Every finding on record at Willow Park Rehabilitation and Care Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services and 2 of 2 resident nourishment rooms reviewed for sanitary conditions.1. The facility failed to ensure a trash barrel containing raw egg shells and other waste was covered in the kitchen.2. The facility failed to ensure meat was not being thawed in a sink on the morning of 6/14/2026.3. The facility failed to ensure foods were in sealed containers and were labeled and dated in the walk-in refrigerator and the non-perishable food storage room on the morning of 6/14/2026.4. The facility failed to ensure dietary employees' food and drinks were not stored in a resident food refrigerator in the kitchen.5. The facility failed to ensure the floor drain cover was not removed with the open drain pipe exposed beneath the food preparation 2-compartment sink.6. The facility failed to ensure the convection oven, a gas oven, a water well in the steam table, and a compartment of the dinner plate warmer were in working order.7. The facility failed to ensure serving utensils were not stored hanging from hooks on a wall peg board, with the sanitized food surfaces exposed to the air.8. The facility failed to ensure the stainless-steel wall panel (back-splash) behind the ovens and deep fryer was not soiled with a build-up of grease.9. The facility failed to ensure the deep fryer unit did not contain dark colored cooking oil and was not soiled with fried food crumbs.10. The facility failed to ensure a dietary aide wore hair restraints to cover facial hair and completely cover the hair at the nape of his neck during meal preparation on 6/16/2026.11. The facility failed to ensure plated food was covered when carried from the kitchen food service line across the hallway to the dining room during the lunch meal on 6/16/2026.12. The facility failed to ensure the refrigerator interior surfaces were not soiled with spilled food and liquids and did not contain food items that were not labeled and dated in 2 of 2 nourishment rooms intended for resident personal food storage and supplements.13. The facility failed to ensure the Nourishment Room for Halls 300 and 400 did not have the ice scoop laying directly on the ice inside the ice chest for Hall 400 on the afternoon of 6/16/2026.14. The facility failed to ensure the Nourishment Room for Halls 300 and 400 did not have water bottles labeled with hummingbird food and Do Not Drink stored in the door shelf of the resident food and supplement refrigerator on 6/16/2026. These failures could place the residents at risk for foodborne illness and compromised health status. The findings included: Observations and interviews during the initial tour of the kitchen on 6/14/2026 at 8:58 AM to 10:15 AM revealed the following: - [NAME] J stated there were a dietary aide and a dishwasher on duty with her and the 3 of them worked together every weekend on Saturday and Sunday for all 3 meals each day. She stated the DM was not present in the facility during the weekend.- An uncovered trash barrel contained the shells from pasteurized eggs and was positioned near the 3-compartment sink.- The 3-compartment sink did not contain water. The first compartment had 3 packages of meat, which were soft and thawed. The faucet water was not running and the bottom of the sink was dry.- [NAME] J stated the 3 packages of meat in the first compartment sink were turkey breasts. She stated the turkey breasts were in the sink for 2 hours to thaw and she had not used running water on the turkey breasts to thaw them. The [NAME] stated she had removed the cardboard case which contained the three 6-pound turkey breasts from the freezer yesterday (6/13/26) and placed them in the refrigerator to thaw. She stated when she arrived at work that morning (on 6/14/26), the turkey breasts were still frozen and she removed them from the box and placed them in the sink to finish thawing. The [NAME] stated she needed to roast them in the oven for the lunch meal.- The walk-in refrigerator revealed an opened package with bun length [NAME] that was opened to the air; the package was partially inside a resealable plastic bag that was labeled as hot dogs, dated 6/12/26; 3 resealed plastic bags which contained cooked meat patties, breaded meat patties, and cream style corn were not labeled or dated; an 18-quart container with tomato soup was covered with foil, dated 6/12/26; an 18-quart container with chicken noodle soup had a ladle inside the container and the lid was not securely in place with the container opened to the air, dated 6/12/26; an opened bag of grated parmesan cheese was wrapped with plastic wrap, dated 9/12 (2025).- [NAME] J removed the 3 resealed bags from the refrigerator and replaced them in another location on the shelf after she labeled them as hamburger patties, Salisbury steak, and cream style corn and dated them 6/13/26. She stated she made them yesterday and would use them today.- The walk-in freezer had a resealed clear plastic bag with frozen dinner roll dough that was not labeled or dated and stored on a shelf.- The reach-in refrigerator in the food preparation area held a small square storage container that was not labeled and dated on a shelf and 3 open bottles of drinking water were in the refrigerator. The [NAME] stated the small storage container was her lunch and the 3 bottles with water belonged to the dietary staff on duty. She stated there was not any place to store her lunch and the bottled water to keep them cold. She removed her lunch storage container and the 3 bottles of drinking water from the refrigerator and said the staff would not put their personal food and drinks in the resident food refrigerator again.- The floor drain cover had been removed and the drainpipe opening was exposed beneath the 2-compartment food preparation sink.- The non-perishable food storage room wire rack shelf units held an opened 42-ounce box of quick oats that was wrapped with plastic wrap and dated 6/8/26; 2 stacked trays, with labels marked with 6/5/26 on both trays, with individual condiment containers with lids that were filled with a dark colored liquid - the top tray held 15 containers and the bottom tray held 23 containers; an opened 1-pound box with corn starch that had not been placed in a resealable bag or container and was not dated when opened; an opened bag with elbow macaroni with the bag knotted closed and dated 4/22/26; an open package of instant au-gratin potatoes was wrapped in plastic wrap and dated 3/17/26; an opened 8-ounce box with gluten free twisted pasta had not been placed in a sealed container and was opened to the air and was not dated when opened.- [NAME] J stated the plastic condiment containers were filled with syrup and were used during the week for breakfast.- The non-perishable food storage room had bread stored on a tray in an open sided cart rack. An opened loaf of raisin bread had been knotted closed and was not dated; a loaf of white bread was knotted closed and dated 6/14/26; and an open loaf of toast style bread was twisted closed and dated 6/1 (2026).- The DM stated groceries were delivered on Monday and Thursday. She entered the non-perishable food storage room and observed the bread dated 6/1. She stated the toast style bread had been frozen and the date was probably the delivery date and not the date it was opened. - A peg board panel on the wall above a counter held wire whisks, spatulas, tongs, serving spoons, butter brushes, and scissors that were hanging from hooks; the food surfaces of the cooking utensils were exposed to any contaminants in the air. - The stainless-steel wall panel (back-splash) behind the ovens and deep fryer was soiled with a build-up of grease.- The deep fryer unit contained dark colored cooking oil and was soiled with fried food crumbs.- [NAME] J stated she cleaned the deep fryer every 2 weekends and changed the cooking oil. She stated the convection oven did not work and 1 of 2 gas ovens did not work. In an interview on 6/16/2026 at 10:27 AM, the DM stated she would provide the facility policy and procedure for food brought in by visitors and food storage. She stated there were nutrition rooms with refrigerators behind each nurses station. She stated snacks, beverages, individual serving size containers with Jello and pudding, health shakes, thickened water, and a carton with thickened juice were available in the nutrition rooms. In an interview on 06/15/2026 at 4:32 PM, the DM stated there was not a specific written policy and procedure for dating foods and food storage. The DM stated foods prepared in the facility kitchen were stored for up to 7 days. In an interview on 6/16/2026 at 7:46 AM, the Maintenance Supervisor stated he had been employed in facility for one month. He stated he was aware of the convection oven and 1 gas oven in the kitchen not working. The Maintenance Supervisor stated he was told about it one week ago and was evaluating the problem. He stated the gas oven occasionally stopped working and if it could not be repaired it would be replaced. He stated the convection oven would be replaced. Observation on 6/16/2026 at 8:30 AM revealed Dietary Aide K was making instant pudding for the lunch meal dessert. The hair at the nape of his neck was not covered by his hair net. He had a short beard and moustache that were not covered. In an interview on 6/16/2026 at 9:05 AM, the DM stated there had been a short supply of plate holders and covers. She stated the Maintenance Supervisor did the ordering and had ordered 24 plate covers and 24 plate holders from the supply company about one month ago and they were delivered. She stated the Maintenance Director ordered another 24 plate covers and 24 plate holders that would be delivered. She stated they were being ordered a few at a time. In an interview on 6/16/2026 at 9:08 AM, [NAME] L stated 1 of 5 hot water wells for the steam table was not working and she used that well for the bread or to place ice for cold food items. She stated she started employment in the facility kitchen during November 2025 and the convection oven had not been working at that time. She stated a repairman came to fix the convection oven and it had worked for a while and then shorted out and stopped working. [NAME] L stated the convection oven had not worked for the past 7 months. She stated the left side gas oven sometimes stopped working and could not be used. Observation on 6/16/2026 at 12:15 PM revealed the dining room meal trays were being served from the steamtable line in the kitchen. The plates and bowls were uncovered on the trays when the nursing staff carried the trays across the hallway from the kitchen to the dining room. During an interview and observation on 6/16/2026 at 12:16 PM, Dietary Aide K stated he had been employed in the facility the past 4 years. He began placing measured spoonfuls of corn into bowls. His hair net did not cover the back of his hair at the nape of his neck and he was not wearing a facial hair/beard restraint to cover his moustache and beard. Dietary Aide K stated he had just started growing a beard and moustache. Dietary Aide K left the serving area and returned wearing a white bouffant style hair restraint over his beard and moustache. In an interview on 6/16/2026 at 12:19 PM, the DM stated Dietary Aide K had just started growing a beard and moustache. She stated he needed to shave again. The DM stated there were beard restraints available. In an interview on 6/16/2026 at 12:55 PM, [NAME] L stated vegetables were always served in small side bowls. [The bowls were not warmed prior to filling.] The cook stated the electric plate warmer had two compartments and held two stacks of dinner sized plates but only one compartment worked. She stated she used the warmed plates first. Observation on 6/16/2026 at 3:11 PM, of the Nourishment Room located behind the nurses station for Halls 100 and 200, revealed a residential style refrigerator with a top door freezer compartment. The interior bottom surface of refrigerator was soiled with spilled food and beverages. The bottom storage drawers were missing and the glass shelf, above where the drawers would have been, was soiled with spilled food. Observation on 6/16/2026 at 3:27 PM, of the Nourishment Room located behind the nurses station for Halls 300 and 400, revealed 2 ice chests on carts. The Hall 400 ice chest had an ice scoop inside that was laying directly on the ice. There were two residential style refrigerators in the room. One refrigerator was not running and was empty. The refrigerator unit to the right-hand side, located closest to the room door, contained 2 bottles labeled with hummingbird food and Do Not Drink in the door shelf. A plastic food storage container with two compartments held a meat patty with gravy and was not labeled or dated. The two plastic food storage drawers contained approximately 1 inch of yellow-colored water in the bottom of the refrigerator and the glass shelf above the drawers was soiled with spilled food. In an interview on 6/17/2026 at 8:35 AM, the ADON stated she thought the housekeeping department was responsible for cleaning the nourishment room and refrigerator. In an interview on 6/17/2026 at 8:39 AM, Housekeeper N stated she was the housekeeper for Halls 100 and 200 and stated it was her 4th day on the job (new hire). She stated she thought the housekeepers were responsible for cleaning the nourishment room and the refrigerator in the nourishment room. Housekeeper N stated she had not cleaned the refrigerator in the nourishment room behind the nurses station. In an interview on 6/17/2026 at 8:44 AM, the DON stated she had been employed in the facility as the DON for 2 years. The DON stated the housekeepers were responsible for cleaning the nourishment room, which included the refrigerator. She stated the nursing staff documented the refrigerator and freezer compartment temperatures in the nourishment rooms on the daily temperature log. The DON stated the nursing staff cleaned out the refrigerator/freezer units in the nourishment rooms last night (6/16/2026) and had thrown away everything that did not belong in the refrigerator/freezer units. In an interview on 6/17/2026 at 8:55 AM, the DM stated the housekeeping department was responsible for cleaning the nourishment rooms behind the nurses stations. She stated the housekeeping supervisor quit last Friday, 6/12/2026, and the supervisor for the laundry department was going to be the housekeeping supervisor. The DM stated to talk with the supervisor in the laundry room. In an interview and record review on 6/17/2026 at 9:00 AM, the Laundry Supervisor stated she recently became the Housekeeping Supervisor. She stated the housekeeping department was responsible for cleaning the nourishment rooms. She found and provided a copy of the housekeeping daily cleaning tasks for review. Review of the daily cleaning task assignment sheet indicated the 100 Hall daily cleaning task included the nurses station /nutrition room and the 300 Hall daily cleaning tasks included cleaning the nurses station/nutrition room. In an interview on 6/17/2026 9:27 AM, the DM stated the policy for infection control indicated hair restraints and beard restraints were to be worn. The DM stated her expectation was for the dietary staff to do things right so they succeeded. She stated sometimes the staff became lackadaisical or were in a hurry and thought they would go back and finish doing something and then did not do it. The DM stated the dietary staff were expected to store foods correctly and date them. The DM stated an outcome for the residents could be physical contamination of foods and foodborne illness and sickness for the residents. In an interview on 6/17/2026 at 11:19 AM, the OM stated the expectation for the dietary department was to store foods properly. He stated the expectation was for foods to be labeled and dated when opened and/or prepared and dated with a use by date, and opened packages were to be placed in sealed bags or containers. The OM stated the housekeeping staff were expected to clean the nourishment rooms, the night shift nursing staff were expected to record the refrigerator and freezer temperatures in the nourishment rooms, and the nourishment rooms and refrigerators/freezer units were to be for resident food and supplements only. The OM stated no staff food or drinks were to be stored in the nourishment room or in the refrigerators/freezers. He stated an outcome of not properly storing and dating food could be cross contamination that could cause foodborne illness with vomiting and diarrhea for the residents. Record review of the facility policy and procedures for Resident/Personal Food Storage, dated as revised 02/2025, indicated [in part]:Policy: Food or beverages brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety.Procedures:1.Food storage areas shall be clean at all times.2.Outside foods brought in to residents by visitors will be stored in personal refrigerator or facility refrigerator designated for resident use.3. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures 4. Resident and individuals bringing food in from outside sources will be educated on safe food handling and storage techniques by designated facility staff as needed. Record review of the facility's Dietary Services Policy/Procedure for Food Storage, dated as reviewed 7/2025, indicated [in part]:Policy: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner.Procedures: 1.Food storage areas shall be clean at all times Record review of the facility's Dietary Services Infection Control Policy / Procedure, dated as revised 10/2021, indicated [in part]: Policy:It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness.Procedures:4. Personal HygieneA. Proper attire for food handlers should include a hair covering (hair nets or caps).Moustaches and sideburns must be kept trimmed. Beards must be covered.5. Food StorageC. All food items must be properly labeled, dated and stored in proper place F. Frozen foods must be thawed at refrigeration temperatures of 40 degrees F or below, or quick-thawed as part of the cooking process.G. Old stock is rotated and used first.6. Proper Food HandlingC. Foods are prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements so as to avoid manual contact of prepared foods .E. Prepared foods should be transported to other areas in closed food carts or covered containers K. Leftovers must be dated, labeled, covered, cooled and stored (within 1/2 hour) in a refrigerator, not at room temperature P. Foods that have stood for several hours at room temperature cannot be considered safe and free from contamination and cannot be made so by refrigeration, especially during the summer season. They must be discarded . Record review of the facility's Job Description for Housekeeping Supervisor, dated 12/27/2021, indicated [in part]: Position Summary: To assist in the management and direction of Environmental Services Department in accordance with federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator, to ensure that the highest degree of quality is maintained at all times .Essential Duties and Responsibilities: Ensures that new employees are oriented and properly trained .Work Environment:Works in all area(s) of the facility (i.e. nurse's stations, resident rooms, offices, etc.) . Record review of the Food and Drug Administration Food Code 2022 specified [in part]: Chapter 2. Management and Personnel2-4 Hygienic Practices2-402 Hair Restraints2-402.11 Effectiveness. (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.Chapter 3 Food3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of thecontents so that the FOOD is not exposed to ADULTERATION or potentialcontaminants.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet the residents' medical, nursing, mental, and psychosocial needs, for 9 of 18 residents (Residents #4, #5, #8, #9, #35, #46, #65, #69, and #77 ) reviewed for care plans.1.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #4's hearing difficulty.2.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #5's skin condition and skin tears.3.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #8's assistance with activities of daily living, hearing loss, choices, walker and wheelchair use, limited range of motion, diagnoses, pain management, history of falls, swallowing difficulty, mechanically altered diet, no natural teeth, high risk medications, or therapy services.4.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #9 assistance with activities of daily living, behaviors, mobility, incontinence, diagnoses, pain, swallowing, at risk for pressure ulcers, pressure reducing devices, hydration, high-risk drugs, or therapy services.5.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #35's activities of daily living, and diagnoses of hypertension, cancer, peripheral vascular disease, obstructive uropathy, multidrug-resistant organism, hyperlipidemia, cerebral palsy, anxiety disorder, depression, or bipolar disorder.6.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #46's diet requirements, advanced directives, or activities of daily living.7.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #65's activities of daily living, bowel and bladder incontinence, dementia care, or Parkinson's care.8.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #69's hip fracture, pain management, limited range of motion, or activities of daily living.9.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #77's hearing loss or hearing aid usage, walker use for mobility, pressure reducing device for bed, activities of daily living, nor for the diagnoses that included cancer, coronary artery disease, heart failure, hypertension, renal failure, diabetes, hyperlipidemia, Alzheimer's, anxiety, and depression.These failures could place all residents at risk of not being provided with necessary care and services. The findings included:1. Resident #4Record review of Resident #4's Face Sheet, dated 6/17/2026, indicated a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included chronic obstructive pulmonary disease (lung disease with shortness of breath), dementia (impaired cognition with memory loss), atrial fibrillation (irregular heart beat), myocardial infarction (heart attack), and bipolar disorder (mental disease with fluctuating mood states ranging from manic - high to depressed - low).Record review of Resident #4's Quarterly MDS Assessment, dated 6/10/2026, indicated a BIMS score of 15 (cognitively intact) and moderate difficulty in ability to hear. Record review of Resident #4's Comprehensive Care Plan dated 6/7/2026 revealed no care planning for hearing difficulty.2. Resident #5Record review of Resident #5's Face Sheet, dated 6/17/2026, indicated an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (cognitive impairment with memory loss), heart failure, hypertension (high blood pressure), gastro-esophageal reflux disease (back-flow of stomach acid into the esophagus), and type 2 diabetes mellitus (body's resistance to insulin resulting with high blood sugar levels).Record review of Resident #5's Quarterly MDS Assessment, dated 5/21/2026, indicated a BIMS score of 3 (severe cognitive impairment) and skin condition with skin tears.Record review of Resident #5's Comprehensive Care Plan dated 5/14/2026 revealed no care planning for skin conditions.3. Resident #8Record review of Resident #8's Face Sheet, dated 6/17/2026, indicated an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including left hip fracture, chronic obstructive pulmonary disease (lung disease with shortness of breath), hypertension (high blood pressure), and osteoarthritis (arthritis in the bone joints).Record review of Resident #8's Comprehensive MDS Assessment, dated 4/10/2026, indicated Resident #8:a.Had moderate difficulty with hearingb.Choices are very importantc.Uses a walker and wheelchair for mobilityd.Had limited range of motion in upper and lower extremitiese.Required moderate assistance with eating, oral hygiene, upper body dressing, and transfers. Max assistance with personal hygiene, showering and toileting. And dependent with lower body dressing and applying footwear.f.Active diagnoses included: hip and knee replacement, cancer, anemia, hypertension, arthritis, hip fracture, asthma, pain, and cataracts or macular degeneration.g.Had pain almost constantly. Affected sleep, interfered with therapy activities, and day to day activities.h.Had a history of falls with major injuryi.Had swallowing difficulty and a mechanically altered diet.j.Had no natural teethk.High risk medication use with anticoagulants and anticonvulsantsl.Therapy services included: Speech, occupational, physical and respiratory therapy. Record review of Resident #8's Comprehensive Care Plan, dated revised 6/15/2026 revealed no care planning for assistance with activities of daily living, hearing loss, choices, walker and wheelchair use, limited range of motion, diagnoses, pain management, history of falls, swallowing difficulty, mechanically altered diet, no natural teeth, high risk medications, or therapy services.4. Resident #9Record review of Resident #9's Face Sheet, dated 6/16/2026, indicated a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. The resident's diagnoses included hypertension (high blood pressure), transient ischemic attacks (mini-strokes), and Alzheimer's disease (most common cause of dementia - loss of mental ability with memory loss).Record review of Resident #9's Quarterly MDS dated revised 6/5/2026, revealed Resident #9:m.Had verbal behaviors directed towards othersn.Uses a wheelchair for mobilityo.Is dependent on all activities of daily living (eating, showering, toileting, dressing, hygiene, and transfers).p.Always incontinentq.Active diagnoses included anemia, hypertension, hyperlipidemia, Alzheimer's, cerebrovascular accident, hemiplegia/hemiparesis, malnutrition, anxiety, depression, bipolar disorder, and psychotic disorder.r.Occasional pain that affects sleeps.Swallowing disorder, loss of liquids when eating or drinking, coughing or choking, and complaints of difficulty or pain with swallowing.t.At risk for pressure ulcers or injuries.u.Had pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems, and application of ointments.v.High-risk drug classes included: Antipsychotic, Antiplatelet, and Anticonvulsants.w.Therapy Services: Speech, Occupational, and Physical Record review of Resident #9's Comprehensive Care Plan, dated revised 6/4/2026 revealed no care planning for assistance with activities of daily living, behaviors, mobility, incontinence, diagnoses, pain, swallowing, at risk for pressure ulcers, pressure reducing devices, hydration, high-risk drugs, or therapy services. 5. Resident #35Record review of Resident #35's Face Sheet, dated 6/17/2026, indicated a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE]. The resident's diagnoses included bipolar disorder (mental disease with fluctuating mood states ranging from manic - high to depressed - low), gastro-esophageal reflux disease (back-flow of stomach acid into the esophagus), peripheral vascular disease (poor circulation), and congestive heart failure (inability of the heart to pump blood to supply oxygen to the body).Record review of Resident #35's Quarterly MDS Assessment, dated 6/4/2026, indicated Resident #35 required:x. set-up assistance for meals and personal hygiene. Supervision with oral hygiene. Moderate assistance with showers and upper body dressing. And was dependent on all transfers, toileting hygiene, lower body dressing, and footwear.y.Active diagnoses of hypertension, cancer, peripheral vascular disease, obstructive uropathy, multidrug-resistant organism, hyperlipidemia, cerebral palsy, anxiety disorder, depression, bipolar disorder. Record review of Resident #35's Comprehensive Care Plan, dated revised 6/4/2026, revealed no care planning for activities of daily living, and diagnoses of hypertension, cancer, peripheral vascular disease, obstructive uropathy, multidrug-resistant organism, hyperlipidemia, cerebral palsy, anxiety disorder, depression, bipolar disorder.6. Resident #46Record review of Resident #46's Face Sheet, dated 6/17/2026, indicated an [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. The resident's diagnoses included cerebral infarction (stroke), type 2 diabetes mellitus (body's resistance to insulin resulting in high blood sugar levels), atrial fibrillation (irregular heart beat), bipolar disorder (mental disease with fluctuating mood swings from manic - high to depressed - low), Alzheimer's disease (most common cause of dementia - loss of mental abilities and memory loss).Record review of Resident #46's Quarterly MDS dated [DATE] revealed Resident #46: z.Required set-up assistance with eating, moderate assistance with personal hygiene, max assist with oral hygiene and turns, and was dependent with toileting hygiene, showers, complete dressing, and footwear.aa.Had limited Range of motion in upper and lower extremities.bb.Required a mechanically altered and therapeutic diet.cc.Dependent on wheelchair for mobilityRecord review of Resident #46's Comprehensive Care Plan, dated 5/12/2026, revised 6/4/2026, revealed no care planning for activities of daily living, diet requirements, or advanced directives.7. Resident #65Record review of Resident #65's Face Sheet, dated 6/17/2026, indicated a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive nervous system disorder affecting movement of the body), mood disorder, dementia (decline in mental ability), depression, hypertension (high blood pressure), anxiety disorder, and repeated falls. Record review of Resident #65's significant change MDS Assessment, dated 4/22/2026 indicated Resident #65:dd.Required set-up assistance with eating and fully dependent with all other activities of daily living.ee.Was incontinent with bowel and bladder.ff.Had diagnoses that included: Dementia and Parkinson's diseases. Record review of Resident #65's Comprehensive Care Plan, dated 5/14/2026, revealed no care planning for activities of daily living, bowel and bladder incontinence, or for diagnoses of dementia and Parkinson's diseases. 8. Resident #69Record review of Resident #69's Face Sheet, dated 6/17/2026, indicated a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included left hip fracture, hypertension (high blood pressure), gastro-esophageal reflux disease (back-flow of stomach acid into the esophagus), and alcoholic cirrhosis of the liver (permanent liver damage).Record review of Resident #69's admission MDS dated [DATE] revealed Resident #69:gg.Had a hip fracturehh.Required pain management related to hip fractureii.Had limited range of motion Record review of Resident #69's Comprehensive Care Plan, dated 5/22/2026, revealed no care planning for hip fracture, pain management, or limited range of motion. 9. Resident #77Record review of Resident #77's Face Sheet, dated 6/17/2026, indicated an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. The resident's diagnoses included hypertension (high blood pressure), congestive heart failure (inability of the heart to pump blood to supply oxygen to the body), type 2 diabetes mellitus (body's resistance to insulin resulting in high blood sugar), and Alzheimer's disease (most common cause of dementia - cognitive impairment with memory loss).Record review of Resident #77's Quarterly MDS dated [DATE] revealed Resident #77:jj.Had moderate difficulty with hearing and used hearing aids.kk.Used a walker for mobility and a pressure-reducing device for bed for skin conditions.ll.Required set-up assistance with all activities of daily living and supervision with transfers.mm.Active diagnoses included cancer, coronary artery disease, heart failure, hypertension, renal failure, diabetes, hyperlipidemia, Alzheimer's, anxiety, and depression.Record review of Resident #77's Comprehensive Care Plan, dated 5/15/2026, revealed no care planning for hearing loss or hearing aid usage, walker use for mobility, pressure reducing device for bed, activities of daily living, nor for the diagnoses that included cancer, coronary artery disease, heart failure, hypertension, renal failure, diabetes, hyperlipidemia, Alzheimer's, anxiety, and depression.In an interview on 06/17/2026 at 10:05 AM, the MD stated that the person-centered care plan was what drives the residents' care and if the plan of care was not complete, that the resident may not receive all the services they need. The MD stated his expectation was that the comprehensive person-centered care plan to reflected the assessment done in the MDS. He further stated a negative outcome could be the residents not receiving the care they need.In an interview on 06/17/2026 at 10:38 AM, ADON 2 stated the comprehensive person-centered care plans are were what determines determined the kind and level of care to provide to the residents, like therapy and goals which help determine if a resident can go home or if they should be moved to long term care. She also stated a negative outcome could be if the care plan was not complete, the residents may not receive the services needed to go home and would have to move to a long term care facility or an assisted living facility. In an interview on 6/17/2026 at 11:30 AM, the DON stated she was responsible for the care plans being accurate and complete, and the new MDS Nurse was in classes that week for MDS and care plan training. The DON further stated that care plans was were how staff knew what interventions or assistance was needed for each resident such as activities of daily living, medications, diagnoses being treated, the residents code status, skin issues, oxygen use or respiratory issues, any weight loss, if the resident was on hospice services, or required enhanced barrier precautions. She stated that by not having a person-centered care plan, it could delay care if staff were not aware of goals, tasks, and interventions, like if a resident was a fall risk, required incontinent care, or had skin problems.In an interview on 06/17/2026 at 12:33 PM, the MDS Coordinator stated the prior company used a baseline care plan form. Review of the baseline care plan indicated areas similar to the MDS assessment. The MDS Coordinator stated the current company used an Initial Care Plan which initiated the comprehensive care plan by an RN. She stated she was in training the week before regarding the MDS assessments and comprehensive care planning.In an interview on 6/17/2026 at 3:35 PM, the OM stated a comprehensive person-centered care plan should cover activities, social work, nursing, diet and patient centered care. He further stated a negative outcome of a care plan not being comprehensive and specific to a resident would be a lack of patient specific care.Record review of the facility policy entitled Comprehensive Care Plans, undated, indicated [in part]: The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 5 of 7 residents (Residents #4, #7, #8, #69, and #72 ) reviewed for respiratory care. 1.The facility failed to ensure oxygen tubing for Residents #4, #7, #8, #69, and #72 was changed weekly, dated, and kept in a bag when not in use. 2.The facility failed to ensure Residents #7, #69, and #72's nebulizer masks were dated or kept in a bag while not in use.3.The facility failed to ensure Residents #4 and #7 had the needed liquid for proper humidification when oxygen was in use.These failures could place residents at risk for infections and transmission of communicable diseases. Findings included: Record review of Resident #4's face sheet, dated 6/17/2026, indicated a [AGE] year-old female, admitted to the facility on [DATE], and readmitted [DATE]. The resident had a diagnosis of chronic obstructive pulmonary disease (lung disorder with shortness of breath).Record review of Resident #4's MDS Quarterly Assessment, dated 06/10/2026 revealed a BIMS score of 15 (cognitively intact). Section I: Active Diagnoses revealed chronic obstructive pulmonary disease, heart failure, and respiratory failure. Section O: Respiratory Treatment was marked for Oxygen Therapy.Record review of Resident #4's Care Plan dated revised 5/15/2026 revealed she had oxygen therapy with interventions that included [in part]: Change tubing, humidifier bottle and clean filter weekly In an observation and interview on 06/15/2026 at 11:41 AM, Resident #4 was seated in her wheelchair and was receiving humidified oxygen via nasal cannula at 2 liters per minute. The humidification bottle attached to the oxygen concentrator was empty with no date. The resident stated the bottle had been empty for a while. Record review of Resident #7's face sheet, dated 6/16/2026, indicated an [AGE] year-old female, admitted to the facility on [DATE]. The resident had a diagnosis of chronic obstructive pulmonary disease.Record review of Resident #7's MDS Quarterly Assessment, dated 05/07/2026 revealed a BIMS score of 15 (cognitively intact). Section I: Active Diagnoses included chronic obstructive pulmonary disease and respiratory failure. Record review of Resident #7's Care Plan dated revised 5/20/2026 revealed [in part]: Focus: Impaired Gas Exchange Chronic Obstructive Pulmonary Disease. Interventions/tasks: Administer oxygen as prescribed or per standing order.Record review of Resident #7's Physician orders dated 6/4/2026 indicated: Change O2 tubing and humidifier bottle every night shift every Monday.In an observation and interview on 6/15/2026 at 3:10 PM, Resident #7 was seated in her wheelchair, oxygen applied via nasal cannula was not dated, nebulizer mask was not in a bag and was not dated, and the humidification bottle attached to the oxygen concentrator was not dated and was empty. Resident #7 stated she believed it was supposed to be changed once a week but was not sure what day. She stated she asked someone a couple of days before and was told another nurse had to take care of it.In a follow-up observation on 6/16/2026 at 8:30 AM, Resident #7's tubing had not been changed and the humidifier bottle remained empty.Record review of Resident #8's Face Sheet dated 6/17/2026 indicated an [AGE] year-old female admitted [DATE]. The resident had a diagnosis of chronic obstructive pulmonary disease.Record review of Resident #8's MDS admission assessment dated [DATE] revealed a BIMS score of 10 (moderate cognitive impairment). Section I: Active Diagnosis included chronic obstructive pulmonary disease. Section O: Respiratory Treatment was marked for Oxygen Therapy.Record review of Resident #8's Care Plan dated 5/20/2026 revealed [in part]: Focus: Has Oxygen Therapy related to chronic obstructive pulmonary disease. Interventions/tasks: Change tubing, humidifier bottle and clean filter weekly.Record review of Resident #8's Physician Orders dated 6/14/2026 indicated: Order date: 5/20/2026 Change O2 tubing and humidifier bottle, clean filter, every night shift every Monday.In an observation on 06/14/2026 at 1:14 PM, Resident #8 was lying in bed and not feeling well. Resident's oxygen tubing was not dated and there was not a bag to store the tubing in when not in use. Record review of Resident #69's Face Sheet, dated 6/17/2026, indicated a [AGE] year-old male admitted [DATE] with a diagnosis of acute respiratory failure.Record review of Resident #69's MDS admission assessment dated [DATE] indicated a BIMS score of 5 (severe cognitive impairment). Section I: Active Diagnosis included Respiratory Failure. Section O: Respiratory treatment was marked for Oxygen therapy.Record review of Resident #69's Care Plan dated 05/20/2026 indicated Focus: Has Oxygen Therapy. Interventions/tasks: Change tubing, humidifier bottle, and clean filter weekly.In an observation and interview on 6/14/2026 at 3:35 PM, Resident #69 was observed lying on his back in bed with his eyes closed and was using oxygen via nasal cannula. The oxygen tubing and humidifier bottle were not dated. A nebulizer was on the bedside nightstand, and the tubing was not dated. The resident's family member was present in the room and stated the resident had scar tissue in his right lung and was now on oxygen continuously.Record review of Resident #72's Face Sheet revealed a [AGE] year-old male admitted [DATE] and readmitted on [DATE]. The resident had a diagnosis of chronic obstructive pulmonary disease.Record review of Resident #72's MDS Quarterly assessment dated [DATE] indicated a BIMS score of 14 (no cognitive impairment). Section I: Active Diagnoses revealed chronic obstructive pulmonary disease and respiratory failure. Section O: Respiratory Treatment was marked for oxygen therapy.Record review of Resident #72's Care Plan dated 05/20/2026 indicated [in part]: Focus: Has oxygen therapy (PRN) related to acute and chronic respiratory failure with hypoxia (lack of oxygen in the body tissues). Interventions/tasks: Change tubing, humidifier bottle, and clean filter weekly when in use.Record review of Resident #72's Physician Orders dated 6/16/2026 indicated: Order date: 5/20/2026 Change O2 tubing and humidifier bottle, clean filter, every night shift every Monday.In an observation and interview on 06/14/2026 at 1:25 PM, Resident #72 was sitting on the side of his bed, oxygen concentrator beside bed with the nasal cannula attached lying on the floor and not in a bag and not dated. Resident #72 stated that he was at the facility for a stroke and had to use oxygen when he felt he needed it. He stated the tubing had not been changed in over two weeks and that he just picked it up and used it. He stated his nebulizer tubing and mask had not been changed longer than that. Nebulizer mask with machine observed, the mask appeared old and dry, and the machine was observed with a brown substance dried on it where the mask lay.In an interview on 06/16/2026 at 1:15 PM, MA F stated she believed the tubing was to be changed weekly but she was not sure. She stated a negative outcome could be cross contamination or bacterial growth depending on the resident.In an interview on 06/17/2026 at 10:20 AM, LVN H stated oxygen tubing was changed every Monday, and the humidification bottles were checked every day. She stated they were supposed to be dated when they changed but had noticed whoever had been changing them was not dating them. Stated the resident was also to have a bag to keep the tubing in when not in use. She further stated a negative outcome could be drying of the resident's nose and airway or infection.In an interview on 06/17/2026 at 11:30 AM, the DON stated her expectation was for all residents' oxygen tubing, nasal cannula, and/or mask to be changed and dated every Monday on night shift, and that residents are provided bags to keep the cannulas or masks in while not in use. She stated the humidification bottles should be addressed every day to make sure they're not empty. Stated a negative outcome could be nose bleeds, dry airway, bacteria growth if the resident had been sick, or cross contamination.In an interview on 06/17/2026 at 12:20 PM, ADON 2 stated the nurses should observe the resident's oxygen and the concentrator to check humidification every day. She stated the tubing and nasal cannulas should be changed and dated weekly, and they should have a bag to place the tubing in when not in use. She stated an adverse effect would be infection.Record review of the facility policy entitled Oxygen Equipment dated as reviewed 7/2025, indicated [in part]: C. Pre-filled humidifiers, when used, are to be dated and replaced every seven (7) days, according to manufacturer recommendations, or as needed.1. Tubing should be replaced every week2. Masks should be replaced every week3. Cannulas should be replaced every weekD.tubing will be routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth.E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms.

Based on interviews, observations and record reviews, the facility failed to ensure residents have the right to formulate an advanced directive for 1 (Resident #10) of 18 residents reviewed for advanced directives. 1. The facility failed to ensure that the electronic medical record dashboard and order reflected Resident # 10's wishes for DNR status. This deficient practice could place residents at risk of not having their wishes known and potentially receiving CPR during an emergency. Findings include: Record review of Resident # 10 reflected an [AGE] year-old female admitted to the facility on [DATE] and re-entered on [DATE]. Medical diagnosis include pulmonary fibrosis, type 2 diabetes, acute respiratory failure with hypoxia (deficiency of the amount of oxygen reaching the tissues), metabolic encephalopathy (a condition which causes brain dysfunction due to an underlying condition causing confusion, memory loss and possible loss of consciousness). Care plan dated [DATE] did not reflect her code status request and only contained six pages and did not reflect a resident centered care plan. BIMS 10 The Out of Hospital DNR was uploaded in the facility electronic record by LMSW and was dated [DATE] but the main page in the resident's electronic record reflected *FULL CODE. An order dated [DATE] reflected FULL CODE. In an interview with Resident # 10 on [DATE] at 4:30 PM she reported she was doing good today. She reported that she was pleased with the facility. Resident # 10 reported that she was a DNR and her wishes were to have peace when it was her time to die. In an interview on [DATE] at 4:35 PM with LVN-O she said that Resident #10, I think she was a DNR. LVN-O stated that she will look at the computer to verify code status. LVN-O stated that she will ask her supervisor about the resident code status and if the supervisor was not at the facility, she will get ahold of them or ask another nurse. She stated a negative outcome to not knowing the code status was that the residents might get CPR when they don't want it. Or it might cause problems and a delay in starting CPR for a resident that does want it. She stated she was not sure who updates the code status and DNR in PCC. She reported that there was a paper copy in the DNR binder at the nurse's station. She walked over to the red binder with the spine labeled DNR which did not have a copy of Resident # 10's DNR. In an interview on [DATE] at 5:10 PM LMSW reported that the staff should look in the electronic record to verify if a resident was a DNR or full code. During the interview LMSW logged into the electronic record of Resident # 10 and the dashboard reflected that she was a full code. Then LMSW looked in the orders tab, and it reflected a full code order and no order for DNR. LMSW reported that they are implementing a binder. He planned on going through it and checking all the DNR's. He updated the facility group when there was anything that was changed for the residents. LMSW reported that the DON or the MDS Coordinator were responsible for updating PCC. In an observation on [DATE] at 5:17 PM LMSW showed the group message about Resident #10's code status change. This occurred on [DATE] at 3:30pm according to his message time stamp. LMSW reported that the DON or the MDS Coordinator were responsible for updating PCC. In an interview on [DATE] at 5:15 PM with the DON she reported that her expectation was for the staff to utilize the binder for a quick look to see the DNR form. When the DNR was completed and then uploaded in the record the MDS Coordinator usually updated the care plan and the order. DON reported that the MDS Coordinator was not in the facility on the date the DNR was completed. The DON reported that she was gone on that day as well. She reported when they are both gone the ADON would need to update the resident's record. A negative outcome would be a resident receiving CPR when they are a DNR and vice versa. In an interview on [DATE] at 5:20 PM with the MDS Coordinator, she reported that she was at MDS bootcamp last week. She reported that LMSW can update the care plan and write an order. MDS reported that her expectation was that when a code status was changed the facility record reflected the resident's wishes. She also expected the order and the electronic dashboard to also reflect the current wishes. In an interview on [DATE] at 10:30 AM with the MD he said his expectations for a resident with a DNR should be updated in the medical record. A negative outcome would be that a resident receives CPR when they shouldn't. Review of facility policy titled Advance Directive and associated Documentation original date 11.2016 with most recent revision on 4.2025 reflects [in part] procedure #6 obtain a copy of the advanced directive and conservatorship/guardian documents and place in the resident health record. #7 advance care planning will occur periodically (at least quarterly, annually, and on change of condition) to review the advanced directive and /or preferences regarding treatment options with the resident or their representative to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded in the medical record. #9 inquiries concerning advanced directives should be referred to social services, and/or to the director of nursing services.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to Privacy and Confidentiality of medical treatment and medical records for 2 of 24 residents care was reviewed.Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to Privacy and Confidentiality of medical treatment and medical records for 2 of 24 (Resident #30, Resident #52) residents care was reviewed. Resident #30 and Resident #52 had handwritten signs placed in the view of residents, staff and visitors that revealed personal medical information. These failures could affect residents by contributing to poor self-esteem, lack of information, and unmet needs. Findings included: Resident #30Record review of Resident #30's face sheet dated 6/17/2026 revealed an [AGE] year old female with initial admission date of 3/17/2026 and readmission date of 4/15/2026 with diagnoses that included myasthenia gravis (a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness), atrial fibrillation (a heart rhythm disorder that causes an irregular very rapid heartbeat), and right arm deep vein thrombosis (blood clot). Record review of Resident #30's MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. Record review for resident #30's Careplan initiated on 5/7/2026 had goals and interventions for monitoring Edema, anticoagulant therapy related to Atrial Fibrillation, Oxygen use (PRN), Mobility Bars, Enhanced barrier precautions for colostomy, and Risk for impaired skin integrity. Observation on 6/14/2026 at 11:40am of Resident #30's room revealed a handwritten sign located on the wall at the foot of the bed inside of the room entrance dated 6/10 {Physician}: *Right upper arm is weeping fluid. *Increase water pill? *more bruising noticeable * possible psych eval? Having trouble with confusion and hallucination scenarios Observation on 6/14/2026 at 11:40am of Resident #30's room revealed a handwritten sign Please give Zofran in morning BEFORE Zinc pill Makes {Resident #30} sick ATTN MEDS Resident #52Record Review for Resident #52's face sheet dated 6/17/2026 revealed a [AGE] year old female with an admission date of 5/16/2025 with diagnoses that included Sjogren syndrome with glomerular disease (a chronic autoimmune disorder), Dysphagia (difficulty swallowing), Dementia without behavioral disturbances (decline in cognitive ability), cognitive communication deficit, pain, weakness, depression and general anxiety disorder. Record review for resident #52's MDS dated [DATE] revealed a BIMS score of 00 (severe cognitive impairment). Record review for resident #52 care plan initiated on 5/15/2026 had goals and interventions for hospice care, falls, and monitoring of medications/treatments for effectiveness and side effects. Observation on 6/16/2026 at approximately 3:00 pm of Resident #52 revealed sign on door of room [Resident #52] cannot tell you when she needs to go to the bathroom. When asked she will say she doesn't need to. Please take her throughout the day to keep her dry. She will go when helped. Thank you. Observation and interview on 6/15/2026 at 3:10PM with DON accompanied to Resident #30's room to observe handwritten signs in Resident #30's room. DON was unaware of these signs being in the room. She was unaware of who posted them or when they were placed there. The signs related to concerns for the physician to assess dated 6/10 and had patient specific information. DON stated this was not how staff communicate with the physician. Communication with the physician was via an app. She removed the signs for this resident and her roommate during this observation/interview. DON verified the physician rounded on 6/10/2026 and did address the concerns on the signs. DON stated a negative outcome of having signs in the room with personal and/or medical information could lead to HIPAA violations. During an interview on 6/16/2026 at 12:20PM OM stated he was aware of the handwritten signs that were posted in Resident #30's room. He was made aware of this yesterday by the DON. He stated the family often posts signs in the room and may have been responsible for the sign with specific concerns to be addressed with physician. He stated he will be contacting the family to ensure they share concerns with the staff so the physician can be made aware sooner. The facility communicates with physicians through communication app (communication application). A negative outcome of signs posted in a resident room with medical information would be a violation of privacy. A negative outcome of leaving notes for a physician could result in delayed treatment if physician is not contacted using app or calling for immediate orders. In an interview on 06/17/2026 at 10:05am with MD, he stated he did see the sign in Resident #30's room and that the resident's daughter had filled it out that morning on 6/10/2026. He stated he was there to see the patient that day and discussed everything with the resident's other daughter who was visiting. He stated that was just the family's way of communicating thoughts and concerns to each other and him and had no concerns with the form of communication. He stated the staff were to use the platform application to communicate with him any concerns they have with residents. He also stated when he messages the staff back using communication application, it automatically goes into the resident's medical record under progress notes. He stated he could not remember a time when a staff member just left a note on a whiteboard or piece of paper for him but if they did a negative outcome could be delay in care for the resident. In an interview on 6/17/2026 at 11:30am with DON, she stated she was unaware of the sign on Resident #52's door. She stated families often make signs to help the staff with knowing what residents need. She stated this was not the form of communication that was used for staff and families. A result of posting personal or medical information about a resident in this form could result in HIPAA violations and result in a loss of dignity. In an interview on 6/17/2026 at 3:35PM with OM, he stated personal information related to residents should be in their care plan. He stated a care plan should address the residents' needs or preferences. A negative result of a resident having personal information in a public area could result in violation of privacy. In a document provided titled Resident Rights Source: Federal Register/Vol. 81, No. 192/Tuesday October 4, 2016/Rules and Regulations states [in part]:As a resident of this facility, you have the right to dignified existence, self-determination, and communication with an access to persons and services inside and outside the facility.Planning and Implementing Care. You have the right to be informed of, and participate in, your treatment including the right to: participate in the development and implementation of your person-centered plan of care.Respect and dignity: You have the right to be treated with respect and dignity including the right to: reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger your or other residents' health or safety.Privacy and Confidentiality. You have the right to personal privacy and confidentiality of your personal and medical records. You have the right to personal privacy, including accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of the family and resident groups.

Based on observation, interview, and record review the facility failed to environment free accident hazards for 2 of 2 residents reviewed. Based on observation, interview, and record review the facility failed to environment free accident hazards for 2 of 2 (Resident #65 and Resident #30) reviewed for accident hazards in that:The facility failed to maintain an environment free from accident hazards for Resident #65 who had a sharp edge on broken bed remote in their room.The facility failed to maintain an environment free from accident hazards for Resident #30 who had a used syringe left on bedside nightstand in their room.These failures had the potential to result in injury and exposure to bloodborne pathogens.Findings include:Resident #65Record review of Resident #65's electronic face sheet dated 06/17/26 revealed he was a [AGE] year-old male. He admitted to the facility on [DATE] with diagnoses of: Parkinsons Disease (a progressive nervous system disorder affecting movement of the body), Mood disorder (a condition that affects a persons emotional state), dementia (Decline in mental ability), Depression (mood disorder that causes sadness), Hypertension(elevated blood pressure), Anxiety disorder ( excessive persistent and uncontrollable worry), and repeated falls. Record review of Resident #65's Quarterly MDS dated [DATE] revealed a BIMS of 12 (moderate cognitive impairment). He required use of a wheelchair for mobility. During an observation on 6/14/2026 at 11:00 AM revealed Resident 65's bed remote was broken with a sharp edge and dried blood. During an interview on 6/14/2026 at 11:00 AM with Resident # 65, he stated he had several falls recently and this caused the bed remote to have a sharp edge and dried blood. He is unsure if the bed remote caused the scabs/bruising to his forearms during recent fall. During an interview with RN-I on 6/14/2026 at 11:18 AM at the resident's bedside, he stated Resident #65 was a high fall risk and did have a fall within the last few days. He stated he had not noticed the bed remote being broken. At conclusion of interview at approximately 11:20 AM, RN-I exited the room and placed a call to the DON reporting a damaged bed remote. Observation on 6/14/2026 at approximately 11:35 AM, revealed two staff members entered Resident #65 room. The broken bed remote was removed and replaced with new bed remote. In an interview on 6/17/2026 at 11:30 AM with the DON, she stated she was unaware of the bed remote having a sharp edge until RN-I notified her on 6/14/2026 at approximately 11:25AM. She stated the bed remote was replaced within 20 minutes of the report. A negative outcome of having broken equipment in a resident area could cause injury. In an interview on 6/17/2026 at 3:35 PM with the OM, he stated he expected direct care staff to check resident rooms for any hazards that could cause injury which included broken or damaged equipment. The expectation was for staff to be observant when in resident rooms for hazards when they were assisting residents or when completing routine rounds. He stated any broken items had the potential to cause injury or harm to a resident. 2. Record review of Resident #30's face sheet, dated 6/17/2026, revealed an [AGE] year old female with initial admission date of 3/17/2026 and readmission date of 4/15/2026. Resident #30 had diagnoses which included myasthenia gravis (a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness), atrial fibrillation (a heart rhythm disorder that causes an irregular very rapid heartbeat), and right arm deep vein thrombosis (blood clot). Record review of Resident #30's care plan, last revised 5/20/2026, revealed Resident #30 was on anticoagulant therapy related to atrial fibrillation but the resident's DVT and use of Lovenox (Order: Lovenox Injection Solution Inject 1 application subcutaneously two times a day for DVT to right arm **Lovenox 1mg/kg BID** (85mg)bid, Check Prothrombin Time (measures how many seconds it takes for blood to clot) and International Noramlized Ration (standardized calculation based on Prothrombin time to verify accuracy of testing) before administration) had not been care planned. Record review of Resident #30's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #30's physician orders revealed, an order dated 6/12/2026, for Lovenox Injection Solution (Enoxaparin Sodium) Order: Lovenox Injection Solution Inject 1 application subcutaneously two times a day for DVT to right arm **Lovenox 1milligram/kilogram BID** (85mg)bid. Record review of Resident #30's Medication Administration Record, dated 6/17/2026, revealed the medication Lovenox Injection Solution (Enoxaparin Sodium) was last administered on 6/15/2026 on the night shift with no specific time of the administration. In an observation on 06/16/2026 at 12:10 PM in Resident #30's room revealed a recapped 3 milliliter syringe and needle used to administer Lovenox along with used alcohol pads were left lying on the resident's nightstand. In an interview on 06/16/2026 at 12:13 PM MA D stated she wasn't sure who gave the injection but would find out. She stated it should have been thrown into the sharps container on the side of the medication cart after administration and an adverse outcome could be the resident sticking themselves or someone else with the used needle. In an interview on 06/16/2026 at 12:18PM with DON, she stated she wasn't sure as well but would find out and complete re-education. She stated her expectation was for needles and syringes to be disposed of in the sharp's container on the side of the medication cart and a negative outcome could be if the resident could get the cap off they could stick themselves and get an infection or bleed. In an interview on 06/16/2026 at 12:22 PM with the OM stated it was his expectation for the nurses to dispose of all sharps supplies into the sharp's containers and that a negative outcome could be infection, re-stick, cross contamination, another resident, employee, or family member could stick themselves. In record review of the facility's policy titled Policy/Procedure, revised on 05/2007 and reviewed on 05/2021 revealed [in part]: Policy: It is the policy of this facility to establish procedures for routine and non-routine care of the facility/building to ensure that the facility remains in good working order for the residents and staff safety. In record review of the facility's, undated, provided policy titled Medication Administration in Long Term Care revealed [in part]: Objective: Review injection practices and sharps safety Injection Practices: Sharps should be immediately disposed of in puncture-resistant sharps containers. Record Review of Lovenox Injectable, completed on 6/25/2026, using Drugs.com stated [in part]: Lovenox is an anticoagulant that helps prevent the formation of blood clots. Lovenox is used to treat or prevent a type of blood clot called deep vein thrombosis (DVT), which can lead to blood clots in the lungs (pulmonary embolism). A DVT can occur after certain types of surgery, or in people who are bed-ridden due to a prolonged illness. This medicine lowers the number of some types of blood cells in your body. Because of this, you may bleed more easily. Stay away from rough sports or other situations where you could be bruised, cut, or injured. Brush and floss your teeth gently. Be careful when using sharp objects, including razors and fingernail clippers. Each single-use prefilled syringe is for one use only. Throw it away after one use, even if there is still medicine left inside. Use a needle and syringe only once and then place them in a puncture-proof 'sharps' container.

Based on observation, interview, and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 2 of 4 residents (Residents #7 and #77) reviewed for medication administration, in that:1. The facility failed to administer Resident #7's medications in a timely manner and withing the facility's medication window for administration on 6/15/2026, which included Keppra (a medication used to treat seizures), Midodrine (a medication used to treat low blood pressure), Eliquis (a blood thinning medication), Fludrocortisone Acetate (a medication used to treat low blood pressure), Loratadine (a medication used to treat allergies), Vitamin D3 (a medication used to treat muscle weakness), Lyrica (a medication used to treat nerve pain), and Potassium Chloride (a medication used to treat low potassium).2. The facility failed to administer Resident #77's medications in a timely manner and withing the facility's medication window for administration on 6/15/2026, which included Align (a probiotic medication used to treat diarrhea), Amlodipine (a medication used to treat high blood pressure), Aspirin (a medication used to treat plaque build up in arteries), Isosorbide mononitrate (a medication used to treat high blood pressure), Losartan Potassium (a medication used to treat high blood pressure), Zoloft (a medication used to treat depression), Ocular Vitamins (a medication used to treat macular degeneration), and Senna (a medication used to treat constipation.This deficient practice could result in a risk to the residents' health and complications which could lead to seizures, low blood pressure, high blood pressure, pain, allergies, vision loss, constipation, diarrhea, and muscle weakness.The findings included:Record Review of Resident #77's face sheet, dated 6/17/2026, indicated an initial admission date of 05/11/2019 and a readmission date of 02/01/2022 with diagnoses which included Alzheimer's disease (an irreversible brain disorder that slowly destroys memory, and thinking skills), hypertension (high blood pressure), macular degeneration (vision loss), hyperlipidemia (high cholesterol), constipation (hard, dry stool difficult to pass), diarrhea (loose watery stools), and depression (a mood disorder characterized by persistent sadness, loss of interest, and a lack of energy).Record review of Resident #77's quarterly MDS assessment dated [DATE] indicated a BIMS score of 8, which indicated the resident had moderate cognitive impairment.Record review of Resident #77's care plan, dated as last revised 5/15/2026, indicated Resident #77 used antidepressant medication related to other recurrent depressive disorders, her goal was to show decreased episodes of signs and symptoms of depression through the review date and interventions or goals of Give antidepressant medications ordered by physician.Record review of Resident #77's physician orders indicated the following medication orders: Dated 4/29/2026 Align Capsule (Probiotic Product) Give 1 capsule by mouth in the morning for supplement related to DIARRHEA. Dated 4/29/2026 Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth in the morning for hypertension related to ESSENTIAL (PRIMARY) HYPERTENSION. Dated 4/29/2026 Aspirin Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet by mouth in the morning for heart related to ATHEROSCLEROSIS OF CORONARY ARTERY. Dated 4/29/2026 Ocular Vitamins Oral Tablet (Multiple Vitamins with Minerals) Give 1 tablet by mouth two times a day for macular degeneration. Dated 5/14/2026 Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for Constipation. Dated 4/29/2026 Zoloft Oral Tablet 25 MG (Sertraline HCl) Give 0.5 tablet by mouth in the morning for hopelessness and sadness related to OTHER RECURRENT DEPRESSIVE DISORDERS. Dated 4/29/2026 Isosorbide Mononitrate Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth in the morning for hypertension related to ESSENTIAL (PRIMARY) HYPERTENSION. Dated 4/29/2026 Losartan Potassium Oral Tablet 50 MG Give 1 tablet by mouth in the morning for Hypertension.Record review of Resident #77's Medication Administration Report dated 6/15/2026 indicated Resident #77 received morning medications but was not time stamped as to when they were given. Resident #77's MAR indicated her blood pressure at the time of the medication administration was 198/116.In an observation and interview on 06/15/2026 at 12:00 PM, Resident #77 was observed coming out of a room walking independently with her walker. Resident #77 stated she was upset because she had not had her morning medications, specifically her blood pressure medication, until just a minute ago and she knew when her blood pressure was high because she could feel it. Resident #77 asked LVN C about her blood pressure. LVN C stated he had just checked her blood pressure and MA F had just given her all of her morning medications. Resident #77 stated, Yes, I know, but they were late. LVN C apologized and Resident #77 continued walking to the dining room for lunch. In an interview on 06/15/2026 at 12:15 PM, MA F stated she was called in that morning and arrived about 8:30 AM to help complete medication passes. She stated someone called off so she came in to help but was not sure why they were so behind. MA F stated medications were expected to be given within certain timeframes and an adverse outcome depended on the medication but that Resident #77's blood pressure was very high and administered her medications as fast as she could. Record review of Resident #7's face sheet, dated 6/16/2026, indicated an admission date of 11/03/2025 with diagnoses which included polyneuropathy (damage of multiple peripheral nerves throughout the body), seizures (sudden change in the brain's normal electrical activity), muscle weakness, atherosclerotic heart disease (buildup of plaque in the arteries, leading to narrowed arteries and reduced blood flow), hypotension (low blood pressure), allergic rhinitis (an allergic reaction that happens when your immune system responds to an allergen), hyperlipidemia (high level of cholesterol or triglycerides in the blood), cerebral infarction (stroke, when the blood supply to part of the brain is blocked or reduced), and hypokalemia (low potassium in blood).Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated a BIMS score of 15 which indicated the resident was cognitively intact.Record review of Resident #7's care plan last revised 5/20/2026 indicated Resident #7 had Anticoagulant therapy related to Atherosclerotic heart disease with interventions which included: Administer Medication per physician orders. (No other medications were listed on the current care plan).Record review of Resident #7's physician orders indicated the following: Dated 4/29/2026 Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for heart disease related to ATHEROSCLEROTIC HEART DISEASE. Dated 4/29/2026 Fludrocortisone Acetate Oral Tablet 0.1 MG (Fludrocortisone Acetate) Give 1 tablet by mouth in the morning related to HYPOTENSION. Dated 4/29/2026 Keppra Oral Tablet 500 MG (Levetiracetam) Give 1 tablet by mouth two times a day for CVA related to CEREBRAL INFARCTION. Dated 6/12/2026 Lipitor Oral Tablet 10 MG (Atorvastatin Calcium) Give 1 tablet by mouth in the evening for hyperlipidemia related to HYPERLIPIDEMIA. Dated 6/12/2026 Loratadine Oral Tablet 10 MG Loratadine) Give 1 tablet by mouth in the morning for allergies related to ALLERGIC RHINITIS. Dated 6/12/2026 Lyrica Oral Capsule 50 MG (Pregabalin) Give 1 capsule by mouth two times a day related to POLYNEUROPATHY. Dated 4/29/2026 Midodrine HCl Oral Tablet 10 MG Give 1 tablet by mouth three times a day for Hypotension related to HYPOTENSION. Dated 4/29/2026 Potassium Chloride ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride) Give 4 tablet by mouth two times a day for hypokalemia. Record review of Resident #7's Medication Administration Report dated 6/15/2026 at 12:25 PM indicated the resident had not received her morning medications scheduled to be administered between 6 AM and 10 AM, which exceeded the medication window of 1 hour before or 1 hour after the scheduled time frame by over 2 hours and 57 minutes.Record review of Resident #7's Progress Notes dated 06/15/2026 at 12:57 PM indicated MA F had administered Resident #7's medications at that time, (which exceeded the medication window of 1 hour before or 1 hour after the scheduled time frame by 2 hours and 57 minutes). In an interview on 06/15/2026 at 12:10 PM, Resident #7 stated she had not received her morning medications yet and she was not sure what was going on. In an interview on 06/15/2026 at 4:30 PM, the DON stated her expectation for medication administration was for residents scheduled to receive morning medications between the hours of 6:00 AM and 10:00 AM to be done on time. She further stated a negative outcome depended on what medication was late; if it was blood pressure or seizure medications, they could have high/low blood pressure or a seizure. The DON stated it was ultimately her responsibility to make sure medications were administered on time. In a follow-up interview on 06/15/2026 5:19 PM, the DON stated she called and spoke to the Medical Director to let him know of the late medications for Residents #77. The DON stated the Medical Director told her he did not feel there was any harm to the resident but to monitor her.In an interview 6/17/2026 at 10:05AM, the Medical Director stated his expectation was for the residents on skilled care services to receive their medications on time and the staff should wake them. He stated for the residents in long term care, he was ok with waiting until the resident was awake, that an hour or two was ok for them. The Medical Director stated as far as the medications that were administered almost 3 hours late, he had not seen any adverse effects yet, but if medication administration continued to be late it could potentially be a problem especially with blood pressure and seizure medications. Record review of the facility policy entitled Medication Administration in Long Term Care, not dated, indicated [in part]: Rights of Medication Administration:Right TIME Record review of the facility schedule for Medication Pass Times indicated [in part]: Liberal medication pass times. 6 AM -10 AM Liberal pass times.

Based on observation, interview and record review, the facility failed to ensure in accordance with State and Federal laws, drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 3 medication carts (Medication Carts Hall 300 and Hall 400) reviewed for medication storage. The facility failed to ensure medication carts were secured and locked.This failure could place residents at risk for drug diversion.Findings included:During an observation and interview on 06/14/2026 at 9:40 AM, LVN A was observed in a resident room and left Medication Cart for Hall 400 unlocked and unattended. LVN A stated she was an agency nurse and had only worked in the facility one time before that day. LVN A stated she typically locks the medication cart but just ran into the resident's room real quick. She stated she didn't know of a negative outcome because I never leave it unlocked.During an observation and interview on 06/15/2026 at 7:50 AM, at the Hall 300/400 Nurses station, a medication cart labeled Hall 300 was observed unlocked and unattended. RN B was observed sitting behind the desk at the nurse's station charting. RN B looked up from her computer and stated it was her medication cart. RN B walked around the desk. RN B stated the expectation was for the nurse responsible to lock the cart and the computer to prevent HIPAA from being observed. She further stated a negative outcome could be a resident being able to access medications that were not for them or a family member could get into it and make them sick.In an interview on 06/16/2026 at 12:25 PM, ADON R stated medication carts should be locked as well as the computer screens any time a nurse or medication aide walked away from the cart, no matter how far away or for any amount of time. She stated, If the nurse were at the nurse's station and it was unlocked; someone could still walk up and take medications out. ADON R also stated a negative outcome could be a resident taking other residents' medications and it could make them sick depending on what they took.In an interview on 06/16/2026 at 2:19 PM, the DON stated medication carts were to be locked any time staff stepped away or turned their back to the cart. She said an adverse outcome could be a resident or other staff member could open the cart and get medications they should not have, and depending on the medication, it could send them to the hospital.Record review of facility policy entitled Medication Administration in Long Term Care, undated, indicated [in part]: Objectives:Review proper storage requirements.Routine Medication Administration:Lock cart and conceal eMAR before entering resident's room.Storage Requirements:Medications in medication rooms, carts, boxes and refrigerators must be:Locked and accessible only to designated staff. Record review of the facility policy entitled Medication Administration Oral, dated as revised 05/2025, indicated [in part]: Essential Points:9. The medication cart is to be kept in clear view and in reach of the person administering medications at all times. It is to be locked when the medication nurse is away from the cart.

Based on observation, interview , and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #80) of three residents (Resident #80) reviewed for infection control practices.CNA M failed to perform proper hand hygiene including which included changing gloves while providing incontinence care to Resident #80 on 06/15/26.This failure could place residents at risk for the spread of infection. Findings Included: Record review of Resident #80's face sheet, dated 06//17/26, revealed a 79- year- old female who was admitted to the facility on [DATE]. Resident #80 had with diagnoses including which included full incontinence of feces, candidiasis (fungus) of skin and nail, pneumonia (lung infection) and constipation (lack of bowel movement). Record review of Resident 80's admission MDS assessment, dated 04/22/26, revealed she required dependent assistance with most activities of daily living (ADLs) including which included toileting. Resident #80 was always incontinent with bladder and bowel. Record review of Resident #80's recent Care Plan, dated 05/14/26, revealed there was no plan for bladder and bowel incontinence. Observation of incontinence care for Resident #80 on 06/15/26 at 2:56p.m. revealed CNA M did not wash her hands prior to donning gloves. CNA M removed Resident #80's brief that which was soiled with fecal matter. CNA M wiped the resident from front to back. She did not change gloves but continued to clean the resident with soiled gloves. Her gloves were visibly soiled with fecal matter. CNA M did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A applied skin protector with the same soiled gloves on Resident #80 before fastened the clean brief. She removed her gloves and picked up the trash. CNA M did not wash hands or perform hang hygiene before exiting Resident #80's room. In an interview on 06/15/26 at 3:06 p.m. with CNA M, she stated she should have changed her gloves and washed her hands before retrieving a clean brief and placing it underneath Resident #80. CNA M stated she has been in the facility for about I year. She said she received infection control training about 1 month ago. CNA M note that hand washing was the most effective way of infection control but forgot to wash her hands before starting incontinent care. CNA M said cross contamination was mixing clean with dirty which occurred while she was providing care. CNA M noted that the resident could acquire an infection when she did not follow good infection practices which included changing gloves before retrieving the clean brief. During interview on 06/17/26 at 4:15 p.m. the DON stated she was aware of some of the concerns raised about infection control practice. She stated she was responsible for infection control in the facility. The DON stated employees received training on hire and annually. She noted she conducted random checks on employees and training with return demonstration periodically. The DON explained aides were expected to follow standard precautions which incuded washing hands and changing gloves while providing care. Record review of the facility's hand-washing policy, revised 07/2025, reflected: POLICY: It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. PURPOSE: Hand washing / hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. Although antiseptics and other hand-washing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination the agent used, the presence of residual activity and hand washing technique followed. PROCEDURES: Handwashing 1. Wet hands and apply soap to hands from soap dispenser. 2. Rub hands in circular motion for not less than fifteen (15) seconds. 3. Rub fingers between fingers for fifteen (15) seconds. 4. Rinse hands with warm water. 5. Dry hands with paper towel. 6. Turn off faucet with paper towel. 7. Discard paper towel in appropriate receptacle.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. MA A failed to perform hand hygiene while administering medication to Resident #1 MA A stuck her bare hands into a pill bottle of buspirone 15 mg which contained multiple pills. These failures could affect the residents by placing them at risk for the spread of infection.Finding included:Review of Resident #1's face Sheet dated 01/13/26, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute respiratory failure, Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, behavior and is the most common cause of dementia), metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss and altered consciousness), restlessness and agitation.Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed BIMS of 2 indicating Resident #1 had severe cognitive impairment. Resident #1 required substantial/maximal with most activities of daily living (ADLs).Review of Resident #1's care plan dated 04/04/23 revealed she used antianxiety medications related to anxiety disorder. The goal was for Resident #1 to be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date.Review of the MAR dated 01/01/2026 through 01/31/2016 for Resident #1 reflected the following:Cyanocobalamin oral tablet 250 mg-Give 1 tablet by mouth in the morning.Folic acid 1 mg-Give I tablet by mouth in the morningMemantine HCL 10 mg-Give 1 tablet by mouth two times a dayBuspirone HCL 15 mg-Give 1 tablet by mouth three times a dayDivalproex Sodium 125 mg-Give 2 capsules by mouth three times a dayLosartan Potassium 25 mg. Give 0.5 tablet by mouth in the morningMultivitamin with Minerals supplement. Give tablet by mouth in the morning.Observation of medication administration for Resident #1 on 01/13/26 at 9:10 a.m. revealed MA A did not wash her hands or perform hand hygiene before retrieving the medication from the medication cards. MA A stuck her bare hands into the bottle/container of buspirone 15 mg tablets touching multiple pills. MA A failed to wash her hands or perform hand hygiene after medication administration for Resident #1.In an interview on 01/13/26 at 9:26 a.m. with MA A, she said she had been employed in the facility since August 2025. She stated she received infection control training during her orientation. MA A stated cross contamination was not washing hands before providing care to a resident. She stated the resident could get sick if good infection practice was not followed.During an interview with the DON on 01/13/26 at 3:06 p.m. he acknowledged he was aware of some of the concerns raised about infection control practices She stated the aides were expected to follow standard protocols which include appropriate hand hygiene when administering medication. She stated the staff receive annual training on infection control and have initiated one-on-one training with MA A.Review of the facility's hand-washing policy from 2001 med-pass reflected:Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections.Policy Interpretation and ImplementationAdministrative Practices to Promote Hand Hygiene1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2) All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.3) Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol based hand-rub (ABHR} dispensers are placed in areas of high visibility and consistent with workflow throughout the facility.Indications for Hand Hygiene1. Hand hygiene is indicated:a. immediately before touching a resident.b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device)after contact with blood, body fluids, or contaminated surfaces.after touching a resident.after touching the resident's environment.before moving from work on a soiled body site to a clean body site on the same resident; andimmediately after glove removal.

Based on observation, interview, and record review the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities for 2 of 2 nurse's stations (Hall 100/200 station and Hall 300/400 station). Resident's emergency call light was not audible at either the Hall 100/200 or Hall 300/400 nurse's stations. This failure placed residents at risk of not receiving timely care/assistance, falls, fall related injuries, head trauma, and hospitalization . Findings included: During observation on 5/23/25 at 5:00am, surveyor was standing at the nurse's station for Halls 100 and 200. Surveyor observed the call light outside of room [ROOM NUMBER] flashing but there was no audible sound at the nurse's station. Surveyor observed that at nurse's station for Halls 300 and 400 the call light system did not submit an audible when the call light was activated from room [ROOM NUMBER]. During an interview on 5/23/25 at 5:06am, LVN CC stated he has worked at the facility for 1 year, on Halls 100 and 200, and the audible system worked when he first started but stated that the audible sound at the nurse's station has not worked in a while. He said he did not recall when it stopped working. LVN CC stated that administration knew it was not working and the maintenance person was working on repairing until the maintenance person quit working at the facility. LVN CC stated he did not know who was working on it now. LVN CC stated that having an audible sound at the nurse's station would help staff on recognizing when a resident needed assistance. During an interview on 5/23/25 at 5:15am, CNA DD stated he has worked at the facility for 2 months. CNA DD stated that he knew to answer call lights by observing the room lights flashing. He said there was no audible sound for the call lights since he has worked here. CNA DD stated it would help if there was an audible sound to go with the light flashing when residents used the call light. During an interview on 5/23/25 at 5:30am, LVN G stated she has worked at the facility for 6 months, on Halls 300 and 400. LVN G stated the call light audible system has not worked since she has worked here. LVN G stated that it would help a lot if they had an audible sound along with the light flashing outside of resident's room. During an interview on 5/23/25 at 10:30am, the Administrator stated the call light system should have a flashing light outside the resident's room and be accompanied by sound at the nurse's station so that if staff could not see a call light request, they could hear it to ensure residents received timely help after pushing their call light. The Administrator stated that without sound the call light system placed residents at risk of falls, not having needs met, food aspiration and then stated, there are so many things that could go wrong if the call lights did not have a sound . The Administrator stated the facility did not have documentation that the call system was routinely maintained or tested by the maintenance department. Record review of the facility's policy titled Resident Call System,, dated September 2022, revealed Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation . The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #12 and Resident #13) of thirteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #12 and Resident #13 on 05/22/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #12's Face Sheet, dated 5/22/25, reflected a [AGE] year-old female, admitted on [DATE]. Resident #12 had diagnoses of, Cerebral infarction (stroke), need for assistance with personal care, vascular dementia (reduced blood flow to brain), muscle wasting (loss of muscle mass). Review of Resident #12's Quarterly MDS Assessment, dated 5/11/25, reflected that Resident #12 had a BIMS score of 3, indicating severe cognitive impairment. The Quarterly MDS Assessment indicated the resident required assistance for toileting, dressing, personal hygiene and transferring. Review of Resident #12's Comprehensive Care Plan, dated 3/13/25, reflected Resident #12 was a fall risk, and one of the interventions was a reachable call light. Observation and interview on 5/22/25 at 11:55am revealed Resident #12 lying in bed. The call light was observed clipped to a power cord of the mini refrigerator located at the foot of Resident #12's bed. Resident #12 stated that she can operate the call light for help if the call light is within reach. Resident #12 pointed to the call light at the foot of her bed and stated she cannot reach that. Review of Resident #13's Face Sheet dated 5/22/25, reflected a [AGE] year-old female, admitted [DATE]. Resident #13 had diagnoses of Dementia (decline in cognitive abilities), malignant neoplasms (cancerous tumors), muscle weakness, history of falling. Review of Resident #13's Quarterly MDS Assessment, dated 3/18/25 reflected that Resident #13 had a BIMS score of 12, indicating moderate cognitive impairment. The Quarterly MDS Assessment indicated that Resident #13 needed assistance with transferring, and toileting. Review of Resident #13's Comprehensive Care Plan dated 4/2/25 reflected that Resident #13 was a fall risk, and an intervention listed was call light within reach. Observation and interview on 5/22/25 at 12:00pm, revealed Resident #13 lying in bed. The call light was laying on the floor under the left side of the bed. Resident #13 stated that sometimes her call light was not within reach. She said staff generally clip it on the bed or handrail, but sometimes she cannot find it when she needs it. Resident #13 stated she did not know where it was now. In an interview on 5/22/25 at 12:07pm, CNA L came into Resident #13's room and stated that she had come from Resident #12's room and placed the call light within reach and then picked up Resident #13's call light and clipped it to her handrail within reach. CNA L stated that call lights need to be within reach for residents, residents that need assistance use the call light, and if residents cannot find or reach the call light, residents could have accidents. CNA L stated that call lights should be always within reach. In an interview on 5/22/25 at 12:15pm, LVN M stated that call lights are to be always within reach for residents, and staff are to make sure when they monitor and provide care, before they leave, the call light is within reach. In an interview on 5/23/25 at 3:05pm, Administrator stated it was his expectation that call lights were to be always within reach for residents, and staff were to make sure when they monitor and provide care, before they leave, the call light is within reach. Incidents can happen if residents cannot call for assistance when needed.

Based on observation, interview, and record review the facility failed to ensure a resident receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 3 residents reviewed for pressure ulcers/wounds. The RN B failed to provide wound care for Resident #3's unstageable pressure ulcer to the right buttock and unstageable pressure ulcer to her right lateral foot on the date of 04/12/25. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings included: Review of Resident # 3's electronic face sheet reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: leg fracture, dementia, and mild protein calorie malnutrition ( nutritional state in which reduced availability of nutrients leads to changes in body composition and function). Review of Resident # 3's Admission MDS assessment dated [DATE] reflected Resident #3 had a BIMS score of 04 indicating severe cognitive impairment. Further review of Section M reflected resident was at risk for pressure ulcers and had no pressure ulcers. Review of Resident #'3's care plan on 04/12/25 last revised 04/09/25 reflected: Focus: The resident has pressure ulcer development .Unstageable to right buttock (04/02/25) worsened due to favoring right side/declining. Review of Resident # 3's electronic physicians orders dated 04/12/25 reflected: Cleanse pressure injury to right buttocks and right lateral ankle with wound cleanse, pat dry, apply collagen sheet, cover with hydrocolloid dressing, dated 04/03/2025 and Cleanse unstageable pressure injury to right buttock with wound cleanser, pat dry, apply calcium alginate with Santyl, cover with dry dressing, order initiated on 04/9/25. Review of Resident #3's Initial Wound Evaluation by wound care physician on 04/08/25, reflected an unstageable pressure ulcer to the right buttocks measuring 2.5 cm by 4.0 cm and an unstageable pressure area covered with necrotic tissue measuring 2 cm by 2 cm. Record review of Resident #3's Administration Report on 04/13/25 which was dated 04/1/25 to 04/30/25 revealed, wound care was documented as completed for 04/11/25, and 04/12/25 on the day shift. An observation on 04/13/25 at 1:00 pm revealed Resident # 3 had a dressing to her right buttocks that was dated 04/11/25. Her right foot was covered by a sock. The paid care giver removed the sock from Resident# 3's Right foot and there was no dressing on the foot covering the wound. In an interview on 04/13/25 at 1:05 PM the paid caregiver stated the dressings on the right buttocks and the right lateral ankle was last changedon 04/11/25 The paid caregiver stated she had not told a nurse that Resident # 3's dressing hadn't been changed. During an interview on 04/13/25 at 1: 10 PM , with the DON, who stated wound care was supposed to be done as ordered. The DON stated during the weekday the Treatment Nurse conducts the wound care and on the weekend the nurses are able and have to do the wound care. The DON stated that nurses are trained to look at the orders while gathering the supplies for the wound treatment and cannot be looking at the orders earlier in the day and doing the wound treatment without looking to verify the orders. The ADON stated the risk would be a decline in the resident's wound condition or infection In an interview at 1:30 PM on 04/13/25 with RN B, who stated he worked on 04/12/25 as charge nurse. He stated it was his responsibility to do the wound care for Resident # 3 and he had not done her wound care on 04/12/24. He stated there was no wound care nurse to help on the weekends and he just got busy and forgot. He stated he documented that the treatment was done because he intended to do it. RN B stated that there was not a Wound Care Nurse on the weekend, but all nurses were able to provide wound care. RN B stated the risk of not providing wound care could be the wound getting worse or infection. In an interview on 04/14/25 at 10:45 AM, with the Treatment Nurse, who stated she provided wound care during the weekdays and on the weekend nurses, the nurses were to be providing the wound care. The Treatment Nurse stated the nurses on the weekend would be able to provide wound care for those residents needing wound care. The Treatment Nurse stated she changed Resident #3s dressing to her right buttocks and right lateral ankle on 04/11/25. She stated she did not work on 04/12/25, and that RN B worked that day. She stated a negative outcome that could result in failure to perform treatments at the ordered frequency could be a delay in the wound in healing. In an interview on 04/14/25 at 2:00 PM the Wound Care Doctor stated the nurses were to be providing wound care. The Wound Care Doctor stated these issues of failure to do wound care had not been brought to his attention. The Wound Care Doctor stated he should have been informed of any missed wound care or significant changes but he was not notified. The Wound Care Doctor stated the risks of failure to provide wound care would be deterioration, or infection. He stated failure to do wound care was definitely a problem that needed to be addressed by the DON and she needed to pinpoint where the failure occurred and correct the problem in order to prevent it happening again. Record review of the facility policy titled Skin Management and Pressure Ulcer Prevention, dated 10/11/22, revealed the following [in part]: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, other altered skin integrity, and to provide treatment and services to heal pressure ulcer/injury and/or altered skin integrity, prevent infection and the development of additional pressure ulcers/injuries. It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and skin management. 1. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 2. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. b. The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: i. Impaired/decreased mobility and decreased functional ability: ii. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus. iii. Drugs such as steroids that may affect healing. iv. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency. v. Resident refusal of some aspects of care and treatment. vi. Cognitive impairment. vii. Exposure of skin to urinary and fecal incontinence. viii. Under nutrition, malnutrition, and hydration deficits; and ix. The presence of a previously healed pressure injury. c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. d. Assessments of pressure injuries and altered skin integrity will be performed by a licensed nurse and documented on the Skin Observation Tool. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task.

Based on observation, interview and record review, the facility failed to follow the menu for 1 of 1 lunch meals observed. 1.The facility failed to ensure a sufficient amount of vegetables were prepared for residents on a regular diet. 2. The facility failed to ensure residents who were on a regular diet received vegetables that were not pureed. These failures could place residents at risk for dissatisfaction, poor intake, altered nutritional status, choking, and/or weight loss. The findings included: During an observation on 04/07/2025 at 11:00 AM the daily menu posted on wall outside of kitchen revealed: Lunch-Smothered Port Tips, Baby Baker, Fried Cabbage, Cornbread, Cookie, Beverage. During an observation of meal service on 04/07/2025 at 12:15 PM dietary staff ran out of regular cabbage for residents on a regular diet. The dietary staff served 3 resident's trays, who were on a regular diet, pureed cabbage. During an observation on 04/07/2025 at 12:36 PM the requested test tray did not have fried cabbage or pureed cabbage on the test tray. During an interview on 04/07/2025 at 12:45 PM the DM stated she did not usually run out of food. The DM stated she would monitor food line and if she saw an item was running low, she would prepare more of that item in case a resident wanted more of that item. The DM stated some residents would not like to eat a pureed food if they normally ate a regular diet. The DM stated not having enough food or the right consistency could cause residents to not eat and to lose weight. During an interview on 04/09/2025 at 2:23 PM the facility's dietician stated any pureed vegetable, meat, starch should not be served to resident who was on a regular diet. The dietician stated the cook should not have run out of anything that was being served for that meal. The dietician stated the cook should have known how much to cook of each item for meals in case the residents wanted an additional serving. The dietician stated the cook should have made sure she was ordering enough groceries for all meals. The dietician stated a resident who was on a regular diet would probably not eat something that was pureed. The dietician stated a resident on a regular diet would possibly not find a pureed food as appealing and would not eat it. The dietician stated this could have led to weight loss for the resident. The dietician stated she monitored the DM and visits facility 2 times a month and monitored lunch service on her visits. The dietician stated she did not know how this failure occurred. During an interview on 04/09/2025 at 3:30 PM the ADMN stated residents should have been served a diet consistency that was ordered by their physician. The ADMN stated a resident with a regular diet should not have been served a puree vegetable. The ADMN stated the residents might be disinterested in eating the food which could have caused weight loss. The ADMN stated the DM or designee should have monitored to ensure there was enough food with the appropriate consistency. The ADMN stated this failure occurred due to miscalculation of needs for regular diets. Record review of facility's policy titled: Menus and Adequate Nutrition (no date) revealed: The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. The facility will ensure that menus meet the nutritional needs of the residents in accordance with established national guidelines . Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value The facility's dietician or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus. 44722

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 2 of 15 employees (MM and CNA B) reviewed for employability. The facility failed to ensure record of criminal history check and/or an EMR/NAR check prior to offering employment were maintained. These findings placed residents at risk of receiving care by someone that was unemployable. The findings included: Record review of MM's employee file revealed a hire date of 07/22/2024 and no evidence of criminal history or an EMR check were completed prior to offering employment. Record review of CNA B's employee filed revealed a hire date of 08/08/2024 and no evidence of criminal history check or a NAR check were completed prior to offering employment. During an interview on 04/09/25 at 02:25 PM the DON stated she was not able to locate the criminal history and EMR/NAR check for MM and CNA B. The DON stated that there has been turn over in the HR position and does not know what had happened to the criminal history and EMR/NAR checks. During an interview on 04/09/25 at 2:45 PM HR stated she had been at this position since February. HR stated she was responsible to complete the criminal history and EMR/NAR checks. HR stated criminal history and EMR/NAR checks should have been completed prior to hiring and kept in the employee file. HR stated she had looked and was not able to locate MM and CNA B's background checks and was not sure why they were not there. During an interview on 04/09/25 at 03:21 PM the ADMN stated his expectation was that criminal history and EMR/NAR checks were completed and maintained per stated and federal requirements, for employees prior to employment. The ADMN stated HR was responsible for completing criminal history EMR/NAR checks. The ADMN stated he monitored background checks being completed monthly and but had only been monitoring for the new hires. The ADMN stated the affect on residents could have been the potential of residents being exposed to someone who could have done them harm. The ADMN stated he felt the checks had been completed but were misplaced. The ADMN stated what led to the failure was staff turnover, in HR position and the Administrator position. Record review of facility policy titled, Background Screening Investigations dated March 2019 revealed: 1. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. 2.The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. 3. For any individual applying for a position as a certified nursing assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file.

Based on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 18 residents (Resident #74) reviewed for accuracy of records, in that: The facility failed to document in Resident #74's weekly skin assessment dated [DATE], that Resident #74 had a pressure ulcer to her right buttocks discovered on 04/02/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. The findings included: Review of Resident #74's electronic face sheet reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: leg fracture, dementia, and malnutrition. Review of Resident #74's Admission MDS assessment dated [DATE] reflected Resident #74 had a BIMS score of 04 indicating severe cognitive impairment. Further review of Section M reflected resident was at risk for pressure ulcers and had no pressure ulcers. Review of Resident #74's care plan last revised 04/09/25 reflected: Focus: The resident has pressure ulcer development .Unstageable to right buttock (04/02/25) worsened due to favoring right side/declining. Review of Resident #74's weekly skin assessment dated [DATE], reflected no evidence of a wound to the right buttocks. Review of Resident #74's electronic physicians orders reflected: Cleanse pressure injury to buttocks with wound cleanse, pat dry, apply collagen sheet l, cover with hydrocolloid dressing, dated 04/03/2025 and Cleanse unstageable pressure injury to right buttock with wound cleanser, pat dry, apply calcium alginate with Santyl, cover with dry dressing, dated 04/09/2025. Review of Resident #74's electronic progress notes reflected: 04/02/2025 2:53 pm noted pressure wound to sacrum measuring 2 by 4 cm, signed by wound care nurse. Review of Resident #74's Initial Wound Evaluation dated 04/08/25, reflected an unstageable pressure ulcer to the right buttocks measuring 2.5 cm by 4.0 cm. During an interview on 04/09/25 at 10:00 AM, the wound care nurse stated the floor nurses were responsible for completing skin assessments and were to notify her of any changes. During an interview on 04/09/25 at 1:45 PM, LVN A she stated she did perform a skin assessment on Resident #74 on 04/08/2025 She stated she did not recall if the resident had a wound to her buttocks or not. She stated that whatever she documented was what she saw. LVN A then stated she must have forgotten and got confused when she completed the skin assessment document and forgot to add the wound. During an interview on 04/09/25 at 03:17 PM, the DON she stated her expectation was for documentation to be completed accurately. She stated she felt the error was from staff not paying attention or not actually doing the skin assessment and just coping the last documentation which was false documentation. She stated all nurses had been repeatedly in-serviced regarding documentation. She stated the negative outcome could be residents would have wounds and they would not get identified or treated which could lead to infection and further skin break down. Review of facility policy titled, Documentation in Medical Record, revised 01/01/24, reflected in part: Policy: Each residents medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation.

Based on observation, interview, and record review the facility failed to conduct an accurate assessment for 1 (Resident #47) of 18 residents reviewed for assessments. The Facility failed to ensure Resident # 47 most recent MDS dated [DATE] was accurately completed with Resident's hospice status, who was receiving hospice care. These failures could place residents at risk by decreasing the accurate information available to determine the care and services needed for each resident. The findings included: Record review of Resident # 47's face sheet dated 04/09/2025 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses heart failure, high blood pressure, and chronic kidney disease. Record review of Resident #47's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Pattern- Resident had a BIMS of 7, meaning moderate cognitive impairment; Section O- Special Treatments, Procedures, and Programs revealed no evidence Resident #47 received hospice care. Record review of Resident #47's most recent physician orders revealed an active order with a start date of 09/17/2025 Admit to {hospice name} for DX: heart Failure; active order with a start date of 02/13/2025 stated Admit to {hospice name} with a diagnosis of heart failure. Record review of Resident #47's Care Plan dated revealed: Resident was admitted to hospice care on 09/19/2024. Observation on 04/07/2025 at 11:56 AM revealed Resident #47 laying in her bed awake. Resident #47 had equipment with hospice name written on it. During an interview on 04/09/25 at 2:25 PM the DON stated the MDS Coordinators were responsible to complete the MDS. The DON stated her expectation was for MDS' to be completed timely and completely. The DON stated if a Resident was receiving hospice care, then their MDS should reflect they were receiving hospice care. The DON stated Resident #47 had been receiving hospice care. The DON stated they did not have a policy for MDS that they followed the RAI. During an interview on 04/09/25 at 03:10PM MDS C stated she was responsible for completing the Resident # 47's MDS. MDS C stated the MDS should have reflected all the current care areas and services a resident was currently receiving. MDS C stated she had only been one of the MDS coordinators for a few weeks and was still learning. MDS C stated she had forgotten to check the box for hospice care on the MDS but had ensured the care plan and orders had stated hospice. MDS C stated she did not think there was a negative effect on residents because Resident #47 was receiving hospice care. MDS C stated oversight on her part led to failure of hospice not being checked on the MDS. During an interview on 04/09/2025 at 3:21 PM the ADMN stated his expectation was that the MDS be updated per policy and procedure. The ADMN stated the effect on Residents could have been a potential for inappropriate communication of resident care needs. The ADMN stated the nursing leadership and the ADMN were responsible for monitoring completion of MDS. The ADMN stated miscommunication of the MDS process by nursing leadership led to failure of items being missed on the MDS.

Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmission for one of four residents (Resident #1) reviewed for discharge planning. 1. The facility failed to implement discharge plan for Resident #1 who was admitted on [DATE] until the day he was discharged on [DATE] . 2. The facility failed to notify the Ombudsman of Resident #1's discharge. 3. The facility failed to notify Resident #1's physician of the discharge. These failures could place residents at risk of not having their care needs addressed after discharge. Findings include: Record review of Resident #1's face sheet, dated 10/18/24, reflected [AGE] years-old male who was admitted to the facility on [DATE]. Record review of Resident #1's physician's admission notes, dated 09/10/2024, reflected Resident #1 had Intellectual disability, history of substance abuse, depression with anxiety, and mood disorder. Record review of Resident #1's care plan, dated 09/30/2024 , reflected Resident #1's care plan did not address discharge planning. Record review of Resident #1's Admission MDS Assessment, dated 09/17/24, reflected Resident #1's BIMS score was 5, which indicated the resident had severe cognitive impairment. Resident #1 had symptoms of depression. Resident #1 had no symptom of delirium, psychosis or behaviors. Resident #1 had no impairment to upper or lower extremities and needed limited set-up or clean-up assistance to eat, toilet, bathe, dress, or personal hygiene. No special treatments or programs needed. Resident #1 participated in his assessment and goal setting. Resident #1's overall goal was to remain in the facility. Active discharge planning for the resident to return to the community had not yet begun. No referrals were made to a local contact agency because the referral was not wanted. In an interview on 10/18/2024 at 10:25 AM with Resident #1's responsible party stated he was notified by the facility's SW of Resident #1's desire to discharge and was asked to meet at the facility to talk about possibly taking Resident #1 home. At the meeting on 09/25/24 at 11:00 AM the family member stated the DON, Administrator, SW, Resident #1, and him were in the facility's conference room. The family member stated he agreed to take Resident #1 home. The family member stated he received Resident #1's medications with written and verbal instruction and that was it. The family member stated he did not receive any Discharge notice from the facility. In an interview on 10/21/2024 at 1:10 PM, the SW stated she was responsible for discharges, and notifying ombudsman, physician, and any care services if resident required. The SW stated she tried to contact the Ombudsman by phone to notify them of the discharge but, was not able to speak to Ombudsman but left a message. The SW stated she did not notify Resident #1's primary physician and did not provide Resident #1 or the family with a Discharge notice or written reason for discharge. The SW stated the discharge happened so quick she did not have time to follow the facility's Discharge procedures. The SW stated she discharge happened quickly because Resident #1 wanted to leave that day. In an interview on 10/21/2024 at 3:15 PM, Resident #1's primary physician stated he was not notified of discharge . Physician stated he is generally notified of any of his resident's discharge. In an interview on 10/23/2024 at 3:30 PM, the Ombudsman stated she was not notified of the resident's discharge and did not receive a phone call or message from the facility or the facility's SW on 09/25/2024. In an interview on 10/23/2024 at 1:48 PM, the DON stated the SW was responsible for resident discharges. The DON stated after the meeting with Resident #1's family, they agreed to take the resident home and she had nothing else to do with the discharge . In an interview on 10/24/2024 at 1:43 PM, by phone, (Previous Administrator working at facility on 09/25/2024 but no longer employed at facility) stated she, the DON and SW had meeting with Resident #1 and his family on 09/25/24 at 11:00 AM. The Administrator stated it was decided Resident #1 would go home with family. The Administrator stated the SW was responsible for discharge. The Administrator stated the SW was to notify the Ombudsman, physician and provide written notice of discharge to the resident and the family. The Administrator stated not following policy and procedure could affect resident's care while in the community. Record review of the Transfer and Discharge policy, dated: 01/01/2024, reflected the following: Policy .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.

Based on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 (Resident #3) of 10 residents reviewed for resident call system. The facility failed to provide a working communication system on 10/01/2024 that was easily at reach and that would allow Resident #3 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Record review of Resident #3's face sheet dated 10/03/2024, revealed: an [AGE] year-old-female admitted on [DATE], with the following diagnosis Hemiplegia and Hemiparesis following Cerebral infraction right dominant side(weakness and paralysis to right side due to stroke), Atrial Fibrillation(irregular heart rate), Type 2 Diabetes, lack of coordination, . Record review of Resident #3's Quarterly MDS dated [DATE] revealed the following: *Section C- Cognitive Patterns revealed Resident #3 did not have a BIMS score completed due to resident was rarely/never understood. *Section GG- Functional Abilities and Goals revealed Resident #3 was dependent on staff for all ADL's. *Section J Health Conditions revealed Resident #3 had a history of falls. Record review of Resident #3's Care Plan dated 09/05/2024 revealed Resident #3 had a history of falls, and an intervention was for the call light to be in reach. During an observation on 10/01/2024 at 10:30 AM Resident #3 was lying in her bed in her room, the call light was lying in the floor out of Resident # 3's reach. During an interview on 10/01/2024 at 10:50 AM LVN A stated Resident #3 had a soft touch call light. LVN A stated Resident # 3 did not really know how to push the call light for assistance. LVN A stated Resident #3's call light was flat and had a sensor that when Resident #3 moved would alert staff that Resident #3 was trying to move, and staff could respond to prevent Resident #3 from having a fall. LVN A stated Resident #3 should have had call within reach. During an interview on 10/02/2024 at 10:10 AM LVN B stated Resident # 3 should have had her call light within reach. During an interview on 10/03/2024 at 11:45 AM the DON stated her expectation was that call lights should have been placed in reach and attached to the bed, blanket, or chair, to prevent from falling out of reach. The DON stated the effect on residents if call light were not placed within reach could have caused residents to fall if trying to get up to toilet themselves. The DON stated all staff were responsible to monitor the placement of call lights. The DON stated she did not what led to failure of call light no being in place, but stated staff may not have been paying attention. During an interview on 10/3/2024 at 12:30 PM the CD stated expectation was that call lights should have been placed within reach of residents. The CD stated the effect on residents was it could have prevented them to call for assistance. The CD stated that everyone that walks in the room was responsible to ensure the call light was in reach of residents. The CD could not provide a reason to what led to failure of the call light not being within reach of the resident. Record review of facility policy titled, Call Lights: Accessibility and Timely Response dated 01/01/2024 revealed: Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed .Providing access to assistive devices . Installing longer cords or providing remote controlled overhead or task lighting so that they are easily accessible.

Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (Resident #1) of 4 residents reviewed for discharge requirements. The facility failed to ensure Resident #1 was provided a discharge in writing with appropriate reason for the necessity of discharge. This failure placed residents at risk of not receiving necessary care and services. Findings included: Record Review of Resident #1's Face Sheet dated 10/03/2024, revealed a [AGE] year-old male, admitted to the facility on [DATE], discharged on [DATE] with the following diagnoses Insomnia, Intellectual Disabilities and Depression. Record review of Resident #1's Admission MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 5, meaning severe cognitive impairment. Record review of Resident #1's progress notes revealed the following: *09/25/2024 at 8:15 AM written by LVN Aindicated Resident has been wandering in and out of other residents room collecting their personal items when trying to redirect resident ,resident states that all items belong to him, this nurse received report from night shift nurse stating that resident has had no sleep and been wandering the halls all night, resident has taken some of his room mates personal items placing them with his things, this nurse reported to DON of building about residents behavior, DON went into residents room to assess resident upon doing so, window was notice with blinds open and window up but screen still intact, resident was not in room staff started looking for resident, became aware that resident had gotten out of facility through window, and had went across street, resident was brought back to facility by [city] police, resident is now one on one with staff, family was notified resident will continue to be monitored. *09/25/2024 at 6:14 PM written by the social worker indicated Per the incident this morning, SW contacted [Resident #'1] [family members] to request that they take him home tonight. SW will continue to find alternative placements for him. Record review of Resident #1's Transfer/Discharge Report dated on 09/25/2024, and signed by Resident #1's family representative, revealed no evidence of why Resident #1 was discharged from the facility. During an interview on 10/01/2024 at 10:50 AM LVN A stated Resident #1 had not been exit seeking and had not been aggressive to other resident or staff. During an interview on 10/02/2024 at 10:30 AM Resident # 1 family representative stated he was called to come get Resident #1 on 09/25/2024 and was not given a reason to why except that Resident #1 had eloped from the building that morning. Resident #1 family representative stated he and a family member were not in good health and could not take care of Resident #1. Resident #1 family representative stated Resident #1 stated he loved the facility and did not want to leave. During an interview on 10/03/2024 at 11:27 AM the SW stated she and the MDS coordinator were responsible for discharges. The SW stated when it was determined a discharge was necessary, she was responsible to make referral to locate alternative placements or ensure that services were in place if going home, arrange transportation and make sure nursing had put orders in chart to ensure medications were ready to be sent home. The SW stated what initiated an immediate discharge was if the facility felt they could no longer meet a resident's needs. The SW stated if residents were eloping, they might need a facility that had a secure unit and they would discharge once they located a facility for the resident to go to. The SW stated she had made some referrals for Resident #1 that day but could not locate a facility to take him that day, so they contacted family to pick Resident #1 that day because they did not want him to escape again. The SW stated the ADMN was the one who stated Resident #1 needed to be discharged that day. The SW stated there was no change in medical condition that warranted him to be discharged , and that they could have continued to do one on ones until a new placement could be located. The SW stated she did not feel the family was given appropriate time to find a new facility and stated family were elderly and were not able to properly take care of resident. The SW stated in her previous experience family should have been given a letter of discharge and also given at least 24 hours. The SW stated she had never encountered a discharge happening same day. During an interview on 10/03/2024 at 11:45 AM the DON sated the facility does not usually do an immediate discharge. The DON stated an immediate discharge would be given due to safety of resident. The DON stated if residents were exit seeking, she would start the conversation about starting to looking for another appropriate facility, especially if they had gotten out of the facility. The DON stated the only interventions that were done after the elopement was Resident #1 was placed on one on ones once until family picked him up. The DON stated there had not been a change in Resident #1's medical condition that the facility was not able to provide appropriate care. During an interview on 10/03/2024 at 12:30 PM the CD stated his expectation was that if a resident was a danger to self or others that would warrant and an immediate discharge as soon as possible. The CD stated the facility should attempt to find alternative placement. The CD stated he was a part of the conversation to discharge Resident #1. The CD stated Resident #1 discharge was appropriate because he was at risk of getting out a window again and it would have been unwise to keep him at the facility. The CD stated Resident #1 was his own decision maker, on admission he was informed that if he wanted to leave to let them know. The CD stated Resident # 1's BIMS score was not a good indicator on his ability to make decisions that it was one tool of many tools used to assess. The CD stated the resident was not aggressive to staff or other residents. The CD stated the elopement piece was what changed the medical needs they could no longer provide for. The CD stated they did not have the staff to do one on ones with resident. Record review of facility policy titled, Transfer and Discharge (including AMA) dated 1/1/24 revealed: once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following species exemptions: A. The transfer discharge is necessary for the residents welfare and the residents needs cannot be met in the facility. B. The transfer or discharge is appropriate because the residents health has improved sufficiently so the resident no longer needs the services provided by the facility. C. The safety of individuals and the facility is in danger due to the clinical or behavioral status to the resident. D. The health of individuals in the facility would otherwise be endangered. E. The resident has failed, after a reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility. Nonpayment applies if the resident it's not submit the necessary paperwork for the third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her state. F. The facility ceases to operate.

Based on interview and record review, the facility failed to have evidence of a thorough investigation of the allegation of abuse for one (Resident #1) of three residents reviewed for abuse. 1. The Administrator, who was the Abuse Coordinator failed to thoroughly investigate an abuse allegation to Resident #1 on 09/17/18. An Immediate Jeopardy (IJ) was identified on 09/20/18. Although, the IJ was removed on 09/21/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to needing to train staff and monitor their implementation of the Plan of Removal (POR). The failure placed residents at risk of serious mental harm, physical harm and or death. Findings Included: Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had unclear speech and she usually understood and could usually make herself understood to others. She was moderately impaired with cognitive skills for daily decision making. She had a depressed, hopeless mood half or more days throughout the week and she required extensive assistance by staff for bed mobility, transfers, dressing, toilet use and personal hygiene. She utilized a wheelchair for mobility and was incontinent of bowel and bladder. Her [DIAGNOSES REDACTED]. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 06/26/18 revealed, Patient required max (maximum) encouragement for participation. Patient stated she didn't care about progressing with therapy. Patient was also resistant to having her husband in room. She requested he leave during treatment in her room. Husband stated that he believe his wife is dying. He stated she refuses to eat and isn't responsive to him. Nurse was notified of discussion with patient and her husband. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/05/18 reported Upon entering room, patient was in supine with ble (bilateral extremities (resident's legs)) were hanging off the bed and husband standing next to her. Patient's husband stated she was trying to get up. He and patient were told that they needed to use call button to request assistance (sic). Her husband stated that she was acting like a [AGE] year and didn't want to do what she needed to do. He was advised that patient requires assistance, but he continued to state that she could do it. Review of Resident #1's Progress Note dated 07/09/18 revealed .Staff report she will do ok at meals with 25-50%, improved since initial RD assessment and seems to do better when husband isn't providing care. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/12/18 reported Arrived to pt's (patient's) room with spouse refusing to let pt participate in therapy . Spouse continued to refuse for her to get out of bed . Spouse does not allow pt to speak for herself, and pt covered face and began crying when husband was arguing with therapists. Spoke with DOR (Director of Rehabilitation) on issue who advised to speak with SW (Social Worker) because therapist to suspicious of abusive relationship d/t (due to) behaviors demonstrated by spouse. Review of Resident #1's Physical Therapy Recertification & Updated Plan of Treatment dated 07/13/18 revealed progress and response to treatment of [REDACTED]. Pt (patient) might benefit from a psych referral. Review of Resident #1's Clinical chart reflected she was not referred to psych services. In an interview with the DON she confirmed Resident #1 did not receive psychiatric services for her depression. DON said she was not aware that she could see therapy notes in the facility's computer system and now that she is aware she will send the referral for psych services for Resident #1. Review of Resident #1's Medical Doctor/Nurse Practitioner Note dated 07/17/18 revealed Husband and pt report decreased appetite, and pt states I just don't want to eat. Staff report that pt eats better when husband not present. Will recommend eating assistance by staff. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/17/18 revealed, Reviewed pt's (patient's) P[NAME] (plan of care) and updated goals. Discussed lack of progress c (with) nurse and DOR (Director of Rehabilitation). Also asked husband and nurse whether pt is suffering from depression and if she's getting any tx (treatment) for it, pt might benefit from psych consult as pt seems to have no interest in anything. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/19/18 revealed, Entered room and pt (patient) was in bed and agreed to perform therapy, spoke to nursing about getting pt up and they wanted pt OOB (out of bed) . The husband told the therapist to get out, honored his wishes. Spoke with nursing and social worker about pts husband hindering her therapy and pt is getting weaker. Nursing asked therapy to go back to get pt up, entered room without husband and pt agreed again to therapy. Review of Resident #1's Physical Therapy Discharge Summary dated 07/23/18 revealed Patient Response of Pt had admitted after a hosp (hospital) stay for [MEDICAL CONDITIONS] c (with) overall goal of returning home c spouse of ALF (assisted living facility) down the street from us. However, pt has been declining and not participating well, c husband refusing to allow pt to get OOB often or to go the DR (dining room) for asst (assistance) c meals. Pt's spouse and dtr (daughter) report that pt has a fatal heart condition (spouse repeatedly tells Nrsg (nursing) and Therapy staff that pt is dying and has told the pt this), and they have requested that all therapies stop (PT, OT, and ST) (Physical Therapy, Occupational Therapy and Speech Therapy). Pt was recently Recert'd (recertified) to cont (continue) PT c goals changed to accommodate for decline in status, c recomend (sic) made for psych services to assess for depression as pt had made some improvement c bed mob (mobility) and when motivated was able to participate c tx (treatment), but most of the time seemed disinterested in anything, appeared depressed, and to have given up. It had also been recommended that pt get OOB daily for all meals and for a short while was doing better per Nrsg until husband refused to let her go to DR or get OOB. Review of Resident #1's Progress Note dated 07/24/18 revealed Restorative needed to get a weight on resident and we got her up in a WC and then we asked her if she wanted to go and eat in the dining room she said yes. As soon as the husband got back in the room with her he said NO and I told him that she wanted to, and he said I don't care she's been up for hours and I told him that we just got her up and he got very mad and irate. Called the daughter to give her an update and she was very mad at first but after I explained to her that patients with dementia will say no they're not hungry and then when we offer food they will eat, and she said she understood. I told her that every time he is not in there she will agree to get up and is very happy and in good spirits. She said that he has had control for so long that his anger is probably out of frustration on not being able to control everything. She said that she will try and have a talk with him, but she doesn't think it'll work. I told her that it would do her mom good physically and mentally to get up and eat and she said that she has arthritis and it hurts to get up, so I educated her that getting up and moving around is a lot better on her than laying there and getting stiff. She said that she will try and talk to him another day but that she has lived a hard life with them because she has never been able to anything right. I told her I understand but we need to all work together and she said that she will try and call him tomorrow. Review of Resident #1's Progress Note dated 07/24/18 reflected Staff is encouraging res to go to dining room to eat, but res's spouse is telling staff not to get res up or help her eat. Res is eating 0-25%, spitting out food, very poor appetite. Res's spouse is telling staff she is dying and to leave her alone. Staff notified daughter about spouse interfering with care. Res is verbally aggressive with staff about meals. Staff has provided spouse with a tray at meal times, as well, but he becomes agitated and verbally aggressive. At lunch today, res wanted to go to DR for lunch and spouse refused to allow res to go. Res visibly upset and crying. Daughter (POA) is aware of above stated concerns and states that res is dying and agrees with the spouse. Review of Resident #1's Care Plan dated 07/24/18 reflected, Resident #1 had unplanned/unexpected weight loss related to poor food intake zero percent most meals, spitting out food and spouse is prohibiting staff from giving care was addressed as a focus area. Care plan did not address interventions of spouse prohibiting her from receiving care from staff. Care plan did not address documented concerns or Resident #1's Spouse who was not allowing her to make own decisions as it related to care. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 08/02/18 reported Family (dtr (daughter)) would like for pt to gain more strength and to be OOB as toler'd (tolerated). (Dtr has POA (power of attorney.) Dtr reported that cardiologist had told family that pt's heart was very weak c a valve defect, pt not approp (appropriate) for surgery, but had not recommended bedrest or hospice care and had not given a prognosis for life-expectancy. Review of Resident #1's Progress Note dated 08/17/18 SW revealed Met with (Resident #1's Spouse) in regards to (sic) the concerns the staff continues to have with him. He continues to interfere with her care and he is now requesting that the roommate leave the room. I have met with the resident's spouse, the roommate, the ADON and the DON. The spouse denies this at first and the nurse addressed the issue with him that she too has witnessed this. At this time, we have removed the roommate from the room and contacted the daughter to inform her of the concern. He continues to interfere with her therapy and meals as well. At this time, it is believed that the resident either needs a private room or the resident's spouse can visit with the daughter. At this time this has only been presented to the daughter as options and a decision has not been made. Interview on 09/20/18 at 10:37AM with Resident #2 revealed she was Resident #1's previous roommate. Resident #2 stated Resident #1 was moved into her room during the evening time and (Resident #1) was as sweet as she could be that night but something changed. Resident #2 said staff got Resident #1 up for breakfast and took her into the dining room. When they brought her back into the room, she said Resident #1's spouse came into the room later that morning and she (Resident #1) was a different person. Resident #2 said Resident #1 was upset and was crying and she refused to stay in the room with Resident #2. Resident #2 revealed and she asked staff to move herself and or Resident #1 and later that day Resident #1 was moved to another room. Resident #2 said Resident #1 did not stay in her room long and she did not know why the resident was upset because she did not stay in the room. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had clear speech, and she understood others and made herself understood to others. She had modified independence, (meaning she had some difficulty in new situations only) with cognitive skills for daily decision making. She required limited assistance by staff for bed mobility, transfers, dressing, and toilet use; she required supervision by staff for locomotion on/off the unit (moving around the unit), and personal hygiene. She utilize a walker and a wheelchair for mobility. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 08/27/18 revealed husband not present in facility this afternoon. Overall pt was alert and in a good mood, more upbeat for most of tx . Overall pt was more alert and attentive than I've seen her in a long time. Interview with LVN R on 09/19/18 at 2:15 PM revealed she was one of Resident #1's nurses who witnessed issues with the resident and her spouse. LVN R stated she was unsure if it was on 09/13/18 or 09/14/18, but she witnessed Resident #1's spouse after lunch remove the resident from the dining room at the resident's request to push her around in her wheelchair. LVN R stated he pushed her roughly in her wheelchair causing her feet to drag under her. LVN R said Resident #1 told him that it hurt and his response to her was that's what you get, because you won't lay down. LVN R stated she and another staff member told him they would push her. She stated then the resident was parked behind the nurse's station. She said she told the nurse who was responsible that day for Resident #1's care and was told she was aware of incident. LVN R stated that whenever Resident #1 was around her husband she looked like a wounded puppy and she looked afraid of him, but the resident never voiced it the fear to her. LVN R revealed she attempted to contact Resident #1's daughter several times in the past but was unsuccessful most time except once, she said the daughter stated, I know what my father is doing, and I washed my hands with him and she stopped answering the facility's calls. Confidential Interview revealed he/she had been noticing interactions between Resident #1 and her spouse which revealed Resident #1 feared him. He/she stated on 09/14/18 after lunch, her spouse was pushing her wheelchair and her feet were dragging the ground and getting caught under her wheelchair. The interviewee revealed the resident started crying and getting upset. He/She said he/she stopped the spouse and told him he could not push her wheelchair in that manner. He/She stated the spouse stated he could do whatever he wanted and he continued to push the wheelchair. The interviewee revealed he/she told him that he/she could push the resident. He/She stated he/she took the resident to the nurse's station where he/she told the nurse what took place. He/She stated he/she was told by the nurse to write a statement, but nothing happened about the incident, he/she said the statement was given to the DON because the Administrator was not in the facility (spoken with Administrtor and DON, no evidence of statement was provided). The interviewee stated he/she Resident #1's husband had gotten upset because Resident #1 would not lie down after lunch. The resident told staff she did not want to lie down when they asked her. The interviewee revealed Resident #1 told him/her and others that her spouse was mean to her and she was afraid of him. Review of Resident #1's Progress Note dated 09/17/18 at 1058 written by LVN K reflected, Writer was doing rounds this am and checked on resident. Writer asked resident if she wanted to get up for breakfast, resident stated no. Writer stated that's fine, would you like to get up for lunch and resident stated, I would like too. Approx. around 1100 (11:00 a.m.) writer went up to husband and told him that resident requested to be up for lunch and residents husband started getting agitated and tried to prevent staff from getting resident up. ADON and writer went back to residents' room to ask her again if she wanted to be up and resident stated yes. Approx. 1107 residents husband came up to writer and tried to explain to writer why resident shouldn't be up. Husband stated, she is here to die and not get well. Writer stated to husband that writer is here to give the best quality of care to resident and that resident requested to get up, so staff will get resident up for lunch. Husband stated to writer that getting her up was writers' choice and writer stated it was resident's choice. Writer explained to husband that resident didn't want to get up for breakfast, so she didn't get up because that was her choice, but she did want to get up for lunch and that was her choice as well. Husband then stated to writer I hope she dies on your shift. ADON and DON notified. Review of Resident #1's Progress Notes dated 09/17/18 at 7:10 PM by ADON G reflected, Residents spouse was in facility today. Resident wanted to get out of bed and resident husband was refusing to allow the aides to get resident out of bed. We ultimately got resident out of bed and brought her to nurses' station. Residents husband sat with her at nurses' station. After being up for approximately an hour and half resident husband told the aides he wanted her to go back to bed. Resident stated she didn't want to go back to bed and residents husband pushed resident on the shoulder. At that time, we moved resident behind the nurse's station with the nurses and reported to the DON. The DON came to speak with the husband and advised him to leave the facility. Resident was not harmed. Resident asked that she stay for a while longer and staff complied. Review of Resident #1's Progress Notes dated 09/17/18 at 1:48 PM by LVN K reflected, Due to concerns with the spouse demonstrating aggressive behavior towards his wife and staff. He refuses to calm down and allow his wife to be treated. The resident appears and states she is frustrated with her spouse. She continues to cry and desires to get out of bed which he is refusing to allow. The daughter, MPOA, has been left several messages including from my cell phone. At this time the Ombudsman has also been left a message. Interview with CNA T on 09/19/18 at 1:59 PM revealed she witnessed the incident between Resident #1 and her spouse on 09/17/18 of him pushing her in her right arm because she would not lie down whenever he requested her to do so. CNA T stated the resident cried and said she did not want to confuse anyone, but she did not want to lie down. CNA T stated that her and two other staff had witnessed the event and were told to write a statement, but nothing was done about it until Resident #1's Spouse pushed her, which he was asked to leave the facility by the DON. CNA T stated on Friday (09/14/18) she heard Resident #1 screaming get away from me, leave me alone and when she went to check on the resident, she found her at the nurse's station. CNA T revealed she was told a LVN R that the resident's husband drug her feet under her wheelchair. CNA T stated she worked on a different hall that Resident #1 previously resided on and she had witnessed the resident's spouse squeezing the resident's cheeks to force her to take her medications. She stated the nurse who administered the medications also witnessed it and was told by the nurse she reported it to the DON. CNA T stated Resident #1 usually looked withdrawn whenever her spouse was present, and she would look down as he spoke. When asked what she wanted, she would state whatever he wants. CNA T said Resident #1's Spouse would tell Resident #1 she was dying and needed to lie down. She stated Resident #1 would cry sometimes whenever he told her that she was dying. Interview with LVN M on 09/19/18 at 3:33 PM revealed she worked with Resident #1 in the past and had witnessed several incidents involving her spouse. LVN M said Resident #1's spouse was a controlling man and that whenever she would give the resident medications when he was present, he would squeeze the resident's cheeks and tell her quit being stupid or an idiot because she took her medication slowly one by one. LVN M stated that once that had happened, she would administer the medications before he would arrive to the facility or if he came before she could give Resident #1's medication she would divert him to do something, so she could give it to her. LVN M stated he only grabbed her face once that she witnessed, and she did not allow him to do it again because she found ways to give her medication without him present. LVN M said she told her ADON about the incident and she was unsure if what he said was verbal abuse or he was just being mean. LVN M said Resident #1 would draw her hands to her chest and stare at her like help me but never would voice anything, LVN M said Resident #1's spouse had aggression towards staff and was hateful to the resident. She revealed Resident #1 just wanted staff to do whatever he would request which was to keep her in bed and refuse care. LVN M stated she witnessed the incident on 09/17/18 and she described the push as a violent push to Resident #1's upper right arm/shoulder area. She revealed he did it because she did not comply with his request of her going back to bed. LVN M stated the DON was aware of incidents and would suggest they divert his attention, so they could provide care. LVN M said she and other staff attempted to contact the daughter, but she did not want anything to do with Resident #1's care. LVN M stated Resident #1's spouse ate the resident's meals. She said Resident #1 did not eat if he was with her, but she would eat after he left. LVN M said she witnessed earlier in the day on 09/17/18 Resident #1's spouse told another nurse in front of Resident #1 that he hopes she dies on her shift because the resident would not lie down. LVN M said if he had been asked to leave at that time and or if management had intervened, then he would not have been able to assault Resident #1 after lunch that day. LVN M said Resident #1 had been smiling, interacting with other residents and participating in activities since he was asked to leave the facility and that was the most she had witnessed of Resident #1 since she been in the facility. LVN M stated that she did receive in-service training on abuse and neglect, but she denied receiving in-service training on calling 911 if he showed up to the facility. LVN M stated that she was unsure of what was required if Resident #1's Spouse returned back to the facility but feels she should know what she's required to do if it's afterhours. She said although she's not Resident #1's nurse anymore she feels it's important for all staff to know who has visitation restrictions. Review of Complaint/Grievance Report dated 09/17/18 revealed staff had concerns for Resident #1 which revealed bedside nurse stated husband refused to allow (Resident #1) to get up to dining room for lunch stated he hopes she dies on your shift Social worker called daughter multiple times (Resident #1's Spouse) asked to leave facility due to safety concerns for (Resident #1). Daughter continues to not return calls. APS (Adult Protective Services) called for (Resident #1's Spouse) due to confusion/safety concerns. Review of Resident #1's updated Care Plan dated 09/19/18 reflected Care Plan was not revised until concerns of resident's safety was brought to the attention of the DON. Care Plan reflected Resident #1 had an ADL self-care performance deficit that was related to her cognitive deficits of Alzheimer's diagnosis. Care Plan reflected Resident #1's Spouse would interfere with her personal care (wanting resident to stay in bed for meals) as a focus area. Interventions were for nursing staff and the facility's social worker to educate spouse and reinforce resident's need for independence. Notify family when needed for support with unrealistic demands of the spouse. If spouse becomes angered with the staff, the staff may ask the spouse to leave the facility. Updated care plan did not reflect assault incident on 09/17/18 nor did it reflect facility restricting Resident #1's Spouse from visiting the facility and or supervised visits; although in an interview with the facility Administrator stated he and his DON knew Resident #1's Spouse was not allowed back into the facility without being supervised by staff, he just hadn't told all staff nor did he add updated information to resident plan of care, according to him. In-services regarding Resident #1 were not conducted until 09/19/18 which covered Abuse and Neglect as well as calling 911 if Spouse entered the building. The in-service sign in sheet did not reflect all staff completed the in-service. Confidential Interview revealed he/she stated they did not want to get in-trouble but said they were not going to lie but they did not receive training on calling 911 if Resident #1's Spouse returned back to the building on 09/19/18. He/she was shown in-service list that had his/her name on it they confirmed the signature was theirs but the information that was stapled and written on the in-service sheet was not provided to him/her. He/she stated that on 09/19/18 they received an in-service on abuse and taking out the trash nothing related to Resident #1. Observations of Resident #1 on 09/19/18 at 11:22 AM on 09/20/18 at 10:50 AM, and on 09/21/18 at 8:40 AM revealed she was up in her wheelchair on all days participating with staff, her husband was not present during observations. She had conversations but was not on topic. An observation of Resident #1 on 09/20/18 at 10:50AM revealed she participated in the music group activity and was smiling and nodding her head as the music group played live music her husband was not present. Interview with LVN R on 09/19/18 at 2:15 PM revealed that since Resident #1's spouse had been removed from the facility, that was the most she had seen the resident up out of the bed and that she seemed happier and now attended most activities during the day. Interview with LVN M on 09/19/18 at 3:33 PM revealed Resident #1 had been smiling, interacting with other residents and participating in activities since the resident's spouse was asked to leave the facility and that was the most she had witnessed of Resident #1 since the resident had been in the facility. Interview with the Staffing Coordinator on 09/19/18 at 12:21 PM revealed she felt that Resident #1's spouse was abusive. She stated she was responsible for assisting with breakfast and she witnessed Resident #1's spouse grab the resident's arm and point his finger in the resident's face The Staffing Coordinator revealed staff always intervened and kept an eye on the resident which they reported to the nurse. She stated Resident #1's spouse would try to isolate the resident and would refuse to allow the resident to get out of the bed. The Staffing Coordinator said she felt Resident #1 was afraid of him by how she responded whenever he was in the facility. The Staffing Coordinator stated Resident #1's Spouse got aggressive quickly towards staff. She stated the resident was generally happy whenever her husband was not around but whenever he was around she just complied with whatever he wanted. Interview with the SW on 09/19/18 at 3:00 PM revealed she was involved in dealing with Resident #1's spouse by educating him daily of staff concerns of him intervening with Resident #1's care. The SW stated Resident #1's spouse had been ugly towards staff and he gotten upset that the resident wanted to get out of bed but as long as the resident stayed in bed he did not have any concerns. She revealed he did not want the resident to participate in therapy because he was fixated on her dying. The SW stated staff said he would curse at them, but she had never witnessed him doing the things they stated he would do. She said she was informed of the incident on 09/17/18 and she contacted the daughter but was unsuccessful of reaching her, so she made an APS referral because she was concerns of Resident #1's Spouse's safety. SW stated she felt Resident #1's Spouse had dementia because she would often get confused on how to get out of the building. SW stated she did not make a referral for Resident #1 to receive psychological or psychiatric care and treatment; however, she did speak with Resident #1's Daughter about her father (Resident #1's Spouse) actions and his cognition. SW said she did not talk with the Resident #1 because Resident #1's Spouse liked her which she was about the only one he liked she would be the one to calm him and divert him while staff provided care. SW said he did not have any issues until staff tried to get resident out of bed. Interview with DOR on 09/20/18 at 3:22 PM revealed she was aware of some of her staff concerns but she did not review the daily notes. The DOR stated Resident #1's spouse would get very upset and irate whenever her staff attempted to provide therapy to Resident #1. She said he ordered them out of the room and once he grabbed a staff's arm. The DOR revealed the resident complied with whatever her spouse wanted and if he got upset, she got upset and cried. The DOR stated when the spouse got like that, staff was to leave the room and report the concerns to her as well as document the occurrence. She stated the DON, SW, herself and other department heads had IDT meetings regarding his actions but Resident #1's Spouse would agree in the meeting but would refuse whenever therapy staff would try to treat resident which was almost every session thing with various of staff which was always reported to the SW since she was able to calm him. DOR stated that Resident #1 was no longer receiving therapy due to spouse requesting she discharge from it. Interview on 09/19/18 with the DON at 10:40 AM revealed on 09/17/18 she was informed by Resident #1's nurse of the incident of her spouse pushing Resident #1 in her arm. The DON stated the spouse would interfere with care and would get aggressive towards staff. She stated she tried to contact Resident #1's daughter but was unsuccessful as well as educate him on staff concerns and Resident #1's rights. The DON revealed staff reported to her on several occasions that he would prevent Resident #1 from eating her meal, her getting out of bed, participating in therapy, and would refuse staff care daily. She stated she and the SW educated him about her rights daily and found way to work around his interference. The DON stated he would get upset with staff and in return Resident #1 would get upset. The DON stated Resident #1's spouse often stated the resident was going to die and to allow her to die, but she would try to tell him that she was not dying. The DON revealed staff reported to her that Resident #1's daughter did not want the facility to call her again. The DON stated after she was aware he pushed Resident #1, he was asked to leave the facility by herself, which was instructed by the Administrator who was out of the facility and she instructed the SW to make a report to APS. The DON stated they were working on what they should do going forward regarding him being in the facility and at the time of the interview no plans were in place. DON said she told staff that if Resident #1 Spouse came back into the facility to call 911 until they (herself and the Administrator) figured out what they were going to do. DON said she wanted to contact the daughter to make a plan because they did not want to say Resident #1's Spouse could not ever return back to the facility. Interview on 09/19/18 with the Administrator at 4:22 PM revealed he was the facility's Abuse Coordinator and in his absence, staff was to report allegations of abuse to the DON. The Administrator stated he received a phone call from the DON, who stated Resident #1 was pushed by her spouse in her arm. He stated his first response was to remove the threat and he told the DON to have Resident #1's spouse exit the building and if he refused and or came back to the facility to call local law enforcement. The Administrator said he did not report the incident because Resident #1 was pushed lightly, while sitting in her wheelchair and she was not harmed so he did not feel it required him to report He said furthermore, the spouse was asked to leave and at that time was not considered a threat. The Administrator stated until 09/19/18 he was not aware of Resident #1's Spouse disruptive behaviors and he had not read the resident's nurses notes until copies were requested. The Adm

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1) of three residents reviewed for abuse. 1. The Administrator failed to implement the Abuse/Neglect Policy including reporting and investigating allegations of abuse for Resident #1. 2. The DON failed to follow the Abuse/Neglect when she did not report multiple incidents of alleged abuse of Resident #1 by the resident's husband to the Administrator. Resident #1 had episodes of tearfulness and fear and she was withdrawn socially. An Immediate Jeopardy (IJ) was identified on 09/20/18. Although, the IJ was removed on 09/21/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to needing to train staff and monitor their implementation of the Plan of Removal (POR). The failure placed residents at risk of serious mental harm, physical harm and or death. Findings Included: Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had unclear speech and she usually understood and could usually make herself understood to others. She was moderately impaired with cognitive skills for daily decision making. She had a depressed, hopeless mood half or more days throughout the week and she required extensive assistance by staff for bed mobility, transfers, dressing, toilet use and personal hygiene. She utilized a wheelchair for mobility and was incontinent of bowel and bladder. Her [DIAGNOSES REDACTED]. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 06/26/18 revealed, Patient required max (maximum) encouragement for participation. Patient stated she didn't care about progressing with therapy. Patient was also resistant to having her husband in room. She requested he leave during treatment in her room. Husband stated that he believe his wife is dying. He stated she refuses to eat and isn't responsive to him. Nurse was notified of discussion with patient and her husband. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/05/18 reported Upon entering room, patient was in supine with ble (bilateral extremities (resident's legs)) were hanging off the bed and husband standing next to her. Patient's husband stated she was trying to get up. He and patient were told that they needed to use call button to request assistance (sic). Her husband stated that she was acting like a [AGE] year and didn't want to do what she needed to do. He was advised that patient requires assistance, but he continued to state that she could do it. Review of Resident #1's Progress Note dated 07/09/18 revealed .Staff report she will do ok at meals with 25-50%, improved since initial RD assessment and seems to do better when husband isn't providing care. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/12/18 reported Arrived to pt's (patient's) room with spouse refusing to let pt participate in therapy . Spouse continued to refuse for her to get out of bed . Spouse does not allow pt to speak for herself, and pt covered face and began crying when husband was arguing with therapists. Spoke with DOR (Director of Rehabilitation) on issue who advised to speak with SW (Social Worker) because therapist to suspicious of abusive relationship d/t (due to) behaviors demonstrated by spouse. Review of Resident #1's Physical Therapy Recertification & Updated Plan of Treatment dated 07/13/18 revealed progress and response to treatment of [REDACTED]. Pt (patient) might benefit from a psych referral. Review of Resident #1's Clinical chart reflected she was not referred to psych services. In an interview with the DON she confirmed Resident #1 did not receive psychiatric services for her depression. DON said she was not aware that she could see therapy notes in the facility's computer system and now that she is aware she will send the referral for psych services for Resident #1. Review of Resident #1's Medical Doctor/Nurse Practitioner Note dated 07/17/18 revealed Husband and pt report decreased appetite, and pt states I just don't want to eat. Staff report that pt eats better when husband not present. Will recommend eating assistance by staff. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/17/18 revealed, Reviewed pt's (patient's) P[NAME] (plan of care) and updated goals. Discussed lack of progress c (with) nurse and DOR (Director of Rehabilitation). Also asked husband and nurse whether pt is suffering from depression and if she's getting any tx (treatment) for it, pt might benefit from psych consult as pt seems to have no interest in anything. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/19/18 revealed, Entered room and pt (patient) was in bed and agreed to perform therapy, spoke to nursing about getting pt up and they wanted pt OOB (out of bed) . The husband told the therapist to get out, honored his wishes. Spoke with nursing and social worker about pts husband hindering her therapy and pt is getting weaker. Nursing asked therapy to go back to get pt up, entered room without husband and pt agreed again to therapy. Review of Resident #1's Physical Therapy Discharge Summary dated 07/23/18 revealed Patient Response of Pt had admitted after a hosp (hospital) stay for [MEDICAL CONDITIONS] c (with) overall goal of returning home c spouse of ALF (assisted living facility) down the street from us. However, pt has been declining and not participating well, c husband refusing to allow pt to get OOB often or to go the DR (dining room) for asst (assistance) c meals. Pt's spouse and dtr (daughter) report that pt has a fatal heart condition (spouse repeatedly tells Nrsg (nursing) and Therapy staff that pt is dying and has told the pt this), and they have requested that all therapies stop (PT, OT, and ST) (Physical Therapy, Occupational Therapy and Speech Therapy). Pt was recently Recert'd (recertified) to cont (continue) PT c goals changed to accommodate for decline in status, c recomend (sic) made for psych services to assess for depression as pt had made some improvement c bed mob (mobility) and when motivated was able to participate c tx (treatment), but most of the time seemed disinterested in anything, appeared depressed, and to have given up. It had also been recommended that pt get OOB daily for all meals and for a short while was doing better per Nrsg until husband refused to let her go to DR or get OOB. Review of Resident #1's Progress Note dated 07/24/18 revealed Restorative needed to get a weight on resident and we got her up in a WC and then we asked her if she wanted to go and eat in the dining room she said yes. As soon as the husband got back in the room with her he said NO and I told him that she wanted to, and he said I don't care she's been up for hours and I told him that we just got her up and he got very mad and irate. Called the daughter to give her an update and she was very mad at first but after I explained to her that patients with dementia will say no they're not hungry and then when we offer food they will eat, and she said she understood. I told her that every time he is not in there she will agree to get up and is very happy and in good spirits. She said that he has had control for so long that his anger is probably out of frustration on not being able to control everything. She said that she will try and have a talk with him, but she doesn't think it'll work. I told her that it would do her mom good physically and mentally to get up and eat and she said that she has arthritis and it hurts to get up, so I educated her that getting up and moving around is a lot better on her than laying there and getting stiff. She said that she will try and talk to him another day but that she has lived a hard life with them because she has never been able to anything right. I told her I understand but we need to all work together and she said that she will try and call him tomorrow. Review of Resident #1's Progress Note dated 07/24/18 reflected Staff is encouraging res to go to dining room to eat, but res's spouse is telling staff not to get res up or help her eat. Res is eating 0-25%, spitting out food, very poor appetite. Res's spouse is telling staff she is dying and to leave her alone. Staff notified daughter about spouse interfering with care. Res is verbally aggressive with staff about meals. Staff has provided spouse with a tray at meal times, as well, but he becomes agitated and verbally aggressive. At lunch today, res wanted to go to DR for lunch and spouse refused to allow res to go. Res visibly upset and crying. Daughter (POA) is aware of above stated concerns and states that res is dying and agrees with the spouse. Review of Resident #1's Care Plan dated 07/24/18 reflected, Resident #1 had unplanned/unexpected weight loss related to poor food intake zero percent most meals, spitting out food and spouse is prohibiting staff from giving care was addressed as a focus area. Care plan did not address interventions of spouse prohibiting her from receiving care from staff. Care plan did not address documented concerns or Resident #1's Spouse who was not allowing her to make own decisions as it related to care. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 08/02/18 reported Family (dtr (daughter)) would like for pt to gain more strength and to be OOB as toler'd (tolerated). (Dtr has POA (power of attorney.) Dtr reported that cardiologist had told family that pt's heart was very weak c a valve defect, pt not approp (appropriate) for surgery, but had not recommended bedrest or hospice care and had not given a prognosis for life-expectancy. Review of Resident #1's Progress Note dated 08/17/18 SW revealed Met with (Resident #1's Spouse) in regards to (sic) the concerns the staff continues to have with him. He continues to interfere with her care and he is now requesting that the roommate leave the room. I have met with the resident's spouse, the roommate, the ADON and the DON. The spouse denies this at first and the nurse addressed the issue with him that she too has witnessed this. At this time, we have removed the roommate from the room and contacted the daughter to inform her of the concern. He continues to interfere with her therapy and meals as well. At this time, it is believed that the resident either needs a private room or the resident's spouse can visit with the daughter. At this time this has only been presented to the daughter as options and a decision has not been made. Interview on 09/20/18 at 10:37AM with Resident #2 revealed she was Resident #1's previous roommate. Resident #2 stated Resident #1 was moved into her room during the evening time and (Resident #1) was as sweet as she could be that night but something changed. Resident #2 said staff got Resident #1 up for breakfast and took her into the dining room. When they brought her back into the room, she said Resident #1's spouse came into the room later that morning and she (Resident #1) was a different person. Resident #2 said Resident #1 was upset and was crying and she refused to stay in the room with Resident #2. Resident #2 revealed and she asked staff to move herself and or Resident #1 and later that day Resident #1 was moved to another room. Resident #2 said Resident #1 did not stay in her room long and she did not know why the resident was upset because she did not stay in the room. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had clear speech, and she understood others and made herself understood to others. She had modified independence, (meaning she had some difficulty in new situations only) with cognitive skills for daily decision making. She required limited assistance by staff for bed mobility, transfers, dressing, and toilet use; she required supervision by staff for locomotion on/off the unit (moving around the unit), and personal hygiene. She utilize a walker and a wheelchair for mobility. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 08/27/18 revealed husband not present in facility this afternoon. Overall pt was alert and in a good mood, more upbeat for most of tx . Overall pt was more alert and attentive than I've seen her in a long time. Interview with LVN R on 09/19/18 at 2:15 PM revealed she was one of Resident #1's nurses who witnessed issues with the resident and her spouse. LVN R stated she was unsure if it was on 09/13/18 or 09/14/18, but she witnessed Resident #1's spouse after lunch remove the resident from the dining room at the resident's request to push her around in her wheelchair. LVN R stated he pushed her roughly in her wheelchair causing her feet to drag under her. LVN R said Resident #1 told him that it hurt and his response to her was that's what you get, because you won't lay down. LVN R stated she and another staff member told him they would push her. She stated then the resident was parked behind the nurse's station. She said she told the nurse who was responsible that day for Resident #1's care and was told she was aware of incident. LVN R stated that whenever Resident #1 was around her husband she looked like a wounded puppy and she looked afraid of him, but the resident never voiced it the fear to her. LVN R revealed she attempted to contact Resident #1's daughter several times in the past but was unsuccessful most time except once, she said the daughter stated, I know what my father is doing, and I washed my hands with him and she stopped answering the facility's calls. Confidential Interview revealed he/she had been noticing interactions between Resident #1 and her spouse which revealed Resident #1 feared him. He/she stated on 09/14/18 after lunch, her spouse was pushing her wheelchair and her feet were dragging the ground and getting caught under her wheelchair. The interviewee revealed the resident started crying and getting upset. He/She said he/she stopped the spouse and told him he could not push her wheelchair in that manner. He/She stated the spouse stated he could do whatever he wanted and he continued to push the wheelchair. The interviewee revealed he/she told him that he/she could push the resident. He/She stated he/she took the resident to the nurse's station where he/she told the nurse what took place. He/She stated he/she was told by the nurse to write a statement, but nothing happened about the incident, he/she said the statement was given to the DON because the Administrator was not in the facility (spoken with Administrtor and DON, no evidence of statement was provided). The interviewee stated he/she Resident #1's husband had gotten upset because Resident #1 would not lie down after lunch. The resident told staff she did not want to lie down when they asked her. The interviewee revealed Resident #1 told him/her and others that her spouse was mean to her and she was afraid of him. Review of Resident #1's Progress Note dated 09/17/18 at 1058 written by LVN K reflected, Writer was doing rounds this am and checked on resident. Writer asked resident if she wanted to get up for breakfast, resident stated no. Writer stated that's fine, would you like to get up for lunch and resident stated, I would like too. Approx. around 1100 (11:00 a.m.) writer went up to husband and told him that resident requested to be up for lunch and residents husband started getting agitated and tried to prevent staff from getting resident up. ADON and writer went back to residents' room to ask her again if she wanted to be up and resident stated yes. Approx. 1107 residents husband came up to writer and tried to explain to writer why resident shouldn't be up. Husband stated, she is here to die and not get well. Writer stated to husband that writer is here to give the best quality of care to resident and that resident requested to get up, so staff will get resident up for lunch. Husband stated to writer that getting her up was writers' choice and writer stated it was resident's choice. Writer explained to husband that resident didn't want to get up for breakfast, so she didn't get up because that was her choice, but she did want to get up for lunch and that was her choice as well. Husband then stated to writer I hope she dies on your shift. ADON and DON notified. Review of Resident #1's Progress Notes dated 09/17/18 at 7:10 PM by ADON G reflected, Residents spouse was in facility today. Resident wanted to get out of bed and resident husband was refusing to allow the aides to get resident out of bed. We ultimately got resident out of bed and brought her to nurses' station. Residents husband sat with her at nurses' station. After being up for approximately an hour and half resident husband told the aides he wanted her to go back to bed. Resident stated she didn't want to go back to bed and residents husband pushed resident on the shoulder. At that time, we moved resident behind the nurse's station with the nurses and reported to the DON. The DON came to speak with the husband and advised him to leave the facility. Resident was not harmed. Resident asked that she stay for a while longer and staff complied. Review of Resident #1's Progress Notes dated 09/17/18 at 1:48 PM by LVN K reflected, Due to concerns with the spouse demonstrating aggressive behavior towards his wife and staff. He refuses to calm down and allow his wife to be treated. The resident appears and states she is frustrated with her spouse. She continues to cry and desires to get out of bed which he is refusing to allow. The daughter, MPOA, has been left several messages including from my cell phone. At this time the Ombudsman has also been left a message. Interview with CNA T on 09/19/18 at 1:59 PM revealed she witnessed the incident between Resident #1 and her spouse on 09/17/18 of him pushing her in her right arm because she would not lie down whenever he requested her to do so. CNA T stated the resident cried and said she did not want to confuse anyone, but she did not want to lie down. CNA T stated that her and two other staff had witnessed the event and were told to write a statement, but nothing was done about it until Resident #1's Spouse pushed her, which he was asked to leave the facility by the DON. CNA T stated on Friday (09/14/18) she heard Resident #1 screaming get away from me, leave me alone and when she went to check on the resident, she found her at the nurse's station. CNA T revealed she was told a LVN R that the resident's husband drug her feet under her wheelchair. CNA T stated she worked on a different hall that Resident #1 previously resided on and she had witnessed the resident's spouse squeezing the resident's cheeks to force her to take her medications. She stated the nurse who administered the medications also witnessed it and was told by the nurse she reported it to the DON. CNA T stated Resident #1 usually looked withdrawn whenever her spouse was present, and she would look down as he spoke. When asked what she wanted, she would state whatever he wants. CNA T said Resident #1's Spouse would tell Resident #1 she was dying and needed to lie down. She stated Resident #1 would cry sometimes whenever he told her that she was dying. Interview with LVN M on 09/19/18 at 3:33 PM revealed she worked with Resident #1 in the past and had witnessed several incidents involving her spouse. LVN M said Resident #1's spouse was a controlling man and that whenever she would give the resident medications when he was present, he would squeeze the resident's cheeks and tell her quit being stupid or an idiot because she took her medication slowly one by one. LVN M stated that once that had happened, she would administer the medications before he would arrive to the facility or if he came before she could give Resident #1's medication she would divert him to do something, so she could give it to her. LVN M stated he only grabbed her face once that she witnessed, and she did not allow him to do it again because she found ways to give her medication without him present. LVN M said she told her ADON about the incident and she was unsure if what he said was verbal abuse or he was just being mean. LVN M said Resident #1 would draw her hands to her chest and stare at her like help me but never would voice anything, LVN M said Resident #1's spouse had aggression towards staff and was hateful to the resident. She revealed Resident #1 just wanted staff to do whatever he would request which was to keep her in bed and refuse care. LVN M stated she witnessed the incident on 09/17/18 and she described the push as a violent push to Resident #1's upper right arm/shoulder area. She revealed he did it because she did not comply with his request of her going back to bed. LVN M stated the DON was aware of incidents and would suggest they divert his attention, so they could provide care. LVN M said she and other staff attempted to contact the daughter, but she did not want anything to do with Resident #1's care. LVN M stated Resident #1's spouse ate the resident's meals. She said Resident #1 did not eat if he was with her, but she would eat after he left. LVN M said she witnessed earlier in the day on 09/17/18 Resident #1's spouse told another nurse in front of Resident #1 that he hopes she dies on her shift because the resident would not lie down. LVN M said if he had been asked to leave at that time and or if management had intervened, then he would not have been able to assault Resident #1 after lunch that day. LVN M said Resident #1 had been smiling, interacting with other residents and participating in activities since he was asked to leave the facility and that was the most she had witnessed of Resident #1 since she been in the facility. LVN M stated that she did receive in-service training on abuse and neglect, but she denied receiving in-service training on calling 911 if he showed up to the facility. LVN M stated that she was unsure of what was required if Resident #1's Spouse returned back to the facility but feels she should know what she's required to do if it's afterhours. She said although she's not Resident #1's nurse anymore she feels it's important for all staff to know who has visitation restrictions. Review of Complaint/Grievance Report dated 09/17/18 revealed staff had concerns for Resident #1 which revealed bedside nurse stated husband refused to allow (Resident #1) to get up to dining room for lunch stated he hopes she dies on your shift Social worker called daughter multiple times (Resident #1's Spouse) asked to leave facility due to safety concerns for (Resident #1). Daughter continues to not return calls. APS (Adult Protective Services) called for (Resident #1's Spouse) due to confusion/safety concerns. Review of Resident #1's updated Care Plan dated 09/19/18 reflected Care Plan was not revised until concerns of resident's safety was brought to the attention of the DON. Care Plan reflected Resident #1 had an ADL self-care performance deficit that was related to her cognitive deficits of Alzheimer's diagnosis. Care Plan reflected Resident #1's Spouse would interfere with her personal care (wanting resident to stay in bed for meals) as a focus area. Interventions were for nursing staff and the facility's social worker to educate spouse and reinforce resident's need for independence. Notify family when needed for support with unrealistic demands of the spouse. If spouse becomes angered with the staff, the staff may ask the spouse to leave the facility. Updated care plan did not reflect assault incident on 09/17/18 nor did it reflect facility restricting Resident #1's Spouse from visiting the facility and or supervised visits; although in an interview with the facility Administrator stated he and his DON knew Resident #1's Spouse was not allowed back into the facility without being supervised by staff, he just hadn't told all staff nor did he add updated information to resident plan of care, according to him. In-services regarding Resident #1 were not conducted until 09/19/18 which covered Abuse and Neglect as well as calling 911 if Spouse entered the building. The in-service sign in sheet did not reflect all staff completed the in-service. Confidential Interview revealed he/she stated they did not want to get in-trouble but said they were not going to lie but they did not receive training on calling 911 if Resident #1's Spouse returned back to the building on 09/19/18. He/she was shown in-service list that had his/her name on it they confirmed the signature was theirs but the information that was stapled and written on the in-service sheet was not provided to him/her. He/she stated that on 09/19/18 they received an in-service on abuse and taking out the trash nothing related to Resident #1. Observations of Resident #1 on 09/19/18 at 11:22 AM on 09/20/18 at 10:50 AM, and on 09/21/18 at 8:40 AM revealed she was up in her wheelchair on all days participating with staff, her husband was not present during observations. She had conversations but was not on topic. An observation of Resident #1 on 09/20/18 at 10:50AM revealed she participated in the music group activity and was smiling and nodding her head as the music group played live music her husband was not present. Interview with LVN R on 09/19/18 at 2:15 PM revealed that since Resident #1's spouse had been removed from the facility, that was the most she had seen the resident up out of the bed and that she seemed happier and now attended most activities during the day. Interview with LVN M on 09/19/18 at 3:33 PM revealed Resident #1 had been smiling, interacting with other residents and participating in activities since the resident's spouse was asked to leave the facility and that was the most she had witnessed of Resident #1 since the resident had been in the facility. Interview with the Staffing Coordinator on 09/19/18 at 12:21 PM revealed she felt that Resident #1's spouse was abusive. She stated she was responsible for assisting with breakfast and she witnessed Resident #1's spouse grab the resident's arm and point his finger in the resident's face The Staffing Coordinator revealed staff always intervened and kept an eye on the resident which they reported to the nurse. She stated Resident #1's spouse would try to isolate the resident and would refuse to allow the resident to get out of the bed. The Staffing Coordinator said she felt Resident #1 was afraid of him by how she responded whenever he was in the facility. The Staffing Coordinator stated Resident #1's Spouse got aggressive quickly towards staff. She stated the resident was generally happy whenever her husband was not around but whenever he was around she just complied with whatever he wanted. Interview with the SW on 09/19/18 at 3:00 PM revealed she was involved in dealing with Resident #1's spouse by educating him daily of staff concerns of him intervening with Resident #1's care. The SW stated Resident #1's spouse had been ugly towards staff and he gotten upset that the resident wanted to get out of bed but as long as the resident stayed in bed he did not have any concerns. She revealed he did not want the resident to participate in therapy because he was fixated on her dying. The SW stated staff said he would curse at them, but she had never witnessed him doing the things they stated he would do. She said she was informed of the incident on 09/17/18 and she contacted the daughter but was unsuccessful of reaching her, so she made an APS referral because she was concerns of Resident #1's Spouse's safety. SW stated she felt Resident #1's Spouse had dementia because she would often get confused on how to get out of the building. SW stated she did not make a referral for Resident #1 to receive psychological or psychiatric care and treatment; however, she did speak with Resident #1's Daughter about her father (Resident #1's Spouse) actions and his cognition. SW said she did not talk with the Resident #1 because Resident #1's Spouse liked her which she was about the only one he liked she would be the one to calm him and divert him while staff provided care. SW said he did not have any issues until staff tried to get resident out of bed. Interview with DOR on 09/20/18 at 3:22 PM revealed she was aware of some of her staff concerns but she did not review the daily notes. The DOR stated Resident #1's spouse would get very upset and irate whenever her staff attempted to provide therapy to Resident #1. She said he ordered them out of the room and once he grabbed a staff's arm. The DOR revealed the resident complied with whatever her spouse wanted and if he got upset, she got upset and cried. The DOR stated when the spouse got like that, staff was to leave the room and report the concerns to her as well as document the occurrence. She stated the DON, SW, herself and other department heads had IDT meetings regarding his actions but Resident #1's Spouse would agree in the meeting but would refuse whenever therapy staff would try to treat resident which was almost every session thing with various of staff which was always reported to the SW since she was able to calm him. DOR stated that Resident #1 was no longer receiving therapy due to spouse requesting she discharge from it. Interview on 09/19/18 with the DON at 10:40 AM revealed on 09/17/18 she was informed by Resident #1's nurse of the incident of her spouse pushing Resident #1 in her arm. The DON stated the spouse would interfere with care and would get aggressive towards staff. She stated she tried to contact Resident #1's daughter but was unsuccessful as well as educate him on staff concerns and Resident #1's rights. The DON revealed staff reported to her on several occasions that he would prevent Resident #1 from eating her meal, her getting out of bed, participating in therapy, and would refuse staff care daily. She stated she and the SW educated him about her rights daily and found way to work around his interference. The DON stated he would get upset with staff and in return Resident #1 would get upset. The DON stated Resident #1's spouse often stated the resident was going to die and to allow her to die, but she would try to tell him that she was not dying. The DON revealed staff reported to her that Resident #1's daughter did not want the facility to call her again. The DON stated after she was aware he pushed Resident #1, he was asked to leave the facility by herself, which was instructed by the Administrator who was out of the facility and she instructed the SW to make a report to APS. The DON stated they were working on what they should do going forward regarding him being in the facility and at the time of the interview no plans were in place. DON said she told staff that if Resident #1 Spouse came back into the facility to call 911 until they (herself and the Administrator) figured out what they were going to do. DON said she wanted to contact the daughter to make a plan because they did not want to say Resident #1's Spouse could not ever return back to the facility. Interview on 09/19/18 with the Administrator at 4:22 PM revealed he was the facility's Abuse Coordinator and in his absence, staff was to report allegations of abuse to the DON. The Administrator stated he received a phone call from the DON, who stated Resident #1 was pushed by her spouse in her arm. He stated his first response was to remove the threat and he told the DON to have Resident #1's spouse exit the building and if he refused and or came back to the facility to call local law enforcement. The Administrator said he did not report the incident because Resident #1 was pushed lightly, while sitting in her wheelchair and she was not harmed so he

Based on interview and record review, the facility failed to ensure the resident's right to be free from abuse for one (Resident #1) of three residents reviewed for abuse. The facility failed to put in place any interventions to protect Resident #1 from physical and verbal abuse by her spouse, identified on 07/24/18 which started less than month after the resident was admitted . Resident #1 had episodes of tearfulness and fear and she was withdrawn socially. An Immediate Jeopardy (IJ) was identified on 09/20/18. Although, the IJ was removed on 09/21/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to needing to train staff and monitor their implementation of the Plan of Removal (POR). The failure placed residents at risk of serious mental harm, physical harm and or death. Findings Included: Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had unclear speech and she usually understood and could usually make herself understood to others. She was moderately impaired with cognitive skills for daily decision making. She had a depressed, hopeless mood half or more days throughout the week and she required extensive assistance by staff for bed mobility, transfers, dressing, toilet use and personal hygiene. She utilized a wheelchair for mobility and was incontinent of bowel and bladder. Her [DIAGNOSES REDACTED]. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 06/26/18 revealed, Patient required max (maximum) encouragement for participation. Patient stated she didn't care about progressing with therapy. Patient was also resistant to having her husband in room. She requested he leave during treatment in her room. Husband stated that he believe his wife is dying. He stated she refuses to eat and isn't responsive to him. Nurse was notified of discussion with patient and her husband. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/05/18 reported Upon entering room, patient was in supine with ble (bilateral extremities (resident's legs)) were hanging off the bed and husband standing next to her. Patient's husband stated she was trying to get up. He and patient were told that they needed to use call button to request assistance (sic). Her husband stated that she was acting like a [AGE] year and didn't want to do what she needed to do. He was advised that patient requires assistance, but he continued to state that she could do it. Review of Resident #1's Progress Note dated 07/09/18 revealed .Staff report she will do ok at meals with 25-50%, improved since initial RD assessment and seems to do better when husband isn't providing care. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/12/18 reported Arrived to pt's (patient's) room with spouse refusing to let pt participate in therapy . Spouse continued to refuse for her to get out of bed . Spouse does not allow pt to speak for herself, and pt covered face and began crying when husband was arguing with therapists. Spoke with DOR (Director of Rehabilitation) on issue who advised to speak with SW (Social Worker) because therapist to suspicious of abusive relationship d/t (due to) behaviors demonstrated by spouse. Review of Resident #1's Physical Therapy Recertification & Updated Plan of Treatment dated 07/13/18 revealed progress and response to treatment of [REDACTED]. Pt (patient) might benefit from a psych referral. Review of Resident #1's Clinical chart reflected she was not referred to psych services. In an interview with the DON she confirmed Resident #1 did not receive psychiatric services for her depression. DON said she was not aware that she could see therapy notes in the facility's computer system and now that she is aware she will send the referral for psych services for Resident #1. Review of Resident #1's Medical Doctor/Nurse Practitioner Note dated 07/17/18 revealed Husband and pt report decreased appetite, and pt states I just don't want to eat. Staff report that pt eats better when husband not present. Will recommend eating assistance by staff. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/17/18 revealed, Reviewed pt's (patient's) P[NAME] (plan of care) and updated goals. Discussed lack of progress c (with) nurse and DOR (Director of Rehabilitation). Also asked husband and nurse whether pt is suffering from depression and if she's getting any tx (treatment) for it, pt might benefit from psych consult as pt seems to have no interest in anything. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 07/19/18 revealed, Entered room and pt (patient) was in bed and agreed to perform therapy, spoke to nursing about getting pt up and they wanted pt OOB (out of bed) . The husband told the therapist to get out, honored his wishes. Spoke with nursing and social worker about pts husband hindering her therapy and pt is getting weaker. Nursing asked therapy to go back to get pt up, entered room without husband and pt agreed again to therapy. Review of Resident #1's Physical Therapy Discharge Summary dated 07/23/18 revealed Patient Response of Pt had admitted after a hosp (hospital) stay for [MEDICAL CONDITIONS] c (with) overall goal of returning home c spouse of ALF (assisted living facility) down the street from us. However, pt has been declining and not participating well, c husband refusing to allow pt to get OOB often or to go the DR (dining room) for asst (assistance) c meals. Pt's spouse and dtr (daughter) report that pt has a fatal heart condition (spouse repeatedly tells Nrsg (nursing) and Therapy staff that pt is dying and has told the pt this), and they have requested that all therapies stop (PT, OT, and ST) (Physical Therapy, Occupational Therapy and Speech Therapy). Pt was recently Recert'd (recertified) to cont (continue) PT c goals changed to accommodate for decline in status, c recomend (sic) made for psych services to assess for depression as pt had made some improvement c bed mob (mobility) and when motivated was able to participate c tx (treatment), but most of the time seemed disinterested in anything, appeared depressed, and to have given up. It had also been recommended that pt get OOB daily for all meals and for a short while was doing better per Nrsg until husband refused to let her go to DR or get OOB. Review of Resident #1's Progress Note dated 07/24/18 revealed Restorative needed to get a weight on resident and we got her up in a WC and then we asked her if she wanted to go and eat in the dining room she said yes. As soon as the husband got back in the room with her he said NO and I told him that she wanted to, and he said I don't care she's been up for hours and I told him that we just got her up and he got very mad and irate. Called the daughter to give her an update and she was very mad at first but after I explained to her that patients with dementia will say no they're not hungry and then when we offer food they will eat, and she said she understood. I told her that every time he is not in there she will agree to get up and is very happy and in good spirits. She said that he has had control for so long that his anger is probably out of frustration on not being able to control everything. She said that she will try and have a talk with him, but she doesn't think it'll work. I told her that it would do her mom good physically and mentally to get up and eat and she said that she has arthritis and it hurts to get up, so I educated her that getting up and moving around is a lot better on her than laying there and getting stiff. She said that she will try and talk to him another day but that she has lived a hard life with them because she has never been able to anything right. I told her I understand but we need to all work together and she said that she will try and call him tomorrow. Review of Resident #1's Progress Note dated 07/24/18 reflected Staff is encouraging res to go to dining room to eat, but res's spouse is telling staff not to get res up or help her eat. Res is eating 0-25%, spitting out food, very poor appetite. Res's spouse is telling staff she is dying and to leave her alone. Staff notified daughter about spouse interfering with care. Res is verbally aggressive with staff about meals. Staff has provided spouse with a tray at meal times, as well, but he becomes agitated and verbally aggressive. At lunch today, res wanted to go to DR for lunch and spouse refused to allow res to go. Res visibly upset and crying. Daughter (POA) is aware of above stated concerns and states that res is dying and agrees with the spouse. Review of Resident #1's Care Plan dated 07/24/18 reflected, Resident #1 had unplanned/unexpected weight loss related to poor food intake zero percent most meals, spitting out food and spouse is prohibiting staff from giving care was addressed as a focus area. Care plan did not address interventions of spouse prohibiting her from receiving care from staff. Care plan did not address documented concerns or Resident #1's Spouse who was not allowing her to make own decisions as it related to care. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 08/02/18 reported Family (dtr (daughter)) would like for pt to gain more strength and to be OOB as toler'd (tolerated). (Dtr has POA (power of attorney.) Dtr reported that cardiologist had told family that pt's heart was very weak c a valve defect, pt not approp (appropriate) for surgery, but had not recommended bedrest or hospice care and had not given a prognosis for life-expectancy. Review of Resident #1's Progress Note dated 08/17/18 SW revealed Met with (Resident #1's Spouse) in regards to (sic) the concerns the staff continues to have with him. He continues to interfere with her care and he is now requesting that the roommate leave the room. I have met with the resident's spouse, the roommate, the ADON and the DON. The spouse denies this at first and the nurse addressed the issue with him that she too has witnessed this. At this time, we have removed the roommate from the room and contacted the daughter to inform her of the concern. He continues to interfere with her therapy and meals as well. At this time, it is believed that the resident either needs a private room or the resident's spouse can visit with the daughter. At this time this has only been presented to the daughter as options and a decision has not been made. Interview on 09/20/18 at 10:37AM with Resident #2 revealed she was Resident #1's previous roommate. Resident #2 stated Resident #1 was moved into her room during the evening time and (Resident #1) was as sweet as she could be that night but something changed. Resident #2 said staff got Resident #1 up for breakfast and took her into the dining room. When they brought her back into the room, she said Resident #1's spouse came into the room later that morning and she (Resident #1) was a different person. Resident #2 said Resident #1 was upset and was crying and she refused to stay in the room with Resident #2. Resident #2 revealed and she asked staff to move herself and or Resident #1 and later that day Resident #1 was moved to another room. Resident #2 said Resident #1 did not stay in her room long and she did not know why the resident was upset because she did not stay in the room. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had clear speech, and she understood others and made herself understood to others. She had modified independence, (meaning she had some difficulty in new situations only) with cognitive skills for daily decision making. She required limited assistance by staff for bed mobility, transfers, dressing, and toilet use; she required supervision by staff for locomotion on/off the unit (moving around the unit), and personal hygiene. She utilize a walker and a wheelchair for mobility. Review of Resident #1's Physical Therapy Treatment Encounter Note dated 08/27/18 revealed husband not present in facility this afternoon. Overall pt was alert and in a good mood, more upbeat for most of tx . Overall pt was more alert and attentive than I've seen her in a long time. Interview with LVN R on 09/19/18 at 2:15 PM revealed she was one of Resident #1's nurses who witnessed issues with the resident and her spouse. LVN R stated she was unsure if it was on 09/13/18 or 09/14/18, but she witnessed Resident #1's spouse after lunch remove the resident from the dining room at the resident's request to push her around in her wheelchair. LVN R stated he pushed her roughly in her wheelchair causing her feet to drag under her. LVN R said Resident #1 told him that it hurt and his response to her was that's what you get, because you won't lay down. LVN R stated she and another staff member told him they would push her. She stated then the resident was parked behind the nurse's station. She said she told the nurse who was responsible that day for Resident #1's care and was told she was aware of incident. LVN R stated that whenever Resident #1 was around her husband she looked like a wounded puppy and she looked afraid of him, but the resident never voiced it the fear to her. LVN R revealed she attempted to contact Resident #1's daughter several times in the past but was unsuccessful most time except once, she said the daughter stated, I know what my father is doing, and I washed my hands with him and she stopped answering the facility's calls. Confidential Interview revealed he/she had been noticing interactions between Resident #1 and her spouse which revealed Resident #1 feared him. He/she stated on 09/14/18 after lunch, her spouse was pushing her wheelchair and her feet was were dragging the ground and getting caught under her wheelchair. The interviewee revealed the resident started crying and getting upset. He/She said he/she stopped the spouse and told him he could not push her wheelchair in that manner. He/She stated the spouse stated he could do whatever he wanted and he continued to push the wheelchair. The interviewee revealed he/she told him that he/she could push the resident. He/She stated he/she took the resident to the nurse's station where he/she told the nurse what took place. He/She stated he/she was told by the nurse to write a statement, but nothing happened about the incident, he/she said the statement was given to the DON because the Administrator was not in the facility (spoken with Administrtor and DON, no evidence of statement was provided). The interviewee stated he/she Resident #1's husband had gotten upset because Resident #1 would not lie down after lunch. The resident told staff she did not want to lie down when they asked her. The interviewee revealed Resident #1 told him/her and others that her spouse was mean to her and she was afraid of him. Review of Resident #1's Progress Note dated 09/17/18 at 1058 written by LVN K reflected, Writer was doing rounds this am and checked on resident. Writer asked resident if she wanted to get up for breakfast, resident stated no. Writer stated that's fine, would you like to get up for lunch and resident stated, I would like too. Approx. around 1100 (11:00 a.m.) writer went up to husband and told him that resident requested to be up for lunch and residents husband started getting agitated and tried to prevent staff from getting resident up. ADON and writer went back to residents' room to ask her again if she wanted to be up and resident stated yes. Approx. 1107 residents husband came up to writer and tried to explain to writer why resident shouldn't be up. Husband stated, she is here to die and not get well. Writer stated to husband that writer is here to give the best quality of care to resident and that resident requested to get up, so staff will get resident up for lunch. Husband stated to writer that getting her up was writers' choice and writer stated it was resident's choice. Writer explained to husband that resident didn't want to get up for breakfast, so she didn't get up because that was her choice, but she did want to get up for lunch and that was her choice as well. Husband then stated to writer I hope she dies on your shift. ADON and DON notified. Review of Resident #1's Progress Notes dated 09/17/18 at 7:10 PM by ADON G reflected, Residents spouse was in facility today. Resident wanted to get out of bed and resident husband was refusing to allow the aides to get resident out of bed. We ultimately got resident out of bed and brought her to nurses' station. Residents husband sat with her at nurses' station. After being up for approximately an hour and half resident husband told the aides he wanted her to go back to bed. Resident stated she didn't want to go back to bed and residents husband pushed resident on the shoulder. At that time, we moved resident behind the nurse's station with the nurses and reported to the DON. The DON came to speak with the husband and advised him to leave the facility. Resident was not harmed. Resident asked that she stay for a while longer and staff complied. Review of Resident #1's Progress Notes dated 09/17/18 at 1:48 PM by LVN K reflected, Due to concerns with the spouse demonstrating aggressive behavior towards his wife and staff. He refuses to calm down and allow his wife to be treated. The resident appears and states she is frustrated with her spouse. She continues to cry and desires to get out of bed which he is refusing to allow. The daughter, MPOA, has been left several messages including from my cell phone. At this time the Ombudsman has also been left a message. Interview with CNA T on 09/19/18 at 1:59 PM revealed she witnessed the incident between Resident #1 and her spouse on 09/17/18 of him pushing her in her right arm because she would not lie down whenever he requested her to do so. CNA T stated the resident cried and said she did not want to confuse anyone, but she did not want to lie down. CNA T stated that her and two other staff had witnessed the event and were told to write a statement, but nothing was done about it until Resident #1's Spouse pushed her, which he was asked to leave the facility by the DON. CNA T stated on Friday (09/14/18) she heard Resident #1 screaming get away from me, leave me alone and when she went to check on the resident, she found her at the nurse's station. CNA T revealed she was told a LVN R that the resident's husband drug her feet under her wheelchair. CNA T stated she worked on a different hall that Resident #1 previously resided on and she had witnessed the resident's spouse squeezing the resident's cheeks to force her to take her medications. She stated the nurse who administered the medications also witnessed it and was told by the nurse she reported it to the DON. CNA T stated Resident #1 usually looked withdrawn whenever her spouse was present, and she would look down as he spoke. When asked what she wanted, she would state whatever he wants. CNA T said Resident #1's Spouse would tell Resident #1 she was dying and needed to lie down. She stated Resident #1 would cry sometimes whenever he told her that she was dying. Interview with LVN M on 09/19/18 at 3:33 PM revealed she worked with Resident #1 in the past and had witnessed several incidents involving her spouse. LVN M said Resident #1's spouse was a controlling man and that whenever she would give the resident medications when he was present, he would squeeze the resident's cheeks and tell her quit being stupid or an idiot because she took her medication slowly one by one. LVN M stated that once that had happened, she would administer the medications before he would arrive to the facility or if he came before she could give Resident #1's medication she would divert him to do something, so she could give it to her. LVN M stated he only grabbed her face once that she witnessed, and she did not allow him to do it again because she found ways to give her medication without him present. LVN M said she told her ADON about the incident and she was unsure if what he said was verbal abuse or he was just being mean. LVN M said Resident #1 would draw her hands to her chest and stare at her like help me but never would voice anything, LVN M said Resident #1's spouse had aggression towards staff and was hateful to the resident. She revealed Resident #1 just wanted staff to do whatever he would request which was to keep her in bed and refuse care. LVN M stated she witnessed the incident on 09/17/18 and she described the push as a violent push to Resident #1's upper right arm/shoulder area. She revealed he did it because she did not comply with his request of her going back to bed. LVN M stated the DON was aware of incidents and would suggest they divert his attention, so they could provide care. LVN M said she and other staff attempted to contact the daughter, but she did not want anything to do with Resident #1's care. LVN M stated Resident #1's spouse ate the resident's meals. She said Resident #1 did not eat if he was with her, but she would eat after he left. LVN M said she witnessed earlier in the day on 09/17/18 Resident #1's spouse told another nurse in front of Resident #1 that he hopes she dies on her shift because the resident would not lie down. LVN M said if he had been asked to leave at that time and or if management had intervened, then he would not have been able to assault Resident #1 after lunch that day. LVN M said Resident #1 had been smiling, interacting with other residents and participating in activities since he was asked to leave the facility and that was the most she had witnessed of Resident #1 since she been in the facility. LVN M stated that she did receive in-service training on abuse and neglect, but she denied receiving in-service training on calling 911 if he showed up to the facility. LVN M stated that she was unsure of what was required if Resident #1's Spouse returned back to the facility but feels she should know what she's required to do if it's afterhours. She said although she's not Resident #1's nurse anymore she feels it's important for all staff to know who has visitation restrictions. Review of Complaint/Grievance Report dated 09/17/18 revealed staff had concerns for Resident #1 which revealed bedside nurse stated husband refused to allow (Resident #1) to get up to dining room for lunch stated he hopes she dies on your shift Social worker called daughter multiple times (Resident #1's Spouse) asked to leave facility due to safety concerns for (Resident #1). Daughter continues to not return calls. APS (Adult Protective Services) called for (Resident #1's Spouse) due to confusion/safety concerns. Review of Resident #1's updated Care Plan dated 09/19/18 reflected Care Plan was not revised until concerns of resident's safety was brought to the attention of the DON. Care Plan reflected Resident #1 had an ADL self-care performance deficit that was related to her cognitive deficits of Alzheimer's diagnosis. Care Plan reflected Resident #1's Spouse would interfere with her personal care (wanting resident to stay in bed for meals) as a focus area. Interventions were for nursing staff and the facility's social worker to educate spouse and reinforce resident's need for independence. Notify family when needed for support with unrealistic demands of the spouse. If spouse becomes angered with the staff, the staff may ask the spouse to leave the facility. Updated care plan did not reflect assault incident on 09/17/18 nor did it reflect facility restricting Resident #1's Spouse from visiting the facility and or supervised visits; although in an interview with the facility Administrator stated he and his DON knew Resident #1's Spouse was not allowed back into the facility without being supervised by staff, he just hadn't told all staff nor did he add updated information to resident plan of care, according to him. In-services regarding Resident #1 were not conducted until 09/19/18 which covered Abuse and Neglect as well as calling 911 if Spouse entered the building. The in-service sign in sheet did not reflect all staff completed the in-service. Confidential Interview revealed he/she stated they did not want to get in-trouble but said they were not going to lie but they did not receive training on calling 911 if Resident #1's Spouse returned back to the building on 09/19/18. He/she was shown in-service list that had his/her name on it they confirmed the signature was theirs but the information that was stapled and written on the in-service sheet was not provided to him/her. He/she stated that on 09/19/18 they received an in-service on abuse and taking out the trash nothing related to Resident #1. Observations of Resident #1 on 09/19/18 at 11:22 AM on 09/20/18 at 10:50 AM, and on 09/21/18 at 8:40 AM revealed she was up in her wheelchair on all days participating with staff, her husband was not present during observations. She had conversations but was not on topic. An observation of Resident #1 on 09/20/18 at 10:50AM revealed she participated in the music group activity and was smiling and nodding her head as the music group played live music her husband was not present. Interview with LVN R on 09/19/18 at 2:15 PM revealed that since Resident #1's spouse had been removed from the facility, that was the most she had seen the resident up out of the bed and that she seemed happier and now attended most activities during the day. Interview with LVN M on 09/19/18 at 3:33 PM revealed Resident #1 had been smiling, interacting with other residents and participating in activities since the resident's spouse was asked to leave the facility and that was the most she had witnessed of Resident #1 since the resident had been in the facility. Interview with the Staffing Coordinator on 09/19/18 at 12:21 PM revealed she felt that Resident #1's spouse was abusive. She stated she was responsible for assisting with breakfast and she witnessed Resident #1's spouse grab the resident's arm and point his finger in the resident's face The Staffing Coordinator revealed staff always intervened and kept an eye on the resident which they reported to the nurse. She stated Resident #1's spouse would try to isolate the resident and would refuse to allow the resident to get out of the bed. The Staffing Coordinator said she felt Resident #1 was afraid of him by how she responded whenever he was in the facility. The Staffing Coordinator stated Resident #1's Spouse got aggressive quickly towards staff. She stated the resident was generally happy whenever her husband was not around but whenever he was around she just complied with whatever he wanted. Interview with the SW on 09/19/18 at 3:00 PM revealed she was involved in dealing with Resident #1's spouse by educating him daily of staff concerns of him intervening with Resident #1's care. The SW stated Resident #1's spouse had been ugly towards staff and he gotten upset that the resident wanted to get out of bed but as long as the resident stayed in bed he did not have any concerns. She revealed he did not want the resident to participate in therapy because he was fixated on her dying. The SW stated staff said he would curse at them, but she had never witnessed him doing the things they stated he would do. She said she was informed of the incident on 09/17/18 and she contacted the daughter but was unsuccessful of reaching her, so she made an APS referral because she was concerns of Resident #1's Spouse's safety. SW stated she felt Resident #1's Spouse had dementia because she would often get confused on how to get out of the building. SW stated she did not make a referral for Resident #1 to receive psychological or psychiatric care and treatment; however, she did speak with Resident #1's Daughter about her father (Resident #1's Spouse) actions and his cognition. SW said she did not talk with the Resident #1 because Resident #1's Spouse liked her which she was about the only one he liked she would be the one to calm him and divert him while staff provided care. SW said he did not have any issues until staff tried to get resident out of bed. Interview with DOR on 09/20/18 at 3:22 PM revealed she was aware of some of her staff concerns but she did not review the daily notes. The DOR stated Resident #1's spouse would get very upset and irate whenever her staff attempted to provide therapy to Resident #1. She said he ordered them out of the room and once he grabbed a staff's arm. The DOR revealed the resident complied with whatever her spouse wanted and if he got upset, she got upset and cried. The DOR stated when the spouse got like that, staff was to leave the room and report the concerns to her as well as document the occurrence. She stated the DON, SW, herself and other department heads had IDT meetings regarding his actions but Resident #1's Spouse would agree in the meeting but would refuse whenever therapy staff would try to treat resident which was almost every session thing with various of staff which was always reported to the SW since she was able to calm him. DOR stated that Resident #1 was no longer receiving therapy due to spouse requesting she discharge from it. Interview on 09/19/18 with the DON at 10:40 AM revealed on 09/17/18 she was informed by Resident #1's nurse of the incident of her spouse pushing Resident #1 in her arm. The DON stated the spouse would interfere with care and would get aggressive towards staff. She stated she tried to contact Resident #1's daughter but was unsuccessful as well as educate him on staff concerns and Resident #1's rights. The DON revealed staff reported to her on several occasions that he would prevent Resident #1 from eating her meal, her getting out of bed, participating in therapy, and would refuse staff care daily. She stated she and the SW educated him about her rights daily and found way to work around his interference. The DON stated he would get upset with staff and in return Resident #1 would get upset. The DON stated Resident #1's spouse often stated the resident was going to die and to allow her to die, but she would try to tell him that she was not dying. The DON revealed staff reported to her that Resident #1's daughter did not want the facility to call her again. The DON stated after she was aware he pushed Resident #1, he was asked to leave the facility by herself, which was instructed by the Administrator who was out of the facility and she instructed the SW to make a report to APS. The DON stated they were working on what they should do going forward regarding him being in the facility and at the time of the interview no plans were in place. DON said she told staff that if Resident #1 Spouse came back into the facility to call 911 until they (herself and the Administrator) figured out what they were going to do. DON said she wanted to contact the daughter to make a plan because they did not want to say Resident #1's Spouse could not ever return back to the facility. Interview on 09/19/18 with the Administrator at 4:22 PM revealed he was the facility's Abuse Coordinator and in his absence, staff was to report allegations of abuse to the DON. The Administrator stated he received a phone call from the DON, who stated Resident #1 was pushed by her spouse in her arm. He stated his first response was to remove the threat and he told the DON to have Resident #1's spouse exit the building and if he refused and or came back to the facility to call local law enforcement. The Administrator said he did not report the incident because Resident #1 was pushed lightly, while sitting in her wheelchair and she was not harmed so he did not feel it required him to report He said furthermore, the spouse was asked to leave and at that time was not considered a threat. The Administrator stated