arm measuring 3cm x 2cm. The facility investigation contained one (1) witness statement that said s/he overheard a commotion and ran to the room, found Resident #12 had open hand contact with Resident #10 trying to pull away. Review of Resident #10's Departmental Progress Notes from 8/1/18 through 12/11/18 revealed 9/13/18: Resident was involved in an altercation with another resident. On 9/12/18 the CNA heard loud noises coming from room ___. When s/he entered s/he saw resident make open hand contact with other resident's upper arms. Both residents were redirected by staff. LMSW talked with resident. The resident did not remember the altercation from the previous morning. S/He said s/he was sorry and s/he just could not remember striking anyone. Resident's room is ___. Resident needs a room reminder, informed SW would create tag with resident's room number. Resident in agreement. Review of Resident #12's Departmental Notes from 8/1/18 - 12/12/18 revealed: 9/12/18: Was informed by floor nurse that CNA brought to her/his attention after hearing commotion s/he entered into room and found Resident #10 making open hand contact to resident's bilateral arms. Residents were redirected by CNA and at this time calm and cooperative. Noted discoloration to bilateral arms, resident denies pain. 9/13/18- Resident has a discoloration to the left upper arm, and right upper arm near his/her elbow, no complaints of pain, and no altercations observed this am. But resident was confused about having a roommate and did not remember him/her. 5:08 PM SS note: Resident was involved in an incident in which another resident made open hand contact to his/her upper arms. Resident was in her/his room when another resident walked in and made physical contact with her/him. Resident had some discoloration where s/he was touched. During an interview on 12/13/18 at 9:34 AM CNA #11 stated On 9/12/18 I was sitting in day room. I heard commotion going on. I ran to her/his room. Resident #10 had her/his hands on the resident and Resident #12 had his/her hands on Resident #10. Resident #12 was up against the dresser drawers (standing up). Each of them were holding on to the others arms The CNA demonstrated holding out both hands on to arms of the other resident. It was Resident #12's room that Resident #10 was in. Resident #12 said this man was in my bed, this is my room. They were holding on to each other. Review of the facility investigation for Resident #13 and Resident #10 dated 11/25/18 revealed a written statement from CNA #15 dated 11/25/18: I heard Resident #13 yelling, Help, Help! So I went into his/her room and s/he told me the man beat me up. Resident #10 was standing over Resident #13, so I walked her/him to her/his room. When I was helping Resident #13 back to bed, s/he showed me the spot of blood on the bed and then a cut on her/his arm. S/He told me the man shook me and wanted me out of my bed. S/He beat me up. I did not see any altercation between the residents. Written statement from CNA #14 and one from CNA # 16 were signed on 12/11/18 and signed as Interviewer and witness by RN dated 12/10/18. Neither were aware of anything that happened. A third Investigative Statement was blank with a signature signed on 12/10/18 and witnessed by same RN on 12/10/18. Although CNA #15 heard the resident yelling, s/he did not witness any altercation between the residents. Review of Resident #13's Departmental Notes from 11/1/18 through 12/10/18 revealed: 11/16/18 12:15 AM Notified by nurse that resident was pulled out of bed by another resident. Assessed for injuries, none noted. 1:25 PM Called to room by yelling. Another resident in room yelling and cursing at him/her. Resident states s/he is afraid for his/her life, asked staff to remove other resident before s/he hurts her/him. During an interview with CNA #15 on 12/13/18 at 3:46 PM CNA #15 stated Resident #10 got in bed with Resident #13 and was holding her/his hands, that caused the redness. Resident #13's family told the CNA of one other incident of Resident #10 in Resident #13's room trying to get the resident out of the bed. Resident #10 doesn't go to any other resident's rooms, s/he has been aggressive at times in other common areas. When the CNA went into the room Resident #13 put him/herself in his/her wheelchair, s/he was wheeling away from the bed in wheelchair, screaming help help. Resident #10 was coming out of the bed when I came in, I saw a blood spot when I put Resident #13 back in bed. I think it happened from resident grabbing her/his hands and shaking them. I think Resident #10 was trying to pull Resident #13 out of bed but I didn't see what happened. I responded when I heard the yelling and Resident #13 was already up in her/his wheelchair and Resident #10 was coming up out of Resident #13's bed. Resident #13 is alert enough to explain what happened, after s/he explained it made sense, by beating her/him up s/he explained Resident #10 grabbed her/him by her/his hands and was shaking, pulling on her/him. The facility investigations revealed that Resident #10 had been involved in three different altercations with three different Residents (Resident #11, #12, and #13). One altercation with Resident #11 on 10/25/18 resulted in Resident #11 sustaining a fractured eye orbit. One altercation with Resident #12 on 9/12/18 resulted in Resident #12 with discoloration marks on her/his arms. The third altercation was with Resident #13 on 11/25/18 and resulted in Resident #13 receiving a skin tear and Resident #13 stated that s/he was afraid for her/his life. The facility investigations failed to clearly identify what may have happened with these residents in all three altercations or to clearly identify the origin of the injuries sustained during these altercations. In addition, the facility investigations were unclear as to which resident initiated the altercations. Review of the facility's Five-Day Follow-Up Report for Resident #9 and Resident #5 dated 9/27/18 indicated on 9/23/18 at 1:15 PM a facility visitor observed Resident #9 swinging his/her hands at Resident #5. Resident #9 made contact with Resident #5's abdomen with a closed hand. Review of the facility's investigative file for the incident revealed the visitor's facility-obtained statement dated 9/23/18 indicated Resident #5 was putting trays in a cabinet with other dirty trays. Resident #9 was sitting in a chair beside the cabinets and began closing the cabinet door hitting Resident #5's arm. Then Resident #9 got up and started punching Resident #5. The visitor went over and asked the resident to stop and that Resident #5 was only trying to help. Resident #9 calmed down right away. Further review of the facility investigation revealed statements by three CNA's who were on duty at the time of the incident that indicated they did not witness or have knowledge of the incident. Review of the facility Staffing Sheet for the unit dated 9/23/18 revealed there were three additional certified nurse aides and two nurses on duty at the time of the incident that did not complete statements. Review of Resident #9's Incident Report dated 9/23/18 revealed incident witnessed by a visitor, another resident swinging closed hand and making contact to Resident #5's abdomen. A body audit was completed on Resident #5 on 9/23/18 at 6:08 PM that indicated there were no areas of concern. Review of Resident #5's medical record revealed a nurse's note dated 9/23/18 at 2:36 PM that indicated it was reported that the resident was in the dayroom putting up a tray in the lunch cart when another resident who was agitated swung his/her arm making contact to Resident #5's abdomen with a closed hand. A body audit was documented as attempted on Resident #9 on 9/23/18 at 6:36 PM and the resident refused. Review of the facility's Five-Day Follow-Up Report for Resident #9 and Resident #4 dated 9/28/18 indicated on 9/23/18 at 3:00 PM Resident #9 was observed by staff to touch Resident #4's foot. Witness to the alleged abuse was noted as Activity aide #1. Review of the facility investigation revealed there was one investigative interview statement. Activity aide #1's facility-obtained statement dated 9/23/18 indicated s/he noticed Resident #9 saying something to Resident #4 with a mean look on his/her face. The activity aide turned around to tell the CNAs and looked back and saw Resident #9 holding Resident #4's leg in the air. Review of Resident #4's nurse's note dated 9/23/18 at 3:40 PM indicated activities staff witnessed another resident picking up Resident #4's leg and lifting it then twisting his/her foot. No injuries were sustained. A body audit was documented as refused on 9/23/18 at 6:34 PM. Review of the facility investigation revealed one investigative interview statement by Activity aide #1. The facility investigation failed to include additional staff statements. Review of the facility Staffing Sheet for the unit on 9/23/18 revealed there were two nurses assigned to work 6:45 AM-7:15 PM. There were six CNA's assigned to work 7:00 AM-3:00 PM and five CNA's scheduled to come in at 3:00 PM. Review of the facility's Five-Day Follow-Up Report for Resident #8, Resident #7 and Resident #6 dated 10/3/18 revealed on 9/28/18 at 8:15 AM Resident #8 reported to staff that Resident #7 had touched his/her arm. Review of the facility investigation revealed Resident #8's facility-obtained statement dated 9/28/18 which indicated Resident #7 came into his/her room and grabbed them like s/he wasn't going to let go of them. Resident #8 got up and went and got the nurse. When they got back Resident #7 had Resident #6 by the throat. Review of the facility unit Staffing Sheet dated 9/28/18 revealed there were two nurses assigned to work 6:45 AM - 7:15 PM and seven CNA's assigned to the unit at the time of the incident. Review of the facility investigation revealed there were three facility-obtained statements from CNA's who did not witness or have knowledge of any incident. The facility investigation failed to include additional staff statements. Review of the Five-Day Follow-Up Report for Resident #4 dated 10/4/18 revealed on 9/29/18 at 7:15 AM Resident #4 reported that another resident touched him/her in the chest with a closed hand. Resident #4 did not know the other resident's name. Review of the facility investigation revealed there were three written statements obtained. CNA #8's facility-obtained statement dated 9/29/18 indicated Resident #4 said someone came in his/her room last night and kept punching him/her in the chest. Resident #4 said s/he never was attacked like that. CNA #8 asked why s/he did not report it the night before. Resident #4 said s/he waited on day shift to come. CNA #9's facility-obtained statement dated 9/29/18 indicated Resident #4 stated that some came into (his/her) room last night and punch (him/her) in (his/her) chest, and when (s/he) was getting up, the person left out (his/her) room. CNA #10's facility-obtained statement dated 9/29/18 indicated when s/he came in on the 7:00 AM-3:00 PM shift Resident #4 said that someone came into his/her room started punching him/her in his/her chest. Resident #4 got up and the resident left out. Resident #4 said it happened last night. Review of Resident #4's medical record revealed a nurse's note dated 9/29/18 at 8:28 AM that indicated notified by floor nurse that resident states that one of the new guys came in (his/her) room and touched (him/her) with closed hand to (his/her) chest . Review of the facility investigation revealed there were no additional statements from the night shift staff that worked during the time of the alleged incident. Review of the Five-Day Follow-Up Report for Resident #9 and Resident #7 dated 10/5/18 revealed on 10/2/18 at 1:30 PM Resident #9 was observed by staff to make contact with closed hands to Resident #7's face. Resident #7 sustained a lower lip abrasion. Review of the facility investigation revealed five staff statements. CNA Trainee #1's facility-obtained statement dated 10/2/18 indicated Resident #9's closed fist made physical contact. S/he saw it twice, outside and inside. Student Nurse #3's facility-obtained statement dated 10/2/18 indicated while in the day room s/he saw Resident #9 make physical contact with Resident #7 in the courtyard. CNA #11's facility-obtained statement dated 10/2/18 indicated s/he witnessed Resident #9 make physical contact with Resident #7 near nurse's station. Activity assistant #1's facility-obtained statement dated 10/2/18 indicated Resident #9 made contact with Resident #7 twice, with closed fist, once on porch/courtyard and again inside. CNA #12's facility-obtained statement dated 10/2/18 indicated Resident #9 walked out into courtyard and approached another resident and made contact with a closed fist. Immediately went to stop. The facility investigation failed to include documentation/evidence that the facility protected Resident #7 from Resident #9. Review of the Five-Day Follow-Up Report for Resident #3 and Resident #4 dated 10/8/18 indicated on 10/3/18 at 10:30 AM Resident #4 was observed by staff to touch Resident #3 with a closed hand on his/her chest and neck. There were no injuries or discolorations noted.

Based on record review, review of facility files and interviews, the facility failed to conduct thorough investigations for 16 of 16 reportable incidents. The findings included: Review of the Facility Investigation for Resident #14 dated 9/27/18 revealed Resident reported to staff a Certified Nursing Assistant (CNA) had touched him/her with closed hands in his/her stomach. Resident with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Upon completion of investigation to include staff and resident interviews, the allegation of abuse was not substantiated. Review of the 5 day report for Resident #14 revealed the CNA had been suspended pending investigation. CNA received re-education on abuse policy and customer service. The Resident's statement dated 9/27/18 stated, Resident stated that on Monday, 9/24/18, after midnight, girl (meaning CNA) came in her/his room and tried to take her/his clothes off. S/He said that s/he told her (CNA) to leave her/him alone because s/he had already had a shower and her/his clothes were clean. S/He said, that girl got mad and hit her/him in the stomach. Girl then went to check on her/his roommate and that was the last time s/he saw her that night. S/He then said the same girl gave her/him a shower today. Licensed Practical Nurse (LPN) #4 wrote a statement dated 9/27/18 which stated Resident #14 told her/him, the CNA hit the resident all over her/his body. The nurse looked her/him over and found no discolorations or marks on the resident. The investigation did not include who the CNA was who had been suspended. The 5 day Report Form stated the alleged perpetrator was CNA #4. CNA #4 had given a statement dated 9/27/18. CNA #4 stated s/he did not work on 9/24/18 on the 11/7 shift. S/he worked on the 7-3 shift on another unit and had no knowledge of the alleged accusation. The facility investigation for Resident #14 failed to show time cards or staff assignments to show who had worked at the time of the alleged incident in order to determine if abuse actually accrued. Review of the facility investigation for Resident #14 dated 10/27/18 revealed Resident #14 with a BIMS score of 3 stated to nurse that one of the CNAs beat up her/his roommate last night then came over and hit her/him. Resident #14 reports s/he does not know the name and is scared to get anyone in trouble. RN (Registered Nurse) assessment completed. Resident interviewed by RN supervisor and reports that s/he heard a large female getting rough with her/his roommate. Resident reports s/he saw the CNA tossing the roommate around and when s/he said something to the CNA, s/he pushed on Resident #14's stomach region with an open hand. Completion of investigation was unsubstantiated. The CNA in question was providing incontinent care to the roommate per staff statements when the resident went into the room. The report failed to identify the CNA in question. Statements were obtained from nurses and CNAs. LPN (Licensed Practical Nurse) #5 gave a statement dated 10/27/18. .S/He (Resident #14) said to me one of the CNA's beat up my roommate last night then came over and hit me. S/He started to cry. I am scared I will get into trouble . The CNAs stated they were unaware of any incident. There was no statement from a CNA which stated the roommate was being provided incontinent care. The facility investigation for Resident #14 failed to identify the CNA assigned to the resident or her/his roommate. In addition, the facility investigation failed to show time cards or staff assignments to show who had worked at the time of the alleged incident in order to determine if abuse actually accrued. Review of the facility investigation for Resident #16 and Resident #15 dated 9/26/18 revealed a summary report of the facility's investigation. Staff alerted to room ___ by a loud noise. Staff observed Resident #15 making contact with Resident #16's neck with an open hand and contact with her/his chest with a closed hand Resident #16 was noted to have red marks on her/his neck. Upon completion of facility investigation no intent to harm was found related to cognitive impairment of both residents Staff will continue to intervene as needed. Review of witness statements revealed a statement from LPN #6 dated 9/26/18. Heard yelling coming out of room___, this nurse ran into room and observed Resident #15 with a closed hand around another resident (resident #16) throat and s/he was on top of her/him in Resident #16's bed. Had to call resident's name several times before we could separate them. A statement was obtained from CNA #5, dated 9/26/18. The CNA stated s/he had heard yelling in resident room. CNA entered resident room and saw Resident #15 standing beside bed of Resident #16 while Resident #16 was lying in the bed. Resident #15 had open hand to Resident #16's neck and closed hand in contact with the chest. CNA separated residents and alerted nurse. Review of Departmental Notes from 8/2/18 through 12/8/18 for Resident #16 revealed: 9/26/18 Around 8:15 pm yelling was heard coming from resident's room, went in to see what was going on and observed a resident on top of this resident holding her/him with a closed hand around her/his neck. Took several minutes to separate residents. Got other resident out of room. Assessed this resident for injuries, s/he did have some redness noted to his/her neck on the right side. No more injuries noted. Review of Resident #15's Departmental Notes from 8/1/18 through 12/10/18 revealed: 9/26/18: Around 8:15 PM nurse heard yelling coming from room ___. Nurse went in to see what was going on and observed resident on top of another resident, holding her/him with a closed hand around resident's neck. Tried for several minutes to separate residents. Once separated, got resident out of room and assessed him/her for injuries, none found. 11:52 PM (late entry of supervisor) Resident was unable to state what happened due to baseline dementia. Body assessment completed, no apparent injuries noted. 9/27/18: Pharmacy Note: Resident had altercation with another resident last night. Unclear if something triggered this. Resident is not prone to behaviors and none have been documented for several months. Will review him/her in PMT for 4 weeks. No irregularities noted on MRR. No recommendations. 11/7/18: Notified by CNA that resident had been verbally and physically approached by another resident. Per witness this resident in return made contact to other resident, altercation not witnessed by this nurse. 11/17/18 Another resident became agitated in the dayroom. Resident became more aggressive making physical contact with open hands to nursing staff. Resident #15 noted physical contact and intervened by asking other resident to stop and then made contact with open hands causing other resident to fall to floor. Resident easily redirected. During an interview on 12/13/18 at 3:10 PM CNA #5 stated s/he Heard yelling coming from Resident #16's room, when I came in Resident #15 had 1 (one) hand around neck 1 (one) hand touching chest, wasn't choking was hitting, wasn't pushing down just had her/his hands on her/him, it was a surprise because they always walk around together, talked to her/him and s/he stopped touching resident, calmed her/him down. Resident #16 was lying in bed when I got in room. The two residents were yelling at each other. The Facility Investigation for Resident #16 and Resident #15 failed to contain an accurate representation of the incident dated 9/26/18. The facility report stated no harm was intended, but witness statements contained in the report stated that Resident #15 had hand over throat and was on top of Resident #16 in the bed. The facility investigation for Resident #16 and Resident #15 failed to provide evidence that Resident #15 had been removed from the room by the CNA and then returned for the nurse to find Resident #15 on top of Resident #16. The facility investigation did not clarify whether the resident was being choked, or held down by the throat nor if the resident was pressing against the resident's chest with a closed hand or if the resident was being punched in the chest with a fist. Review of the facility investigation for Resident #18 for injury of unknown origin revealed on 8/27/18 at time of x-ray results. PT (Physical Therapy) alerted staff that resident was unable to bear weight during her/his restorative program, RN assessment and body audit were completed. Resident had pain with ROM (range of motion). X-ray of right hip revealed acute right femoral fracture. Bedrest, pain meds. Statements obtained. CNA #6's interview dated 8/27/18 revealed I noticed the resident was in pain. I assisted in helping x-ray technician get x-ray of hip and then was informed to leave in bed. Resident did resist a little during x-ray and brief change. CNA # 7 statement dated 8/27/18 revealed I took care of the resident two days prior. S/He was guarding her/his right hip during ADL care. I informed the nurse that the resident was not acting right. During an interview on 12/13/18 at 9:30 AM CNA # 6 stated that on 8/27/18 After I came back from a 2 day break I noted Resident #18 was in pain. I reported to the nurse. I assisted tech to get x-ray. S/He resisted the x-ray. S/He could not communicate. It was a facial expression and grunting. I just said s/he seemed to be in pain. I didn't know it was coming from her/his hip. Additional information provided included Incident Report of 8/27/18. Narrative: Alerted by PT staff that resident unable to bear weight to right leg. Upon ROM assessment, resident screamed in agony. Hip x-ray in place, bed fast and pain med prn. Will monitor. Review of Resident #18's Departmental Notes from 8/1/18 through 9/29/18 revealed. On 8/4/18 resident was noted on the floor on his/her left side with wheelchair turned over on side. Resident denied acute pain. Assisted back to wheelchair by staff. No moaning or grimacing noted. 12:26 PM. Resident fought during body audit. No notable skin changes. 8/7/18 No distress noted. Active in seat of chair. Propelling self with feet, neurochecks wnl (within normal limits). 8/27/18 2:20 PM Was informed by PT that resident was having difficulty bearing weight to Right leg today. Upon assessment noted resident in gerichair in room resting. When performing Range of Motion (ROM) resident guarded R (right) leg and moaned. Dr. aware and x-ray ordered to right hip to r/o (rule out) fracture. 6:17 PM Late Entry for 1701 on 8/27/18. Dr. telephoned and stated saw x-ray and appears to have a possible R [MEDICAL CONDITION]. New orders received for bedrest and pain management. 6:19 PM Alerted by PT staff that resident unable to bear weight to right leg upon ROM assessment res. (resident) screamed in agony, hip x-ray taken [MEDICATION NAME] 50 mg (milligrams) po (by mouth) tid (three times a day) prn (as needed). There was no evidence that the facility investigation was completed as to how Resident #18 may have obtained the fracture. The facility investigation did not include any further investigation into CNA #7's statement of the resident guarding his/her hip 2 days prior to the identified incident, and reported to nurse. In addition, the facility investigation failed to identify the nurse that CNA #7 reported to and failed to include any statements from that nurse related to the incident. Additional information provided by the facility to the surveyor related to the facility's investigation did not include Resident #18's x-ray report. Review of the facility investigation for Resident #17 for injury of unknown origin dated 8/25/18 revealed Resident with laceration to left side of nose. Resident sent to hospital for treatment and evaluation. X-ray report revealed non-displaced fracture of nose. Padded siderails were added to bed. Resident's nails were trimmed and filed. Neurochecks and O2 sats initiated. Pain management. Care Plan updated. Resident with BIMS of 5 and able to reposition self in bed. Padded siderails added to bed for protection when repositioning in the bed. Care Plan updated. 5 statements obtained, dated 8/25/18. All with no knowledge of any incident. Review of Resident #17's Departmental notes from 8/1/18 to 10/26/18. On 8/22/18 9:54 AM Late Entry 7AM notified that resident was found sitting on the floor. No noted injuries. On 8/25/18 at 2:45 am this resident was noted to have a nose bleed, when assessed closer to find a laceration on the left side of the nose near the center. Area cleansed with normal saline (NS). Skin prep applied to surrounding area, then steri-strips, applied, Supervisor notified. Will continue to monitor. 5:06 AM Supervisor informed by floor nurse that this resident was noted with a small laceration to her/his left nostril. Resident is unable to state how laceration was obtained due to baseline dementia, Resident denies pain, body assessment complete. No other injuries notes. 10:11 AM Upon walking into dayroom this am noted steristrip to nose saturated with blood, steri strips removed for assessment and noted deep laceration/split to left nostril with swelling and redness noted to bridge of nose. Physician informed for need of sutures and possible x-ray and order received to send to Emergency Department (ED) for treatment. 10:34 AM Transferred to ED 8/25/18 2:52 PM: 1346 resident returned from ED with [DIAGNOSES REDACTED]. Left nare laceration was treated with dermabond. 2:52 PM Notified by CNA, that resident had a skin tear. Observed a skin tear 3.5 cm long to his left, posterior wrist. Area was cleansed with NS and wound was approximated w steri strips- resident tolerated the procedure well. 4:10 PM, new order for padded side rails to bed. 4:10 PM New order received to pad siderails Last fall documented was on 8/22/18. Resident found on floor in front of nurse's desk. Review of Resident #17's physician progress notes [REDACTED]. Had recent fall and laceration to nose that required dermabond in ER. Has frequent falls. Up in broda chair when out of bed. Review of Resident #17's ED Report of 8/25/18 revealed Patient was reported by nursing home staff to a fall 10 hours ago. The day nurse put steri strips on it and sent him/her here for x-ray and a couple of stitches. The facility was unable to provided additional information/evidence to the surveyor that any assessment as to the cause of injury for Resident #17 was documented. The facility documented on the incident report resident hit siderail and to pad siderail. The facility investigation failed to provide evidence that Resident #17 hit the side rail. The facility investigation failed to provide documentation that Resident #17 had restlessness in bed, no indication of any movement which would cause a nasal fracture or laceration. The facility investigation failed to provide documentation/evidence that Resident #17 was being injured from the siderails or that the resident had a fall since 8/22/18. Documentation of the fall on 8/22/18 stated there was no injury. Review of the facility investigation for Resident #11 and Resident #10 dated 10/25/18 revealed On 10/26/18 Resident #11 noted with a change in neuro status and continued complaints of pain to the right eye. Resident sent to ER for evaluation. X-ray obtained and reveals a right orbital fracture. No surgical intervention needed. Witness statement of CNA #13 of 10/25/18: Heard residents yelling out of room ___. When entering room both residents was in contact with one another. Residents #10 and Resident #11 was both on the floor. Removed Resident #10 out of the room and the two other CNAs went and picked up Resident #11 off the floor. Notify the nurse that was duty. Review of Resident #11's Departmental Notes from 10/3/18 through 12/10/18: 10/26/18 2:34 AM Upon entering room, resident on floor, roommate standing up. CNA states made contact with roommate. Skin tear to left forearm, discoloration to right face. Supervisor notified, Attempted to call Responsible Party (RP), message (msg) left. Resident stated, S/He got me pretty well. Separated from roommate. 10/26/18 4:36 AM-late entry for 10/25/18 11:15 PM, informed by floor nurse that resident was noted lying on floor of bedroom and making physical contact with roommate. Resident had change in neuro checks. Resident is lying in bed, bruising noted to right eye. Left pupil reactive to light, right pupil non-reactive. Hand grasps equal. Follows instruction. MD notified to send to ER for evaluation. 10:38 AM Resident will change from room. 3:24 PM diagnosed with [REDACTED]. Resident being monitored and on behavior management. CNA #14 gave a witness statement, Heard resident yelling Help out of room ---. The assigned CNA entered the room and asked for help. Upon entering the room, I saw Resident #11 on the floor with discoloration under his/her right eye. CNA #13 took Resident #10 out of the room while me and another CNA helped the nurse get resident #11 back to her/his bed. Review of Resident #10's Departmental Progress Notes from 8/1/18 through 12/11/18 revealed 10/26/18: Resident noted on bedroom floor making physical contact with roommate. Residents separated and redirected. Resident unable to state what happened. 10:53 AM: Resident will be getting a new roommate. Added to Behavior management program. Review of the facility investigation for Resident #12 and Resident #10 of incident dated 9/12/18 revealed. Staff observed Resident #10 make contact with resident #12's arms with open hands. RN assessments and body audits were completed. Resident #12 was observed with red discolorations to the right inner arm measuring 2 cm x 2 cm and left outer arm measuring 3cm x 2cm. The facility investigation contained one (1) witness statement that said s/he overheard a commotion and ran to the room, found Resident #12 had open hand contact with Resident #10 trying to pull away. Review of Resident #10's Departmental Progress Notes from 8/1/18 through 12/11/18 revealed 9/13/18: Resident was involved in an altercation with another resident. On 9/12/18 the CNA heard loud noises coming from room ___. When s/he entered s/he saw resident make open hand contact with other resident's upper arms. Both residents were redirected by staff. LMSW talked with resident. The resident did not remember the altercation from the previous morning. S/He said s/he was sorry and s/he just could not remember striking anyone. Resident's room is ___. Resident needs a room reminder, informed SW would create tag with resident's room number. Resident in agreement. Review of Resident #12's Departmental Notes from 8/1/18 - 12/12/18 revealed: 9/12/18: Was informed by floor nurse that CNA brought to her/his attention after hearing commotion s/he entered into room and found Resident #10 making open hand contact to resident's bilateral arms. Residents were redirected by CNA and at this time calm and cooperative. Noted discoloration to bilateral arms, resident denies pain. 9/13/18- Resident has a discoloration to the left upper arm, and right upper arm near his/her elbow, no complaints of pain, and no altercations observed this am. But resident was confused about having a roommate and did not remember him/her. 5:08 PM SS note: Resident was involved in an incident in which another resident made open hand contact to his/her upper arms. Resident was in her/his room when another resident walked in and made physical contact with her/him. Resident had some discoloration where s/he was touched. During an interview on 12/13/18 at 9:34 AM CNA #11 stated On 9/12/18 I was sitting in day room. I heard commotion going on. I ran to her/his room. Resident #10 had her/his hands on the resident and Resident #12 had his/her hands on Resident #10. Resident #12 was up against the dresser drawers (standing up). Each of them were holding on to the others arms The CNA demonstrated holding out both hands on to arms of the other resident. It was Resident #12's room that Resident #10 was in. Resident #12 said this man was in my bed, this is my room. They were holding on to each other. Review of the facility investigation for Resident #13 and Resident #10 dated 11/25/18 revealed a written statement from CNA #15 dated 11/25/18: I heard Resident #13 yelling, Help, Help! So I went into his/her room and s/he told me the man beat me up. Resident #10 was standing over Resident #13, so I walked her/him to her/his room. When I was helping Resident #13 back to bed, s/he showed me the spot of blood on the bed and then a cut on her/his arm. S/He told me the man shook me and wanted me out of my bed. S/He beat me up. I did not see any altercation between the residents. Written statement from CNA #14 and one from CNA # 16 were signed on 12/11/18 and signed as Interviewer and witness by RN dated 12/10/18. Neither were aware of anything that happened. A third Investigative Statement was blank with a signature signed on 12/10/18 and witnessed by same RN on 12/10/18. Although CNA #15 heard the resident yelling, s/he did not witness any altercation between the residents. Review of Resident #13's Departmental Notes from 11/1/18 through 12/10/18 revealed: 11/16/18 12:15 AM Notified by nurse that resident was pulled out of bed by another resident. Assessed for injuries, none noted. 1:25 PM Called to room by yelling. Another resident in room yelling and cursing at him/her. Resident states s/he is afraid for his/her life, asked staff to remove other resident before s/he hurts her/him. During an interview with CNA #15 on 12/13/18 at 3:46 PM CNA #15 stated Resident #10 got in bed with Resident #13 and was holding her/his hands, that caused the redness. Resident #13's family told the CNA of one other incident of Resident #10 in Resident #13's room trying to get the resident out of the bed. Resident #10 doesn't go to any other resident's rooms, s/he has been aggressive at times in other common areas. When the CNA went into the room Resident #13 put him/herself in his/her wheelchair, s/he was wheeling away from the bed in wheelchair, screaming help help. Resident #10 was coming out of the bed when I came in, I saw a blood spot when I put Resident #13 back in bed. I think it happened from resident grabbing her/his hands and shaking them. I think Resident #10 was trying to pull Resident #13 out of bed but I didn't see what happened. I responded when I heard the yelling and Resident #13 was already up in her/his wheelchair and Resident #10 was coming up out of Resident #13's bed. Resident #13 is alert enough to explain what happened, after s/he explained it made sense, by beating her/him up s/he explained Resident #10 grabbed her/him by her/his hands and was shaking, pulling on her/him. The facility investigations revealed that Resident #10 had been involved in three different altercations with three different Residents (Resident #11, #12, and #13). One altercation with Resident #11 on 10/25/18 resulted in Resident #11 sustaining a fractured eye orbit. One altercation with Resident #12 on 9/12/18 resulted in Resident #12 with discoloration marks on her/his arms. The third altercation was with Resident #13 on 11/25/18 and resulted in Resident #13 receiving a skin tear and Resident #13 stated that s/he was afraid for her/his life. The facility investigations failed to clearly identify what may have happened with these residents in all three altercations or to clearly identify the origin of the injuries sustained during these altercations. In addition, the facility investigations were unclear as to which resident initiated the altercations. Review of the facility's Five-Day Follow-Up Report for Resident #9 and Resident #5 dated 9/27/18 indicated on 9/23/18 at 1:15 PM a facility visitor observed Resident #9 swinging his/her hands at Resident #5. Resident #9 made contact with Resident #5's abdomen with a closed hand. Review of the facility's investigative file for the incident revealed the visitor's facility-obtained statement dated 9/23/18 indicated Resident #5 was putting trays in a cabinet with other dirty trays. Resident #9 was sitting in a chair beside the cabinets and began closing the cabinet door hitting Resident #5's arm. Then Resident #9 got up and started punching Resident #5. The visitor went over and asked the resident to stop and that Resident #5 was only trying to help. Resident #9 calmed down right away. Further review of the facility investigation revealed statements by three CNA's who were on duty at the time of the incident that indicated they did not witness or have knowledge of the incident. Review of the facility Staffing Sheet for the unit dated 9/23/18 revealed there were three additional certified nurse aides and two nurses on duty at the time of the incident that did not complete statements. Review of Resident #9's Incident Report dated 9/23/18 revealed incident witnessed by a visitor, another resident swinging closed hand and making contact to Resident #5's abdomen. A body audit was completed on Resident #5 on 9/23/18 at 6:08 PM that indicated there were no areas of concern. Review of Resident #5's medical record revealed a nurse's note dated 9/23/18 at 2:36 PM that indicated it was reported that the resident was in the dayroom putting up a tray in the lunch cart when another resident who was agitated swung his/her arm making contact to Resident #5's abdomen with a closed hand. A body audit was documented as attempted on Resident #9 on 9/23/18 at 6:36 PM and the resident refused. Review of the facility's Five-Day Follow-Up Report for Resident #9 and Resident #4 dated 9/28/18 indicated on 9/23/18 at 3:00 PM Resident #9 was observed by staff to touch Resident #4's foot. Witness to the alleged abuse was noted as Activity aide #1. Review of the facility investigation revealed there was one investigative interview statement. Activity aide #1's facility-obtained statement dated 9/23/18 indicated s/he noticed Resident #9 saying something to Resident #4 with a mean look on his/her face. The activity aide turned around to tell the CNAs and looked back and saw Resident #9 holding Resident #4's leg in the air. Review of Resident #4's nurse's note dated 9/23/18 at 3:40 PM indicated activities staff witnessed another resident picking up Resident #4's leg and lifting it then twisting his/her foot. No injuries were sustained. A body audit was documented as refused on 9/23/18 at 6:34 PM. Review of the facility investigation revealed one investigative interview statement by Activity aide #1. The facility investigation failed to include additional staff statements. Review of the facility Staffing Sheet for the unit on 9/23/18 revealed there were two nurses assigned to work 6:45 AM-7:15 PM. There were six CNA's assigned to work 7:00 AM-3:00 PM and five CNA's scheduled to come in at 3:00 PM. Review of the facility's Five-Day Follow-Up Report for Resident #8, Resident #7 and Resident #6 dated 10/3/18 revealed on 9/28/18 at 8:15 AM Resident #8 reported to staff that Resident #7 had touched his/her arm. Review of the facility investigation revealed Resident #8's facility-obtained statement dated 9/28/18 which indicated Resident #7 came into his/her room and grabbed them like s/he wasn't going to let go of them. Resident #8 got up and went and got the nurse. When they got back Resident #7 had Resident #6 by the throat. Review of the facility unit Staffing Sheet dated 9/28/18 revealed there were two nurses assigned to work 6:45 AM - 7:15 PM and seven CNA's assigned to the unit at the time of the incident. Review of the facility investigation revealed there were three facility-obtained statements from CNA's who did not witness or have knowledge of any incident. The facility investigation failed to include additional staff statements. Review of the Five-Day Follow-Up Report for Resident #4 dated 10/4/18 revealed on 9/29/18 at 7:15 AM Resident #4 reported that another resident touched him/her in the chest with a closed hand. Resident #4 did not know the other resident's name. Review of the facility investigation revealed there were three written statements obtained. CNA #8's facility-obtained statement dated 9/29/18 indicated Resident #4 said someone came in his/her room last night and kept punching him/her in the chest. Resident #4 said s/he never was attacked like that. CNA #8 asked why s/he did not report it the night before. Resident #4 said s/he waited on day shift to come. CNA #9's facility-obtained statement dated 9/29/18 indicated Resident #4 stated that some came into (his/her) room last night and punch (him/her) in (his/her) chest, and when (s/he) was getting up, the person left out (his/her) room. CNA #10's facility-obtained statement dated 9/29/18 indicated when s/he came in on the 7:00 AM-3:00 PM shift Resident #4 said that someone came into his/her room started punching him/her in his/her chest. Resident #4 got up and the resident left out. Resident #4 said it happened last night. Review of Resident #4's medical record revealed a nurse's note dated 9/29/18 at 8:28 AM that indicated notified by floor nurse that resident states that one of the new guys came in (his/her) room and touched (him/her) with closed hand to (his/her) chest . Review of the facility investigation revealed there were no additional statements from the night shift staff that worked during the time of the alleged incident. Review of the Five-Day Follow-Up Report for Resident #9 and Resident #7 dated 10/5/18 revealed on 10/2/18 at 1:30 PM Resident #9 was observed by staff to make contact with closed hands to Resident #7's face. Resident #7 sustained a lower lip abrasion. Review of the facility investigation revealed five staff statements. CNA Trainee #1's facility-obtained statement dated 10/2/18 indicated Resident #9's closed fist made physical contact. S/he saw it twice, outside and inside. Student Nurse #3's facility-obtained statement dated 10/2/18 indicated while in the day room s/he saw Resident #9 make physical contact with Resident #7 in the courtyard. CNA #11's facility-obtained statement dated 10/2/18 indicated s/he witnessed Resident #9 make physical contact with Resident #7 near nurse's station. Activity assistant #1's facility-obtained statement dated 10/2/18 indicated Resident #9 made contact with Resident #7 twice, with closed fist, once on porch/courtyard and again inside. CNA #12's facility-obtained statement dated 10/2/18 indicated Resident #9 walked out into courtyard and approached another resident and made contact with a closed fist. Immediately went to stop. The facility investigation failed to include documentation/evidence that the facility protected Resident #7 from Resident #9. Review of the Five-Day Follow-Up Report for Resident #3 and Resident #4 dated 10/8/18 indicated on 10/3/18 at 10:30 AM Resident #4 was observed by staff to touch Resident #3 with a closed hand on his/her chest and neck. There were no injuries or discolorations noted. Review of the facility investigation revealed there were two staff statements completed. Activity Aide #1's facility-obtained statement dated 10/3/18 indicated another resident made physical contact with Resident #3 with a closed fist. Resident #3 was touched around the neck/chest area. CNA trainee #1's facility-obtained statement dated 10/3/18 indicated Resident #3 was physically touched by Resident #4 closed fisted, in the neck area. The facility investigation for Resident #3 and Resident #4 failed to include additional staff statements. Review of the facility's Five-Day Follow-Up Report for Resident #1 dated 11/2/18 revealed the incident occurred on 10/30/18 at 1:25 PM. It was reported to the social worker by a nursing student that while attempting to give Resident #1 a shower, a CNA was rude with the resident for not showing the nursing students how to turn th

Based on record review and interviews, the facility failed to implement their abuse policy on investigating and protecting residents from abuse for 16 of 16 Facility Reported Incidents of abuse/neglect and injury of unknown origin. The findings included: Cross refer to F610- Thoroughly Investigating Allegations of Abuse/Neglect Review of the facility investigation for Resident #14 dated 9/27/18 revealed Resident reported to staff a Certified Nursing Assistant (CNA) had touched him/her with closed hands in his/her stomach. Review of the facility investigation for Resident #14 dated 10/27/18 revealed Resident #14 with a BIMS score of 3 stated to nurse that one of the CNAs beat up her/his roommate last night then came over and hit her/him. Resident #14 reports s/he does not know the name and is scared to get anyone in trouble. The facility investigation dated 10/27/18 failed to identify the CNA assigned to the resident or her/his roommate. In addition, the facility investigation failed to show time cards or staff assignments to show who had worked at the time of the alleged incident in order to determine if abuse actually accrued. Review of the facility investigation for Resident #16 and Resident #15 dated 9/26/18 revealed that staff observed Resident #15 making contact with Resident #16's neck with an open hand and contact with her/his chest with a closed hand Resident #16 was noted to have red marks on her/his neck. The Facility Investigation for Resident #16 and Resident #15 failed to contain an accurate representation of the incident dated 9/26/18. Review of the facility investigation for Resident #18 for injury of unknown origin dated 8/27/18 revealed Resident had pain with ROM (range of motion). X-ray of right hip revealed acute right femoral fracture. The facility investigation contained a statement from CNA #7. CNA #7 stated s/he had taken care of Resident #18 on 8/25/18 and that Resident #18 was guarding her/his right hip during ADL care. CNA #7 reported to the nurse that Resident #18 was not acting right. There was no evidence that the facility investigation was completed as to how Resident #18 may have obtained the fracture. The facility investigation did not include any further investigation into CNA #7's statement of the resident guarding his/her hip 2 days prior to the identified incident, and reported to nurse. In addition, the facility investigation failed to identify the nurse that CNA #7 reported to and failed to include any statements from that nurse related to the incident. Additional information provided by the facility to the surveyor related to the facility's investigation did not include Resident #18's x-ray report. Review of the facility investigation for Resident #17 for injury of unknown origin dated 8/25/18 revealed Resident with laceration to left side of nose. Resident sent to hospital for treatment and evaluation. X-ray report revealed non-displaced fracture of nose. The facility was unable to provided additional information/evidence to the surveyor that any assessment as to the cause of injury for Resident #17 was documented. Review of the facility investigation for Resident #11 and Resident #10 dated 10/25/18 revealed On 10/26/18 Resident #11 noted with a change in neuro status and continued complaints of pain to the right eye. Resident sent to ER for evaluation. X-ray obtained and reveals a right orbital fracture. CNA #13's witness statement dated 10/25/18 revealed Heard residents yelling out of room ___. When entering room both residents was in contact with one another. Resident #10 and Resident #11 was both on the floor. Removed Resident #10 out of the room and the two other CNAs went and picked up Resident #11 off the floor. Notify the nurse that was duty. Review of the facility investigation for Resident #12 and Resident #10 dated 9/12/18 revealed Staff observed Resident #10 make contact with Resident #12's arms with open hands. RN assessments and body audits were completed. Resident #12 was observed with red discolorations to the right inner arm measuring 2 cm x 2 cm and left outer arm measuring 3cm x 2cm. The facility investigation contained one (1) witness statement that said s/he overheard a commotion and ran to the room, found Resident #12 had open hand contact with Resident #10 trying to pull away. Review of the facility investigation for Resident #13 and Resident #10 dated 11/25/18 revealed a written statement from CNA #15 dated 11/25/18 I heard Resident #13 yelling, Help, Help! So I went into his/her room and s/he told me the man beat me up. Resident #10 was standing over Resident #13, so I walked her/him to her/his room. When I was helping Resident #13 back to bed, s/he showed me the spot of blood on the bed and then a cut on her/his arm. S/He told me the man shook me and wanted me out of my bed. S/He beat me up. I did not see any altercation between the residents. Review of Resident #13's Departmental Notes from 11/1/18 through 12/10/18 revealed: 11/16/18 12:15 AM Notified by nurse that resident was pulled out of bed by another resident. Assessed for injuries, none noted. 1:25 PM Called to room by yelling. Another resident in room yelling and cursing at him/her. Resident states s/he is afraid for his/her life, asked staff to remove other resident before s/he hurts her/him. The facility investigations revealed that Resident #10 had been involved in three different altercations with three different Residents (Resident #11, #12, and #13). One altercation with Resident #11 on 10/25/18 resulted in Resident #11 sustaining a fractured eye orbit. One altercation with Resident #12 on 9/12/18 resulted in Resident #12 with discoloration marks on her/his arms. The third altercation was with Resident #13 on 11/25/18 and resulted in Resident #13 receiving a skin tear and Resident #13 stated that s/he was afraid for her/his life. The facility investigations failed to clearly identify what may have happened with these residents in all three altercations or to clearly identify the origin of the injuries sustained during these altercations. In addition, the facility investigations were unclear as to which resident initiated the altercations. Review of the facility's Five-Day Follow-Up Report for Resident #9 and Resident #5 dated 9/27/18 indicated on 9/23/18 at 1:15 PM a facility visitor observed Resident #9 swinging his/her hands at Resident #5. Resident #9 made contact with Resident #5's abdomen with a closed hand. Review of the facility investigation dated 9/23/18 revealed statements by three CNA's who were on duty at the time of the incident that indicated they did not witness or have knowledge of the incident. Review of the facility Staffing Sheet for the unit dated 9/23/18 revealed there were three additional CNA's and two nurses on duty at the time of the incident that did not complete statements. Review of the facility's Five-Day Follow-Up Report for Resident #9 and Resident #4 dated 9/28/18 indicated on 9/23/18 at 3:00 PM Resident #9 was observed by staff to touch Resident #4's foot. Witness to the alleged abuse was noted as Activity aide #1. Review of the facility investigation revealed one investigative interview statement by Activity aide #1. The facility investigation failed to include additional staff statements. Review of the facility Staffing Sheet for the unit on 9/23/18 revealed there were two nurses assigned to work 6:45 AM-7:15 PM. There were six CNA's assigned to work 7:00 AM-3:00 PM and five CNA's scheduled to come in at 3:00 PM. Review of the facility's Five-Day Follow-Up Report for Resident #8, Resident #7 and Resident #6 dated 10/3/18 revealed on 9/28/18 at 8:15 AM Resident #8 reported to staff that Resident #7 had touched his/her arm. Review of the facility investigation revealed Resident #8's facility-obtained statement dated 9/28/18 indicated Resident #7 came into his/her room and grabbed them like s/he wasn't going to let go of them. Resident #8 got up and went and got the nurse. When they got back Resident #7 had Resident #6 by the throat. Review of the facility unit Staffing Sheet dated 9/28/18 revealed there were two nurses assigned to work 6:45 AM - 7:15 PM and seven CNA's assigned to the unit at the time of the incident. Review of the facility investigation revealed there were three facility-obtained statements from CNA's who did not witness or have knowledge of any incident. The facility investigation failed to include additional staff statements. Review of the Five-Day Follow-Up Report for Resident #4 dated 10/4/18 revealed on 9/29/18 at 7:15 AM Resident #4 reported that another resident touched him/her in the chest with a closed hand. Resident #4 did not know the other resident's name. Review of the facility's investigation revealed there were three written statements obtained. The facility investigation failed to include additional staff statements from the night shift staff that worked during the time of the alleged incident. Review of the Five-Day Follow-Up Report for Resident #9 and Resident #7 dated 10/5/18 revealed on 10/2/18 at 1:30 PM Resident #9 was observed by staff to make contact with closed hands to Resident #7's face. Resident #7 sustained a lower lip abrasion. Review of the facility investigation revealed five staff statements. CNA Trainee #1's facility-obtained statement dated 10/2/18 indicated Resident #9's closed fist made physical contact. CNA Trainee #1's stated S/he saw it twice, outside and inside. Student Nurse #3's facility-obtained statement dated 10/2/18 indicated while in the day room s/he saw Resident #9 make physical contact with Resident #7 in the courtyard. CNA #11's facility-obtained statement dated 10/2/18 indicated s/he witnessed Resident #9 make physical contact with Resident #7 near nurse's station. Activity assistant #1's facility-obtained statement dated 10/2/18 indicated Resident #9 made contact with other resident twice, with closed fist, once on porch/courtyard and again inside. CNA #12's facility-obtained statement dated 10/2/18 indicated Resident #9 walked out into courtyard and approached another resident and made contact with a closed fist. Immediately went to stop. The facility investigation failed to include documentation/evidence that the facility protected Resident #7 from Resident #9. Review of the Five-Day Follow-Up Report for Resident #3 and Resident #4 dated 10/8/18 indicated on 10/3/18 at 10:30 AM Resident #4 was observed by staff to touch Resident #3 with a closed hand on his/her chest and neck. Review of the facility investigation revealed there were two staff statements completed. Activity Aide #1's facility-obtained statement dated 10/3/18 indicated another resident made physical contact with Resident #3 with a closed fist. Resident #3 was touched around the neck/chest area. CNA trainee #1's facility-obtained statement dated 10/3/18 indicated Resident #3 was physically touched by Resident #4 closed fisted, in the neck area. The facility investigation for Resident #3 and Resident #4 failed to include additional staff statements. Review of the facility's Five-Day Follow-Up Report for Resident #1 dated 11/2/18 revealed the incident occurred on 10/30/18 at 1:25 PM. It was reported to the social worker by a nursing student that while attempting to give Resident #1 a shower, a CNA was rude with the resident for not showing the nursing students how to turn the shower head on. It was stated that the resident mumbled something under his/her breath and that the CNA said to Resident #1 you keep on and I will get you in trouble and you will be out. The facility investigation revealed a statement provided by CNA #1 on 10/30/18. CNA #1 indicated on 10/30/18 s/he was working in the shower room with CNA #2. Review of the facility investigation revealed written statements from six other staff members that indicated they did not witness the incident. The facility investigation failed to include a written statement from CNA #2. Review of the facility's Five-Day Follow-Up Report for Resident #2 dated 11/12/18 indicated on 11/7/18 at 6:34 PM staff observed RN #1 tell Resident #2 oh no you have threatened me three times today. Resident #2 was trying to apologize and reaching out to the staff member. Review of the facility investigation revealed there were three staff statements related to the allegation, one from CNA #14, CNA #10, and RN #1. Review of the facility unit Staffing Schedule for the date and time of the incident revealed there were six additional CNAs and one nurse whose statements were not obtained. CNA #10 was not on the unit's schedule to work for the day and time of the incident. The facility investigation for Resident #2 failed to include additional staff statements. Review of the facility Policy on Abuse revised on (MONTH) (YEAR) revealed. Purpose: To identify, prohibit, and prevent resident abuse. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, resident representatives, friends, and other individuals. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful: The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy included: Physical abuse-- Includes but is not limited to hitting slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Investigation: It is the policy of the facility to thoroughly investigate injuries of unknown origin, and any allegations of abuse that include: Verbal Abuse, Sexual Abuse, Physical Abuse, Mental Abuse, Neglect, Involuntary Seclusion, and Misappropriation of Property, Exploitation, Mistreatment, and Suspicion of a Crime. As a part of the Policy on Investigation, it stated, At the conclusion of the investigation, the Administrator and Director of Nursing and designated staff will review all evidence and reach a conclusion if abuse has been substantiated, and any corrective actions to be taken. Report the results to the proper authorities as applicable. On (MONTH) 12, (YEAR) at approximately 10:40 AM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0607 at a scope and severity of [MI] The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on (MONTH) 25, (YEAR) and is ongoing.

Based on record review, review of facility records, and interviews, the facility failed to protect residents from abuse/harm for 6 of 18 residents reviewed for abuse. Residents #7, #11, #12, #13 and #16 received injury from resident to resident abuse. Resident #1 was verbally abused by Certified Nursing Aid (CNA) #1. The findings included: The facility admitted Resident #16 on 5/7/18 with [DIAGNOSES REDACTED]. Review of Resident #16's Departmental Notes from 8/17/18 through 9/26/18 revealed: 8/17/18 Resident moved to room ___ (private room) 9/2/18 Resident continues to try to boss other residents around when they don't do what s/he says s/he curses and sometimes makes comment, I can take you down if you don't do things the right way. Resident has been redirected when speaking to other residents in a threatening manner. 9/24/18 DC (discontinued) from Behavior Management Program on 9/24/18 after IDT (Interdisciplinary Team) team review due to no further incidents with other residents. 9/26/18 Around 8:15 PM yelling was heard coming from resident's room, went in to see what was going on and observed a resident on top of this resident holding her/him with a closed hand around her/his neck. Took several minutes to separate residents. Got other resident out of room. Assessed this resident for injuries, s/he did have some redness noted to his neck on the right side. No more injuries noted. Review of the facility investigation for Resident #16 and Resident #15's incident dated 9/26/18 revealed a summary report of the facility's investigation. Staff alerted to room ___ by a loud noise. Staff observed resident #15 making contact with resident #16's neck with an open hand and contact with her/his chest with a closed hand. Resident #16 was noted to have red marks on her/his neck. Upon completion of facility investigation no intent to harm was found related to cognitive impairment of both residents Staff will continue to intervene as needed. Review of witness statements revealed a statement from CNA #5 dated 9/26/18. The CNA stated s/he had heard yelling in resident room. CNA entered resident room and saw Resident #15 standing beside bed of Resident #16 while Resident #16 was lying in the bed. Resident #15 had open hand to Resident #16's neck and closed hand in contact with the chest. CNA separated residents and alerted nurse. Review of witness statements revealed a statement from Licensed Practical Nurse (LPN) #6 dated 9/26/18. The LPN stated Heard yelling coming out of room___, this nurse ran into room and observed Resident (#15) with a closed hand around another Resident (Resident #16) throat and s/he was on top of her/him in Resident #16 bed. Had to call resident's name several times before we could separate them. The Facility Investigation for Resident #16 and Resident #15 failed to contain an accurate representation of the incident dated 9/26/18. The facility report stated no harm was intended, but witness statements contained in the report stated that Resident #15 had hand over throat and was on top of Resident #16 in the bed. The facility investigation for Resident #16 and Resident #15 failed to provide evidence that Resident #15 had been removed from the room by the CNA and then returned for the nurse to find Resident #15 on top of Resident #16. The facility admitted Resident #11 on 10/3/18 with [DIAGNOSES REDACTED]. Review of Resident #11's medical record revealed an Admission MDS of 10/13/18: BIMS- 7 of 15, Behaviors- [MEDICAL CONDITION], Verbal behavior directed towards others. Overall presence of behaviors. Rejection of care 1- 3 days during look back period. Supervision to independent with activities of daily living, ambulatory. S/he required limited assist with toilet use and hygiene. No history of falls. Received antipsychotics and antidepressants for 7 days of the look back period. Review of Resident #11's medical record revealed the resident's Plan of Care. 10/26/18: Right Orbital Fracture and Abrasion to right face. Observe for signs and symptoms of complications, provide proper safety as possible. Observe right orbital area every shift and as needed. Notify physician as needed, At risk for skin tear problem. Treatment as ordered, assess wound and record measurements as needed, observe for signs of infection, notify physician as needed. Observe standard precautions. Review of Resident #11's Departmental Notes revealed: 10/4/18 Not happy about being at facility. Guardian endorses paranoid behaviors, calling 911 and verbal outbursts. Resident noted to be pleasant and cooperative. 10/5/18 Resident slamming doors and stated, I'll tear this place apart. Resident asked where his belongings were. Nurse instructed belongings in closet. 10/26/18 2:34 AM Upon entering room, resident on floor, roommate standing up. CNA states made contact with roommate. Skin tear to left forearm, discoloration to right face. Supervisor notified, attempted to call Responsible Party (RP), message (msg) left. Resident stated, S/He got me pretty well. Separated from roommate. 10/26/18 4:36 AM-late entry for 10/25/18 11:15 PM, informed by floor nurse that resident was noted lying on floor of bedroom and making physical contact with roommate. Resident had change in neuro checks. Resident is lying in bed, bruising noted to right eye. Left pupil reactive to light, right pupil non-reactive. Hand grasps equal. Follows instruction. MD notified to send to ER for evaluation. 10:38 AM Resident will change from room. 3:24 PM diagnosed with [REDACTED]. Resident being monitored and on behavior management. Review of the facility investigation for Resident #11 and Resident #10 dated 10/25/18 revealed: On 10/26/18 resident #11 noted with a change in neuro status and continued complaints of pain to the right eye. Resident sent to ER for evaluation. X-ray obtained and reveals a right orbital fracture. No surgical intervention needed. Review of witness statements revealed a statement from CNA #13 dated 10/25/18. The CNA stated Heard residents yelling out of room ___. When entering room both residents was in contact with one another. Residents #10 and Resident #11 was both on the floor. Removed Resident #10 out of the room and the two other CNAs went and picked up Resident #11 off the floor. Notify the nurse that was duty. Review of witness statements revealed a statement from CNA # 14. The CNA stated Heard resident yelling Help out of room ---. The assigned CNA entered the room and asked for help. Upon entering the room, I saw Resident #11 on the floor with discoloration under his/her right eye. CNA #13 took Resident #10 out of the room while me and another CNA helped the nurse get Resident #11 back to her/his bed. The facility admitted Resident #12 on 7/25/18 with [DIAGNOSES REDACTED]. Review of Resident #12's medical record revealed the resident's Plan of Care. [DIAGNOSES REDACTED]. Psych consult as needed. Risk for injury/falls related to Alzheimers, Post-Traumatic Stress Disorder, [MEDICAL CONDITION] Med Use. Risk for skin tears/discolorations due to thin fragile skin. Handle skin cautiously, lubricate skin, Skin inspections routinely. If agitated provide for safety. Review of Resident #12's Departmental Notes from 8/1/18 through 12/12/18 revealed: 8/9/18 Adjusting well, still exit seeks. 9/12/18 Was informed by floor nurse that CNA brought to her/his attention after hearing commotion s/he entered into room and found Resident #10 making open hand contact to resident's bilateral arms. Residents were redirected by CNA and at this time calm and cooperative. Noted discoloration to bilateral arms, resident denies pain. 9/13/18 Resident has a discoloration to the left upper arm, and right upper arm near his/her elbow, no complaints of pain, and no altercations observed this am. But resident was confused about having a roommate and did not remember him/her. 5:08 PM Social Services note: Resident was involved in an incident in which another resident made open hand contact to his/her upper arms. Resident was in her/his room when another resident walked in and made physical contact with her/him. Resident had some discoloration where s/he was touched. Review of the facility investigation for Resident #12 and Resident #10 of incident dated 9/12/18 revealed: Staff observed Resident #10 make contact with Resident #12's arms with open hands. Registered Nurse (RN) assessments and body audits were completed. Resident #12 was observed with red discolorations to the right inner arm measuring 2 cm x 2 cm and left outer arm measuring 3 cm x 2 cm. 1 (one) witness statement that said s/he overheard a commotion and ran to the room, found Resident #12 had open hand contact with Resident #10 trying to pull away. During an interview on 12/13/18 at 9:34 AM CNA #11 stated On 9/12/18 I was sitting in day room. I heard commotion going on. I ran to her/his room. Resident #10 had her/his hands on the resident and Resident #12 had his/her hands on Resident #10. Resident #12 was up against the dresser drawers (standing up). Each of them were holding on to the others arms The CNA demonstrated holding out both hands on to arms of the other resident. It was Resident #12's room that Resident #10 was in. Resident #12 said this man was in my bed, this is my room. They were holding on to each other. The facility admitted Resident # 13 on 11/1/18 with [DIAGNOSES REDACTED]. Review of Resident #13's medical record revealed an Admission MDS dated [DATE]. The resident had a BIMS core of 8 out of 15. Behaviors-[MEDICAL CONDITION] checked. No behaviors coded. Extensive assistance needed with ADLs except for supervision required with eating. Resident non-ambulatory. History of falls prior to admission. Received antipsychotics and antidepressants for 7 days of the look back period. Review of Resident #13's care plan revealed: 11/25/18 At risk for skin tears/discolorations, due to resident has thin fragile skin. Handle skin cautiously. Observe for skin tears/discolorations, keep skin lubricated with lotion, offer additional fluids. Skin inspections routinely. If resident is agitated, provide for resident's safety and leave alone for a little while and come back to resident later. Observe skin tears for signs and symptoms of infection, observe for complications. 11/16/18 Behavior Management Program- resident involved in physical altercation from another resident. Staff separated and redirected and SW to provide psychosocial support as needed. 11/26/18 Behavior management program- resident involved in physical altercation from another resident. Staff separated and redirected. Review of Resident #13's Departmental Notes from 11/1/18 through 12/10/18 revealed: Social Services note dated 11/1/18 Admission note: Resident displays agitation, confusion, combativeness, depression at times, forgetfulness, restlessness, has delusions, hallucinations and refuses care. Resident shakes his/her head yes and no, communication barrier. Resident did exit seek at the last facility and staff is to monitor for these behaviors. 11/16/18 12:15 AM Notified by nurse that resident was pulled out of bed by another resident. Assessed for injuries, none noted. 1:25 PM Called to room by yelling. Another resident in room yelling and cursing at him/her. Resident states s/he is afraid for his life, asked staff to remove other resident before s/he hurts her/him. Review of the facility investigation for Resident #13 and Resident #10 dated 11/25/18 revealed a written statement from CNA #15 dated 11/25/18: I heard Resident #13 yelling, Help, Help! So I went into his/her room and s/he told me the man beat me up. Resident #10 was standing over Resident #13, so I walked her/him to her/his room. When I was helping Resident #13 back to bed, s/he showed me the spot of blood on the bed and then a cut on her/his arm. S/he told me the man shook me and wanted me out of my bed. S/he beat me up. I did not see any altercation between the residents. Review of witness statements revealed a statement from CNA #15 obtained on 11/15/18. The CNA stated I heard (Resident # 13) yelling 'Help, Help!' So I went into her/his room and s/he told me the man beat me up. Resident #10 was standing over Resident #13, so I walked her/him to the door and told her/him to go back to her/his room. When I was helping Resident #13 back into bed, s/he showed me the spot of blood on the bed and then the cut on her/his arm. S/he told me the man shook me and wanted me out of my bed. S/he beat me up. I did not see any altercation between the residents. During an interview with CNA #15 on 12/13/18 at 3:46 PM CNA #15 stated Resident #10 got in bed with Resident #13 and was holding her/his hands, that caused the redness. Resident #13's family told the CNA of one other incident of Resident #10 in Resident #13's room trying to get the resident out of the bed. Resident #10 doesn't go to any other resident's rooms, s/he has been aggressive at times in other common areas. When the CNA went into the room Resident #13 put him/herself in his/her wheelchair, s/he was wheeling away from the bed in wheelchair, screaming help help. Resident #10 was coming out of the bed when I came in, I saw a blood spot when I put Resident #13 back in bed. I think it happened from resident grabbing her/his hands and shaking them. I think Resident #10 was trying to pull Resident #13 out of bed but I didn't see what happened. I responded when I heard the yelling and Resident #13 was already up in her/his wheelchair and Resident #10 was coming up out of Resident #13's bed. Resident #13 is alert enough to explain what happened, after s/he explained it made sense, by beating her/him up s/he explained Resident #10 grabbed her/him by her/his hands and was shaking, pulling on her/him. The facility investigations revealed that Resident #10 had been involved in three different altercations with three different Residents (Resident #11, #12, and #13). One altercation with Resident #11 on 10/25/18 resulted in Resident #11 sustaining a fractured eye orbit. One altercation with Resident #12 on 9/12/18 resulted in Resident #12 with discoloration marks on her/his arms. The third altercation was with Resident #13 on 11/25/18 and resulted in Resident #13 receiving a skin tear and Resident #13 stated that s/he was afraid for her/his life. The facility investigations failed to clearly identify what may have happened with these residents in all three altercations or to clearly identify the origin of the injuries sustained during these altercations. In addition, the facility investigations were unclear as to which resident initiated the altercations. Review of the facility's Five-Day Follow-Up Report for Resident #1 dated 11/2/18 revealed the incident occurred on 10/30/18 at 1:25 PM. It was reported to the social worker by a nursing student that while attempting to give Resident #1 a shower, a CNA was rude with the resident for not showing the nursing students how to turn the shower head on. It was stated that the resident mumbled something under his/her breath and that the CNA said to Resident #1 you keep on and I will get you in trouble and you will be out. Review of Resident #1's Social Service Note dated 10/30/18 at 3:57 PM revealed Resident #1 was alert and oriented, very confused, can make most of his/her needs known to staff other times staff has to anticipate his/her needs. Resident Brief Interview for Mental Status score was noted as 5. CNA #1's facility-obtained statement dated 10/30/18 indicated s/he did not say anything inappropriate to Resident #1 that day. Resident #1 was not following instructions in the shower room. CNA #1 asked him/her not to act up in front of the students. Resident #1 mumbled under his/her breath to the students she's a b****. CNA #1 stated s/he didn't say anything else. There was a second statement provided by CNA #1 on 10/30/18 that was not witnessed. CNA #1 indicated on 10/30/18 s/he was working in the shower room with CNA #2. Two students from the high school brought Resident #1 into the shower room. When they came in, CNA #1 asked the resident why did you come in with all those clothes because you will have to take them off. CNA #2 was standing behind them and heard Resident #1 tell the students she's a b**** talking. The two students started laughing. CNA #2 said you should not call him/her that when s/he told me what the resident said. CNA #1 helped the resident get dressed because the students did not put his/her catheter bag inside his/her pants leg. CNA #1 and CNA #2 put Resident #1 in his/her wheelchair. CNA #1's statement indicated not one time did I cuss at the resident. Student Nurse #1's facility-obtained statement dated 10/31/18 indicated s/he and Student Nurse #2 were in the shower room. CNA #1 and CNA #2 were also in the shower room. CNA #1 was fussing at them to hurry. They helped the resident get undressed. They were having trouble with the shower head. CNA #1 said to Resident #1 why didn't you tell them how to turn the shower on. Resident mumbled under his/her breath - was unable to make out what s/he said. CNA #1 said if you don't watch what you say to me, you will get in trouble and be kicked out of here. Resident #1 did not say anything else. After the shower, CNA #1 asked Resident #1 why didn't you tell them to put your catheter through your pants leg. You know you should tell them that. CNA #1 fixed his/her catheter. Student Nurse #2's facility-obtained statement dated 10/31/18 indicated CNA #1 told them to hurry up and help get Resident #1 undressed. They were trying to turn on the shower head and CNA #1 looked at Resident #1 and asked him/her why s/he didn't tell them how to turn it on and told the resident not to be showing out. Resident #1 then mumbled, Student Nurse #2 did not know what s/he said. Then the CNA said you keep on and I will get you in trouble and you will be out of here. They finished his/her shower and got the resident dressed. Student Nurse #2 forgot to put his/her catheter through the pants. CNA #1 asked Resident #1 why didn't you tell them to put your catheter through your pants. Resident #1 said s/he did not know. The facility failed to protect Resident #1 from abuse by CNA #1. Review of the Five-Day Follow-Up Report for Resident #9 and Resident #7 dated 10/5/18 revealed on 10/2/18 at 1:30 PM Resident #9 was observed by staff to make contact with closed hands to Resident #7's face. Resident #7 sustained a lower lip abrasion. Review of Resident #7's medical record revealed a Social Service note dated 10/3/18 that indicated s/he was asked on 10/2/18 to make psychosocial visit with resident in reference to an altercation s/he was involved in with another resident. According to staff, Resident #7 was outside in the courtyard when another resident made contact with his/her face with a closed hand. Staff witnessed resident being struck twice in the face. Both residents were brought inside to be separated and redirected. Review of Resident #7's Nurses Note on 10/2/18 at 3:04 PM indicated the nurse was notified by CNA that another resident made contact with a closed hand to Resident #7. An abrasion was noted to Resident #7's lower lip. 10/2/18 at 2:36 PM Resident #7 was noted through window of day room in courtyard with another resident. Stated other resident made closed hand contact to Resident #7 at least twice to resident's face. Per activities the first contact s/he witnessed was outside in courtyard on porch area and again once brought inside from courtyard. Residents were separated by staff. Resident noted with abrasion to left side of face and left lower lip. CNA Trainee #1's facility-obtained statement dated 10/2/18 indicated Resident #9 closed fist made physical contact. I saw it twice, outside and inside. Student Nurse #3's facility-obtained statement dated 10/2/18 indicated while in the dayroom s/he saw Resident #9 make physical contact with Resident #7, in courtyard. CNA #11's facility-obtained statement dated 10/2/18 indicated s/he witnessed Resident #9 make physical contact with Resident #7 near the nurse's station. Activity assistant #1's facility-obtained statement dated 10/2/18 indicated Resident #9 made contact with other resident twice, with closed fist, once on porch/courtyard and again inside. CNA #12's facility-obtained statement dated 10/2/18 indicated Resident #9 walked out into courtyard and approached another resident and made contact with a closed fist. Immediately went to stop. The facility investigation failed to include documentation/evidence that the facility protected Resident #7 from Resident #9. Review of the investigative file, Incident Report, and nurse's note revealed no documentation as to how or if staff immediately went to stop Resident #9 from hitting Resident #7, then Resident #7 was hit a second time inside the building. There was no documentation on timeframes between when both incidents occurred and any interventions made by staff in between both incidents to prevent further abuse.