Every finding on record at Windsor Calallen

Based on interview and record review, the facility failed to ensure each resident had the right to request, refuse, and/or formulate an advance directive for 1 of 4 residents (Resident #1) reviewed for advance directives.The facility failed to ensure Resident #1's advance directive was signed by a physician on 07/26/2022. This failure could place residents at risk of not having their end-of-life care wishes honored. The findings included:Record review of Resident #1's face sheet, dated 08/24/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's pertinent diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities) and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning).Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMs score of 04, which indicated severely impaired cognition. Resident #1's MDS revealed a care area was triggered for Dementia.Record review of Resident #1's Physician Order Summary, dated 08/24/2026, revealed an active order for DNR. Record review of Resident #1's social services progress note, dated 08/03/2026 and written by the SW, revealed Resident #1 had elected DNR code status. Record review of Resident #1's Care Plan, initiated 08/12/2026, revealed a care plan focus for DNR. Interventions included ensure the DNR was signed in the medical record, and mark the chart and all pertinent documents with DNR status. Record review of Resident #1's OOH-DNR, dated 07/26/2022, revealed the DNR was not signed by a physician. The DNR had Resident #1's signature, the witnesses' signatures, but it did not have the physician's signature. In an interview on 08/24/2026 at 2:42 PM, after reviewing Resident #1's DNR, the SW stated the DNR was missing the physician's signature on it. She stated the DNR was not considered valid without the physician's signature. She stated this could have kept the resident's advanced directive choices from being honored. She stated she was the one who dealt with advanced directives, and she was definitely going to reach out to the family and physician today (08/23/2026) and have the DNR completed.In an interview on 08/24/2026 at 3:50 PM, the ADON stated he was not responsible for the DNR or advanced directives. He stated there was an order in the physician order summary for the DNR, and it had been care planned, but he was not aware the DNR itself had not been signed by a physician. He stated without a valid DNR, Resident #1 may not have had their choices regarding their DNR honored. Attempted to interview Resident #1 on 08/24/2026 at 4:50 PM, but Resident #1 was only concerned with what time it was and if someone was bringing her dinner. Record review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy, implemented 10/24/2022, revealed Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Policy Explanation and Compliance Guidelines: 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 8. Decision regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions.

Based on observation, interview and record review, the facility failed to ensure residents had the right to privacy and confidentiality for 2 of 4 residents (Resident #1 and Resident #2) reviewed for privacy and confidentiality.The facility failed to ensure Resident #1's medication was not given to Resident #2's family member after Resident #2 discharged on 08/14/2026.This failure could place residents at risk of feeling disrespected and a loss of dignity due to a lack of privacy.The findings included: 1. Record review of Resident #1's face sheet, dated 08/24/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's pertinent diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities).Record review of Resident #1's admission MDS Assessment, dated 08/03/2026, revealed a BIMs score of 04, which indicated severely impaired cognition. Resident #1's MDS revealed a care area was triggered for Dementia.Record review of Resident #1's Physician Order Summary, reviewed 08/24/2026, revealed an order for Donepezil (a medication used to treat Dementia) 10 MG by mouth one time a day. 2. Record review of Resident #2's face sheet, dated 08/24/2026, revealed an [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 08/13/2026. Resident #2's pertinent diagnoses included Dementia.Record review of Resident #2's admission MDS Assessment, dated 07/30/2026, revealed a BIMs score of 12, which indicated moderately impaired cognition. Resident #2's MDS revealed a care area was triggered for Dementia.Record review of Resident #2's Physician Order Summary, reviewed 08/24/2026, revealed an order for Donepezil 10 MG by mouth one time a day.Record review of Resident #2's Order Review Report, dated 08/14/2026, and signed by the ADON, revealed Resident #2 was discharged with 15 tablets of Donepezil 10 MG.In an observation on 08/25/2026 at 4:00 PM, Resident #2's family member was observed to be in possession of Resident #1's Donepezil medication.In an interview on 08/24/2026 at 10:20 AM, Resident #2's family member stated when she went to pick up Resident #2's belongings and medications, she was given a trash bag full of medications. She stated she was given medications which belonged to her family member's roommate. She stated it was only the Donepezil which belonged to the roommate, but she was concerned about the facility giving her the wrong resident's medication, and she had not known what to do with the medication.In an interview on 08/24/2026 at 2:42 PM, the SW stated Resident #2 was discharged abruptly due to her family not bringing her back to the facility on [DATE], so the typical discharge process had not taken place. She stated the nursing department handled returning the medication to Resident #2's family, so she was not aware of what was given to the family. In an interview on 08/24/2026 at 3:50 PM, the ADON stated he was the one who gave Resident #2's medications to the family when they came to pick up her belongings on 08/14/2026. He stated he reviewed each medication as he gave it to the family, so he was not sure how Resident #2's family could have ended up with Resident #1's medication, and he did not understand why Resident #2's family would not have mentioned or returned Resident #1's medication if it was accidentally given to them. He stated Resident #2 and Resident #1 were roommates, and one of their medications was the same. He stated if someone obtained the wrong medication, or the wrong resident's medication, it could possibly have caused harm to the resident or anyone who may have ingested the medication. After reviewing the Resident #1's Medication Administration Record, he stated Resident #1 had not missed any of her doses of her medications as a result of this. In an interview on 08/24/2026 at 5:40 PM, the Administrator stated he did not believe there was physical evidence to support the allegation of a resident's family receiving another resident's medication. He stated the nursing staff go over the medications with the families when the families pick up their belongings. The DON was unavailable on 08/24/2026 for an interview. Record review of the facility's Facility Manual, revised 07/14/2020, revealed Resident Rights: Statement of Resident Rights: 6. Privacy. 8. Have facility information about you maintained as confidential. Rights of Elderly Individuals: Rights of the Elderly: G. An elderly individual is entitled to privacy. This right applies to medical treatment.

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 and to help prevent the development and transmission of communicable diseases and infection for one (Resident #1) of five residents reviewed for infection control, in that:1. The facility failed to ensure CNA A removed her contaminated gloves and performed hand hygiene after touching multiple surfaces prior to initiating Resident #1's perineal care on 08/16/2026. 2. The facility failed to ensure CNA A performed hand hygiene and gloves changes while performing incontinent care. These failures could place residents at risk for contamination and infection.The findings include: Record review of Resident #1's admission record dated 08/16/2026 revealed an [AGE] year-old-female who was initially admitted to the facility on [DATE] Resident #1 was admitted with multiple diagnoses which included the need for assistance with personal care, overactive bladder, and dementia (impaired cognition). Record Review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS of 5 which indicated severe cognitive impairment. Resident #1 needed partial/moderate assistance for ADLs. Resident #1 was not coded for having any form of infections. Record review of Resident #1's Care Plan date revision on: 02/17/2026 documented [Resident #1] has bladder incontinence r/t Dementia, Impaired Mobility [Resident #1] risk for septicemia (blood infection) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Monitor/document/report PRN any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. During an observation of incontinent care on 08/16/2026 at 1:48PM CNA A washed her hands for 20 seconds using soap and water then proceeded to close the entry door using her foot and hip, then returned to Resident #1's bedside, applied clean gloved hands, then proceeded to move the bedside table, use the bed controls to lower the head of the bed, elevate the bed to waist height, removed Resident #1's blanket, removed the brief flaps, and rolled brief down with the same gloved hands, retrieved clean wipes and cleaned the perineal area. CNA A, after completion of cleaning Resident #1's perineal area, turned Resident #1 to the left side, removed the soiled brief, then proceeded to clean Resident #1's gluteal area. CNA A then retrieved a clean brief, attached the clean brief on Resident #1. Throughout the incontinent care CNA A did not change gloves nor complete any form of hand hygiene. During an interview on 08/16/2026 at 2:06PM CNA A stated she typically changed gloves after touching Resident #1's surroundings but she was nervous and anxious and forgot to complete the hand hygiene step after she touched Resident #1's items. CNA A stated the facility educated her that surfaces had unknown microorganisms and hand hygiene was a precautionary measure to decrease the possibility of contracting microorganisms. CNA A stated she should have changed her gloves and completed hand hygiene once she touched Resident #1's bedside table, bed control, and blanket to promote infection control. CNA A stated she was aware she had to change her gloves and complete hand hygiene when she cleaned Resident #1's perineal area to Resident #1's gluteal area. CNA A reiterated she was nervous and anxious and forgot to change her gloves and perform hand hygiene when she cleaned Resident #1's perineal area to Resident #1's gluteal area. CNA A stated she would actively ensure hand hygiene performance prior to turning the resident to clean the buttock area. CNA A stated by not completing hand hygiene and gloves changes for the two instances the resident could have contracted germs which could negatively impact the resident. CNA A reiterated she would ensure she completed hand hygiene according to the CDC recommendations. During an interview on 08/16/2026 at 2:15PM the DON stated while reviewing the observation of Resident #1, the facility followed the CDC guidelines regarding when to perform hand hygiene. The DON stated CNA A should have removed her gloves and completed hand hygiene after she touched Resident #1's bedside table, blanket and bed controls, and secondly prior to turning Resident #1 to her side to clean Resident #1's buttock. The DON stated by not changing gloves and performing hand hygiene there could be a cross contamination and could negatively affect Resident #1. The DON stated the facility initiated a hand hygiene in-service recently, however, would continue with re-educating the clinical staff on when to perform hand hygiene. Record review of the facility's Hand Hygiene policy date implemented 10/24/2022 revealed, hand hygiene is indicated 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice (policy did not detail the specific situations to perform hand hygiene). Record review of the facility's Perineal Care date implemented 10/24/2022 revealed 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. A. cleanse buttocks and anus, front to back; vagina to anus in females. 10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. Record review of the CDC guidelines Clinical Safety: Hand Hygiene for Healthcare Workers updated on 02/27/2024 revealed Know when to clean your hands, -Immediately before touching a patient.-Before moving from work on a soiled body site to a clean body site on the same patient-After touching a patient or patient's surroundings-After contact with blood, body fluids, or contaminated surfaces-Immediately after glove removal.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Resident #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure RN A did not document Resident #1's vital signs as NA on 6 of 6 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN A did not document Resident #1's respiratory vital signs as NA on 6 of 6 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN B did not document Resident #1's vital signs as NA on 5 of 5 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN C did not document Resident #1's temperature as NA on 3 of 4 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN D did not document Resident #1's vital signs as NA or X on 4 of 4 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN E did not document Resident #1's vital signs as X on 5 of 5 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN F did not document Resident #1's vital signs as X on 4 of 4 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN G documented Resident #1's blood pressure on the MAR when the resident's 3 blood pressure altering medications were administered on 08/09/26.2. The facility failed to ensure RN A did not document Resident #2's vital signs as NA on 7 of 7 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN A did not document Resident #2's oxygen saturation as NA on 6 of 7 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN B did not document Resident #2's vital signs as NA on 4 of 4 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN C did not document Resident #2's temperature as NA on 3 of 4 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN D did not document Resident #2's vital signs as NA or X on 4 of 4 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN E did not document Resident #2's vital signs as X on 6 of 6 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN F did not document Resident #2's vital signs as X on 4 of 4 opportunities between 08/01/26 and 08/11/26. This failure could place residents at risk of errors in care and treatment. The findings included: 1. Record review of Resident #1's admission record dated 08/11/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation (an irregular, often fast heartbeat), chronic pancreatitis (a progressive inflammatory disease of the pancreas which is an accessory organ of digestion), unspecified protein calorie malnutrition (a state of inadequate nutrient intake), hyperlipidemia (high cholesterol), hypertension (high blood pressure), anxiety (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), polyneuropathy(weakness, numbness and or pain or pins and needles sensation to the hands and feet caused when multiple peripheral nerves are damaged due to any one or more of several causes), chronic pain syndrome (persistent pain that lasts longer than 3 to 6 months), chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes inflammation and difficulty breathing), and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities).Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 12 which indicated she had moderate cognitive impairment.Record review of Resident #1's care plan dated 07/29/26 reflected she had hypertension. The goal was for her to remain free of signs and symptoms or complications related to hypertension and the interventions included give anti-hypertensive medications as ordered and monitor for side effects and effectiveness, initiated on 07/29/26. The care plan reflected she was on pain medication related to chronic pain syndrome and the interventions included monitor for respiratory depression; monitor respiratory rate, depth, and effort after administration of pain medications, initiated 07/29/26. The care plan reflected Resident #1 was at risk for hypoxia (low oxygenation). The goal was she would maintain normal breathing pattern and have no complications related to shortness of breath. Interventions included monitor/document breathing patterns and report abnormalities to the provider, initiated on 07/29/26.Record review of Resident #1's order summary report dated 08/11/26 reflected the following orders: Respiratory - Monitor respirations, pulse, 02 sat and lung sounds one time a day ordered on 07/29/26. Vital signs every shift ordered on 07/29/26. Amlodipine Besylate Oral Tablet 10mg. Give 1 tablet by mouth one time a day related to Essential (primary) hypertension. Hold for SBP less than 100 or DBP less than 60 ordered on 07/29/26. Lisinopril Oral Tablet 40mg. Give 1 tablet by mouth one time a day related to Essential (primary) hypertension. Hold for SBP less than 100 or DBP less than 60 ordered on 07/29/26. Metoprolol Tartrate Oral Tablet 25mg. Give 1 tablet by mouth two times a day related to Essential (primary) hypertension. Hold for SBP less than 100 or DBP less than 60 ordered on 07/29/26.Record review of Resident #1's August 2026 MAR reflected the following:On 08/01/26, 08/04/26, 08/05/26, 08/06/26, 08/07/26, and 08/11/26, RN A documented NA for Resident #1's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 6:00 am and 10:00 am every day.On 08/01/26, 08/04/26, 08/05/26, 08/06/26, 08/07/26, and 08/11/26, RN A documented NA for Resident #1's pulse, resp, and O2 sats which were to be documented for the respiratory order between 6:00 am and 10:00 am every day.On 08/02/26, 08/03/26, 08/08/26, 08/09/26, and 08/10/26, LVN B documented NA for Resident #1's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 6:00 am and 10:00 am every day.On 08/03/26, 08/08/26 and 08/09/26, RN C documented NA for Resident #1's temp which was to be documented for the vital signs order between 2:00 pm and 6:00 pm every day.On 08/04/26, 08/06/26 and 08/07/26, RN D documented NA for Resident #1's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 2:00 pm and 6:00 pm every day.On 08/04/26, RN D documented X for Resident #1's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 10:00 pm and 2:00 am every day and code 7-sleeping-see progress note in the space for administration.On 08/01/26, 08/05/26, 08/06/26, 08/07/26, and 08/10/26, LVN E documented X for Resident #1's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 10:00 pm and 2:00 am every day and code 7-sleeping-see progress note in the space for administration.On 08/02/26, 08/03/26, 08/08/26, and 08/09/26, LVN F documented X for Resident #1's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 10:00 pm and 2:00 am every day and code 7-sleeping-see progress note in the space for administration.On 08/09/26, LVN G documented NA for BP and pulse when she administered Resident #1's morning dose of Amlodipine, Lisinopril, and Metoprolol (blood pressure altering medications). 2. Record review of Resident #2's admission record dated 08/12/26 reflected a [AGE] year-old male admitted to the facility o 07/20/26. His diagnoses included type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), morbid obesity (weight is more than 80 to 100 pounds above a person's ideal body weight), essential (primary) hypertension (high blood pressure), unspecified heart failure (when the heart does not pump blood as well as it should causing fluid to build up in the lungs), respiratory failure with hypercapnia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function due to too much carbon dioxide in the body), and mixed receptive-expressive language disorder (difficulty understanding spoken language and expressing thoughts through speech).Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 11 which indicated he had moderate cognitive impairment.Record review of Resident #2's order care plan dated 07/21/26 reflected he had congestive heart failure and oxygen therapy. His goal was to have clear lung sounds and his heart rate and rhythm would be within normal limits, and the interventions included check breath sounds and monitor/document for labored breathing, initiated on 07/21/26. The care plan also reflected he was at risk for decreased cardiac tissue perfusion due to hypertension. The goal was he would remain free from signs/symptoms/complications of hypertension and the interventions included give anti-hypertensive medications as ordered, initiated on 07/22/26.Record review of Resident #2's order summary report dated 08/12/26 reflected the following: Oxygen Saturation - Check every shift for hypoxia ordered on 07/20/26. Vital signs every shift ordered on 07/20/26.Record review of Resident #2's August 2026 MAR reflected the following:On 08/01/26, 08/04/26, 08/05/26, 08/06/26, 08/07/26, and 08/10/26, RN A documented NA for Resident #2's O2 sats which were to be documented for the oxygen saturation order between 6:00 am and 10:00 am every day.On 08/01/26, 08/04/26, 08/05/26, 08/06/26, 08/07/26, 08/10/26 and 08/11/26, RN A documented NA for Resident #2's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 6:00 am and 10:00 am every day.On 08/02/26, 08/03/26, 08/08/26, and 08/09/26, LVN B documented NA for Resident #2's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 6:00 am and 10:00 am every day.On 08/03/26, 08/08/26 and 08/09/26, RN C documented NA for Resident #2's temp which was to be documented for the vital signs order between 2:00 pm and 6:00 pm every day.On 08/04/26, 08/06/26 and 08/07/26, RN D documented NA for Resident #2's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 2:00 pm and 6:00 pm every day.On 08/04/26, RN D documented X for Resident #2's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 10:00 pm and 2:00 am every day and code 7-sleeping-see progress note in the space for administration.On 08/01/26, 08/05/26, 08/06/26, 08/07/26, 08/10/26 and 08/11/26, LVN E documented X for Resident #2's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 10:00 pm and 2:00 am every day and code 7-sleeping-see progress note in the space for administration.On 08/02/26, 08/03/26, 08/08/26, and 08/09/26, LVN F documented X for Resident #2's BP, temp, pulse, resp, O2 sats, and pain level which were to be documented for the vital signs order between 10:00 pm and 2:00 am every day and code 7-sleeping-see progress note in the space for administration.On 08/11/26 at 1:28 pm, an interview was attempted with Resident #1 however she was too sleepy for interview.In an interview with Resident #1's FM on 08/11/26 at 1:30 pm, she stated she was here most days with Resident #1. She stated the nurses checked the resident's vital signs and did an assessment every morning, but she was not sure what time it was done. She stated the resident had COVID and had been very lethargic for the past few days.In an interview on 08/11/26 at 2:30 pm, the DON stated it was her expectation the nurses would document the resident's vital signs as it was ordered by the provider. She stated it was not acceptable to document NA or an X in place of any vital signs on the MAR. She stated vital signs could and should be checked even if a resident was sleeping. She stated in-services were done monthly and as needed and she would start an in-service today about documenting in the MAR and following physician orders.In an interview 08/12/26 at 9:44 am, RN A stated she understood from the DON that it was not acceptable to document NA in the MAR. She stated she documented Resident #1 and Resident #2's vital signs on the daily skilled note, but not in the MAR. She stated it was important to document the vital signs in the MAR every shift at the correct time to ensure the resident did not have any changes in condition. RN A stated in-services were done at least once a month, and the last one was this week.In an interview on 08/12/26 at 10:09 am, the NP stated it was not acceptable to not document a resident's vital signs on the MAR as ordered by the provider. She stated the reason vital signs were ordered once per shift was to ensure the resident was not declining.In an interview on 08/12/26 at 12:40 pm, Resident #2 stated the nurse came in everyday to check him over and they checked his vital signs and put a thingy on his finger.In an interview on 08/12/26 at 1:56 pm, RN D stated if the provider ordered anything to be done once per shift, then it was to be done once per shift on every shift. She stated the nurses worked 8-hour shifts, so that meant three times a day. She stated she did check vital signs most of the time, but they did not get documented because sometimes she was just very busy and ran out of time. She stated those were not good reasons and she would make it a priority to ensure everything was done and documented as ordered by the provider.In an interview on 08/12/26 at 4:03 pm, RN C stated she put N/A on the temperatures because the wire was frayed on the thermometer on the facility's vital signs machine, so she did not check temperatures with it. She stated if the resident was in the facility and not out at the hospital or something, there was not a reason not to check her vital signs. RN C stated she probably should have reported the frayed wire to the DON or maintenance or to the supply person so that it could be replaced or repaired. She stated the last in-service on medication administration and documentation was within the last couple of weeks.8/12/26 at 4:29 pm, LVN E stated documenting X was not an appropriate response on the MAR. He stated he usually did not want to wake people up at night to check vital signs because some people were grouchy when you woke them up. He stated it was important to check the vital signs to make sure they were stable throughout the night. If vital signs were not checked, the resident could be deteriorating, and it would not be caught until later which could lead to hospitalization. He stated the last in-service was yesterday and they were usually about once a month.On 08/12/26, attempts were made to contact LVN B, LVN F, and LVN G without success.Record review of the facility's medication administration policy dated 10/24/22 reflected the following: Policy:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected in part: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and including enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.3. Principles of documentation include, but are not limited to:b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/ or responses to care.

Based on interviews and record reviews, the facility failed to ensure residents were treated with respect and dignity and failed to care for each resident in a manner and environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for dignity.The facility failed to ensure Resident #1 was dressed appropriately for a doctor's appointment on 08/10/26.This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.The findings included:Record review of Resident #1's admission record dated 08/11/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation (an irregular, often fast heartbeat), chronic pancreatitis (a progressive inflammatory disease of the pancreas which is an accessory organ of digestion), unspecified protein calorie malnutrition (a state of inadequate nutrient intake), hyperlipidemia (high cholesterol), hypertension (high blood pressure), anxiety (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), polyneuropathy(weakness, numbness and or pain or pins and needles sensation to the hands and feet caused when multiple peripheral nerves are damaged due to any one or more of several causes), chronic pain syndrome (persistent pain that lasts longer than 3 to 6 months), chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes inflammation and difficulty breathing), and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities).Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 12 which indicated she had moderate cognitive impairment.Record review of Resident #1's care plan dated 07/29/26 reflected she had an ADL self-care performance deficit. Interventions included she was totally dependent on 1 staff for dressing and assist her to choose simple comfortable clothing that enhanced her ability to self-dress, initiated on 07/29/26. The care plan reflected Resident #1's cognition fluctuated throughout the day due to her diagnosis of dementia. The goal was she would be able to communicate basic needs on a daily basis through the review date and interventions included ask her yes/no questions in order to determine her needs, initiated on 07/29/26.Record review of Resident #1's order summary reflected the EMS company was to pick her up at 7:30 am on 08/10/26 for her 8:30 am appointment with her cardiologist.On 08/11/26 at 1:28 pm, an interview was attempted with Resident #1 however she was too sleepy for interview.In an interview on 08/11/26 at 1:30 pm, the resident's FM stated the resident was sent to her cardiologist appoint wearing only a zip up sweater, a brief, pants, socks, and shoes. She was not wearing a bra or a shirt under the zip up sweater and the sweater was only zipped about halfway up. Another of the resident's family members stated she was on the phone with the resident while staff dressed her and the resident never stated she did not want to wear a shirt. Resident #1's FM stated the resident had plenty of clothes, she just did not want to wear the shirt the staff member picked out for her that morning. The FM stated they should have given her other choices. Resident #1's FM stated the resident would not have agreed to go to a doctor's appointment without being properly dressed in a bra, a shirt, pants, and shoes. The FM stated the resident would probably have taken a jacket because she got cold easily.In an interview on 08/11/26 at 2:30 pm, the DON stated she thought LVN F assisted Resident #1 to get dressed on the morning of her doctor appointment. She stated she was told by a FM that Resident #1 supposedly said she did not want to wear a shirt that morning, but the FM stated the resident did not say that. The DON stated there were several family members involved with Resident #1, so she was not sure who said what about the resident getting dressed that morning. She stated it was not acceptable for the resident not to be dressed in the way that she preferred. The DON stated it could cause the resident to be depressed or withdrawn if they were not treated with respect and dignity. She stated in-services on resident rights were about monthly and as needed.In an interview 08/12/26 at 9:44 am, RN A stated she thought LVN F got Resident #1 dressed the morning of her cardiology appointment and when the resident left, she had on a sweater that was zipped up and pants. She stated she did not notice if Resident #1 had a shift on under the sweater because the sweater was zipped up. RN A stated she did not think it was acceptable to not have at least put a shirt on under the sweater. RN A stated it was important to help residents dress in the way that they preferred to promote their dignity and choices. She stated in-services on resident rights were at least once every 3 months and as needed.On 08/12/26 at 4:27 pm, an attempt was made to contact LVN F without success.Record review of the facility's Promoting/Maintaining Resident Dignity dated 01/13/23 reflected in part: Policy:It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in manner and in an environment that maintains or enhances resident quality of life by recognizing each resident's individuality.Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .4. The resident's former lifestyle and personal choices will be considered in providing care and services to meet the residents needs and preferences .9. Groom and dress residents according to resident preference .Record review of the facility's Resident admission Agreement revised on 10/14/21 reflected in part: .3. Rights and Obligations of the Resident3.1 Resident Rights. As a resident of Facility, Resident is entitled to various rights that Facility encourages Resident to exercise. A statement of rights is available on the Texas Secretary of State website and is attached hereto.Attachment G-1:G. Resident's rights (Federal Law)Each resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside of the facility. The facility will protect and promote the rights of each resident including each of the following rights: .Each employee will be required and expected to uphold and promote the above Resident Rights, and all other Resident Rights established by law, in the course of performing their job.

Based on observation, interview and record review the facility failed to provide a safe environment for residents in 1 of 6 hallways (300 Hall) with 1 of 3(IT room) locked non-residential rooms left unlocked. 1.The facility failed to ensure the safety of the residents in the 300 hall by not closing the door to the IT room, which contained hazardous items. These failures have the potential to result in an injury to residents. The findings included:The findings included: In the initial facility observation on 07/20/26 at 9:48 AM the 300 Hall revealed the door to the IT room left unlocked with no one in the hallway to monitor. The IT room contained a large wall panel with many wires for cable for the television, floor polishing equipment, a cart, 2 vacuums and a high voltage power loss relay box with no staff with and could be a hazardous for a with a resident with a cognitive mental condition and becoming locked in with others knowing for some time. The items can also result in the resident possibly tripping over items on floor, become entangled in the wire causing a fall, becoming electrocuted causing serious harm with hospitalization and death. In an interview on 07/20/2026 at 10:06 PM with the maintenance man he stated he and the floor tech guy have a key and his responsibility to make sure the door shut. The maintenance man stated it may have been the floor tech who may have entered and left the door open. The maintenance man stated he does a monthly check on all the doors to all in the facility to make sure they are all in working condition and non-residential rooms can be locked. The maintenance man stated the if a resident with mental cognitive condition could walk in could fall, become entangled pulling wires and may get electrocuted and can result in death. The maintenance man stated they will be changing the lock with a key pad and only he and the floor tech will have the key. In an interview on 07/14/26 at 4:53 pm, the Adm stated the only two people who had keys to the IT room was the maintenance man and floor tech. The Administrator stated he did not know who left the door open but it is to be locked every time they leave the room they change the doorknob to one that unlocked with a keypad. The Administrator stated the maintenance man will continue to make checks on the conditions of locks monthly, and the staff will be in serviced on make sure all non-resident doors are locked after use. The Administrator stated they had no policy or procedure on the maintenance or functions of the doors in the facility, but did have one on physical environment of the facility. Record review of the facility's Physical Environment dated 01/2023 stated Environmental issues the community is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #6) of 5 residents reviewed for respiratory care.The facility failed to ensure Resident #6's oxygen was administered at the correct setting of 4 liters per minute on 07/20/2026 as ordered by the physician.This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.The findings included:Record review of Resident #6's face sheet, dated 07/20/2026, revealed a [AGE] year-old male with an admission date of 06/10/2026. Pertinent diagnoses included Dysphagia, Oropharyngeal Phase (difficulty with swallowing) Aphasia (a disorder which affected an individual's ability to communicate effectively), Hemiplegia (severe or complete paralysis on one side of the body), and Hemiparesis (mild to moderate weakness on one side of the body). Record review of Resident #6's Quarterly MDS assessment, dated 07/17/2026 (this was the current, unsubmitted MDS), revealed a BIMS score of 10, which indicated moderately impaired cognition. Record review of Resident #6's active physician order summary, reviewed 07/20/2026, revealed an order, started 06/10/2026, for Oxygen at 4 liters per minute via nasal cannula every shift for hypoxia (a condition in which the body did not receive enough oxygen). An observation on 07/20/2026 at 10:06 AM revealed Resident #6's oxygen concentrator (a medical device used to deliver oxygen to an individual) was set at 2 liters per minute.In an interview on 07/22/2026 at 8:45 AM, RN-A stated he was the charge nurse for this hall, and it was the charge nurse's responsibility to set and adjust the oxygen concentrator settings for residents. He stated the order should have been verified, then the setting on the concentrator verified to match the order. He stated nurses assessed the settings on the concentrators when they did patient rounds at the beginning of the shift and during the shift. RN-A was not sure what Resident #6's oxygen orders were off the top of his head, and he was not sure how Resident #6's concentrator ended up on 2 liters. He stated oxygen was used for patients with respiratory issues, and if they were not getting enough oxygen, it could cause or increase respiratory issues. In an interview on 07/22/2026 at 9:47 AM, the ADON stated the floor nurses set and adjusted the oxygen settings on the concentrator based on the physician's orders. She stated Resident #6 had an order for 4 liters per minute continuous oxygen, and she was not sure why his oxygen was set at 2 liters per minute. The ADON stated the nurses should have been checking the concentrators for accuracy when they do their patient rounds. She stated if Resident #6 was not getting enough oxygen, his oxygen saturation could drop, and he could have become confused and had respiratory issues.An Oxygen Administration Policy was requested from both the Administrator and the DON on 07/22/2026 at 11:03 AM, but the Administrator stated they did not have a policy for Oxygen Administration.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 8 residents (Resident #49) reviewed for medication errors. The facility failed to administer Resident #49's metoprolol tartrate (medication that lowers blood pressure) when Resident #1's blood pressure was inside the physician's parameters on 07/17/26 and 07/20/26. These failures could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.The findings included: Record review of Resident #49's face sheet dated 07/22/26 revealed a [AGE] year-old male with an admission date of 04/15/26. Resident #49's pertinent diagnosis included Essential Primary Hypertension (high blood pressure with no identifiable secondary medical cause). Record review of Resident #49's admission MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. Record review of Resident #49's Comprehensive Care Plan dated 07/22/26 revealed the focus [Resident #49] has hypertension (high blood pressure initiated on 04/16/26. An intervention listed for this focus included Give anti hypertensive medications as ordered initiated on 04/16/26. Record review of Resident #49's order summary dated 07/22/26 revealed an active order for metoprolol tartrate 25 MG give 1 tablet by mouth two times a day related to Essential Primary Hypertension Hold for SBP less than 100 or DBP less than 60. Record review of Resident #49's MAR for July 2026 revealed metoprolol tartrate was held at the following dates with associated blood pressures:07/17/26 - 103/64 by RN B07/20/26 - 101/66 by RN B During an interview on 07/22/26 at 11:21 AM, the DON stated based on the July 2026 MAR for Resident #49 it appeared the metoprolol was held when it should have been administered on 07/17/26 and 07/20/26. The DON stated not giving blood pressure medications when they were indicated could cause blood pressure to become elevated leading to dizziness, sweating, or headaches. The DON stated if the blood pressure and heart rate were within physician parameters then it should be administered. During an interview on 07/22/26 at 2:18 PM, RN B stated she always checked the blood pressure and pulse of a resident as needed before administering medications. RN B stated she saw that Resident #49's blood pressure was just above the threshold of the physician's parameters on 07/17/26 and 07/20/26 and used her nursing judgement to hold the metoprolol. RN B stated she did not contact the doctor before holding the medication on either day, but she should have. RN B stated it was important to follow physician's orders when administering blood pressure medications to prevent hypertension (high blood pressure) symptoms like headaches, blurred vision, or chest pain. Record review of the facility policy Medication Administration effective 10/01/19 revealed the following policy: .2. Administration.B. Medications are administered in accordance with written orders of the prescriber

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles for medications stored in 1 of 5 medication carts (400-Hall Nurse Cart) reviewed for storage. The facility failed to ensure the Lispro Insulin pen (short acting insulin used to lower blood glucose) for Resident #97 in the 400-Hall Nurse Cart was labeled with the date it was opened. This failure could place residents at risk of receiving expired medications and not receiving the therapeutic benefit of the medication from staff.The findings included: Record review of Resident #97's face sheet dated 07/21/26 revealed a [AGE] year-old male with an admission date of 07/09/26. Resident #97's pertinent diagnosis included Type 2 Diabetes (chronic condition where your body resists insulin or doesn't make enough of it, causing blood sugar levels to spike). Record review of Resident #97's admission MDS assessment dated [DATE] revealed a BIMS score 3 indicating severe cognitive impairment. Further review revealed Resident #97 was taking hypoglycemic medication during the assessment. Record review of Resident #97's Comprehensive Care Plan dated 07/21/26 revealed the focus [Resident #97] has altered endocrine status DIABETES initiated on 07/09/26. Interventions listed for the focus included monitoring for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) and to report any significant changes to the Medical Director. Record review of Resident #97's order summary revealed an active order for Insulin Lispro Inject as per sliding scale: 70 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; greater than 400 = 10 units and notify [Medical Director], subcutaneously (layer situated just beneath the skin and above the muscle) before meals and at bedtime initiated on 07/10/26. During an observation of the 400-Hall Nurse Cart on 07/21/26 at 3:50 PM, an open Insulin Lispro Pen was found in the top drawer. The label on the pen indicated the pen was for Resident #97 with no open date documented. During an interview on 07/21/26 at 4:12 PM, RN A stated he was currently in charge on the 400-Hall Nurse Cart. RN A stated he administered the insulin to Resident #97 earlier in the day using the undated insulin pen. RN A stated he was supposed to check the expiration date on medications before administering them, but he forgot to when he administered the insulin to Resident #97 in the morning. RN A stated insulin pens expired around a month after opening them. RN A stated the resident had only been in the facility for approximately a week and a half, so the pen was not expired. RN A stated it was important to check the expiration dates on medications before administering them to ensure a resident was not administered an expired medication. RN A stated an expired medication would not be as effective and may not have the desired therapeutic effect on residents. During an interview on 07/22/26 at 11:21 AM, the DON stated insulin pens should have the open date and new expiration date written on the pen or label so it was readily visible once they were opened. The DON stated it was important to have the dates visible so residents were not administered expired insulin. The DON stated she saw the Insulin Lispro pen for Resident #97 and it did not have either the open date or new expiration date written on it. The DON stated Resident #97 was admitted to the facility on [DATE] so the pen was not expired yet. The DON stated insulin pens were usually good for around a month once they were opened. The DON stated expired medications may not have the desired therapeutic effect on residents when administered. Record review of the facility policy titled Expiration Dating and Expired Medications dated 10/01/19 revealed the following: .5. For multi-dose vials of injectable drugs:Date and initialed when openedThe expiration date for multi dose injectable vials is the manufacturer's printed date, unless otherwise indicated by the manufacturer.8. It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the Facility.

Based on observation, interviews and record review, the facility failed to wear hair restrains correctly, ensure food preparation and service area was clean and storage of food in accordance with professional standards for food service safety for 1 of 1-refrigerator (1 of 1 facility refrigerator) and 1 of 1 freezer (1 of 1 resident freezer reviewed for storage, preparation and sanitation. The facility failed to ensure food items in the refrigerators were sealed correctly preventing exposure to air and cross contamination The facility failed to ensure items in the freezers were sealed correctly preventing exposure to air and cross contamination. The facility failed to ensure steam table wells were clean and free from debris to ensure proper working condition. The facility failed to ensure kitchen staff were wearing hair restaints properly while in the kitchen to prevent cross contamination.Observations during the initial tour of the kitchen on 07/20/26 at 8:30 AM revealed kitchen manager not wearing beard restrains correctly covering his mustache and some of his beard. Observation of the facility refrigerator revealed a container of ham not sealed correctly, and a box of packaged boiled eggs with one package open with two eggs out of opened package possibly coming contaminated. Observation of facility freezer revealed bag of cooked fried chicken unsealed exposed to air possibly coming contaminated. Observation of Hot table revealed the hot steam wells with a grey scaly substance at the bottom of each hot steam well. In second observation and interview on 07/21/26 at 11:16 AM of kitchen revealed cook not wearing beard restrain properly over mustache and beard. The cook stated it was important that all facial hair be in a hair restraint so that the food being cooked could not become contaminated. The cook stated the resident could become sick possibly hospitalized if contaminated food is eaten. The cook stated all food is to be properly sealed and labeled when stored in freezer or refrigerator. The cook stated if residents were to have eaten the contaminated food they could become sick and possibly hospitalized . The cook stated the last in-service on proper storage of food was a week ago. The cook stated the last in service on proper hygiene was about 2 months ago. In an interview 07/21/26 at 11:24 AM with DA C she stated all food should be sealed correctly to prevent cross contamination of all food stored in the refrigerator. DA C stated she did not know why the food items were not sealed corrected only that they must have been missed when the refrigerator or freezer was checked for expired or unsealed food items. All the kitchen staff is responsible for ensuring all food is stored properly. DA C stated the last in service on proper storage of food was about 1 week ago.In an interview 07/21/26 at 11:31 AM with DA D she stated the refrigerator and freezer should be checked everyday and the ham and eggs must have been missed or just used for breakfast. DA D stated the last person who used the food item and put them back in should be making sure the items are closed completely. DA D stated it is important for food to be closed correctly so it is not exposed to air and become cross contaminated. DA stated the if a resident was to eat contaminated food they could get sick and end up in the hospital. DA D stated the last in service for proper storage of food was about a week ago. In an interview on 07/21/2026 at 11:42 AM with the Dietary Manager he stated any items that are stored in the refrigerator and freezer must be sealed completely closed to prevent cross contamination of the food item. The DM stated that food that is exposed to air can make residents ill, be hospitalized , and even death if resident is already compromised. The DM stated he does do random inspections of both freezer and refrigerator everyday to ensure so food items are open. The DM stated the ham and eggs must have just been used and not properly inspected before being placed inside the refrigerator and have been thrown away. The DM stated in the freezer the chicken must have not been sealed correctly since placed there because they had not been used and have been thrown away. The DM stated all employee are responsible for the items that a be labeled and sealed correctly before food is storage either freezer, refrigerator, and dry goods pantry in the kitchen. Any items that are found open or in an unsealed container and over 3 days old are thrown away immediately so that they are not used to feed the residents. The DM stated the last in-service he held with kitchen staff was in about a week ago but will have another to reenforce the proper sealing of food items.The DM stated all hair restraints need to be worn properly overall facial hair to prevent cross contamination and will do an in-service with all staff. In record review the of the Food Storage policy and procedure stated to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Dry storaged. To ensure freshness, store opened and bulk items in tightly covered containers. All containers, must be labeled and dated. RefrigeratorsDate, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Freezerse. Store frozen foods in moisture-proof containers that are labeled and dated. In record review of Employee Sanitation dated 10/01/2018 it stated The Nutrition and Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness.3 b. Hairnets, hairbands, caps beard coverings or other effective hair restraints must be worn to keep hair form food and food-contact surfaces.

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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #11) reviewed for infection control practices. The facility failed to ensure LVN-E performed proper and adequate tracheostomy care and hand hygiene for Resident #11 on 07/21/2026.The facility failed to ensure RN-B performed adequate hand hygiene during a medication pass on 07/21/2026 and tracheostomy care on 07/21/2026. The facility failed to ensure Resident #11 had one accurate physician order for EBP. These failures could place residents at risk for cross-contamination and infection due to inadequate care and hygiene being used.The findings included:Record review of Resident #11's face sheet, dated 07/22/2026, revealed a [AGE] year-old female with an original admission date of 04/17/2020, and a current admission date of 05/12/2026. Pertinent diagnoses included Cerebral Palsy (a group of conditions which affect movement, balance, and posture) and Chronic Respiratory Failure (a long-term condition in which the lungs cannot supply enough oxygen). Record review of Resident #11's active physician order summary, reviewed 07/22/2026, revealed an order with a start date of 07/14/2026 to change disposable 6 MM uncuffed inner cannula (a tracheostomy [an incision to access the windpipe] tube which was inserted into the trachea [the windpipe, a tube which allows air to pass to the lungs] to assist with breathing) for copious secretions, one time a day, and as needed. There was another order, with a start date of 07/10/2026, for EBP: Use gown and gloves for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices), every shift. Resident #11's physician order summary had a second order for EBP: Use gown and gloves for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices) one time a day. Record review of Resident #11's Quarterly MDS assessment, dated 06/10/2026, revealed no BIMS score as Resident #11 was rarely or never understood. The Annual MDS assessment revealed Resident #11 received respiratory care to include suctioning and tracheostomy care.Record review of Resident #11's care plan initiated 10/04/2024 and revised 04/25/2025, revealed a focus for Enhanced Barrier Precautions due to trach. Interventions included gown and gloves for high contact resident care activities (dressing, bathing, showering, personal hygiene, changing linens, assisting with toileting, incontinent care, medical device care, wound care). An observation of Resident #11's trach care on 07/21/2026 at 3:20 PM revealed LVN-E performed hand hygiene and continued to get out supplies for trach care; Surveyor did not observe bedside table to be sanitized as LVN-E stated she had previously disinfected the table she was using for her sterile field, so it did not need to be disinfected again. RN-B, who assisted with trach care, was observed to perform hand hygiene improperly by turning on the water, applying soap to her hands, without wetting her hands, she began scrubbing for approximately 3 seconds, then applied water to hands, scrubbed for approximately 3 more seconds, then applied more water, scrubbed for 3 more seconds, then rinsed and dried hands. LVN-E placed her stethoscope around her neck with her hair falling over it, then took stethoscope off her neck and assessed Resident #11's respiratory status. Resident #11 was observed to be forcefully coughing up thick, green sputum (a material coughed up and expelled from the airways) throughout the respiratory assessment and trach care. LVN-E placed the stethoscope back around her neck against and under her hair and over her gown. After assessing Resident #11's respiratory status, LVN-E performed hand hygiene with ABHS and continued to prep for trach care. LVN-E was observed touching the trash-can to move it closer to her, then proceeding with set-up and donning (to put on) sterile gloves. After starting trach care, LVN-E's gown became untied and fell very loosely down below her chest while her hair was loosely falling over her shoulders and over her gown throughout trach care. LVN-E's scrub top was exposed for the majority of the trach care, while she both leaned over the sterile field and leaned over Resident #11 to perform care. At no point during the actual trach care (after initial gathering of supplies, respiratory assessment, and hand hygiene with ABHS) did LVN-E stop to put her hair up, fix or re-apply her gown, or perform hand hygiene again, and during trach care, LVN-E was not noted to clean the trach and neck area 3-4 inches out from trach, in a circular motion from inner to outer. She was noted to wipe each side of the trach area. RN-B was observed to stop Resident #11's feeding pump prior to trach care and hold Resident #11's trach - oxygen mask which supplied oxygen to the trach. RN-B did not perform hand hygiene and apply new, clean gloves when she assisted LVN-E with applying the new, clean trach collar after trach care. LVN-E was also noted to touch and adjust Resident #11's oxygen concentrator before applying the new, clean trach collar. An observation of med-pass on 07/21/2026 at 5:33 PM revealed RN-B performed inadequate hand hygiene. After applying hand sanitizer, RN-B only rubbed hands together for approximately 3-4 seconds. In an interview on 07/22/2026 at 8:18 AM, LVN-E stated she should not have touched something dirty like the trash-can or oxygen concentrator then moved back to a clean or sterile area without performing hand hygiene and donning clean or sterile gloves. She stated hand hygiene should be performed when going from any dirty to clean area. LVN-E stated she probably should not have placed her stethoscope around her neck and hair both before and after assessing Resident #11's respiratory status. LVN-E stated she should have put her hair up so it was not hanging over her clean gown, her sterile field, or the resident when performing care, and she should have stopped trach care and re-applied her gown or donned a new gown, performed hand hygiene again, and donned new sterile gloves after her gown fell down. LVN-E stated not performing proper or adequate hand hygiene, not wearing appropriate PPE, and not performing adequate trach care could have caused cross contamination and infection. In an interview on 07/22/2026 at 9:47 AM, the ADON, who was also the ICP, stated RN-B had improperly performed hand hygiene, and the proper hand hygiene process with soap and water consisted of turning the water on, wetting hands, applying soap, rubbing hands and applying friction for 20 seconds, blotting hands dry, then using a paper-towel to turn the water off. The ADON also stated LVN-E should have stopped trach care, put her hair up so it did not hang over her shoulders, gown, sterile field, or the resident, pulled her gown up and re-tied it, then re-sanitized her hands, donned new gloves, and continued trach care. She also stated hang hygiene should be performed, and clean gloves donned anytime the nurses or staff went from a dirty area to a clean area. In an interview on 07/22/2026 at 2:18 PM, RN-B stated prior to assisting with trach care she should have performed adequate hand hygiene and should have wet her hands first prior to applying soap, then scrubbed her hands for 20 seconds before rinsing them. She also stated she should have rubbed hands for approximately 20 seconds with ABHS, and 3-4 seconds was not long enough to perform hand hygiene with ABHS. She stated not performing hand hygiene properly could cause cross contamination and infection.Record review of the facility's Tracheostomy Care Competency Assessment, no date available, revealed 4. Perform hand hygiene and put on gloves and other PPE. 8. Remove resident's tracheostomy dressing. then discard dressing; 10. Remove and discard gloves; 11. Perform hand hygiene; 12a. Open tracheostomy kit using aseptic technique; 12b. [NAME] sterile gloves; 12c. Setup sterile field; 12d. Empty contents onto sterile field; 12e. Pour sterile solution into basins.12k. Reinsert inner cannula into the tracheostomy tube and lock into place. 13. Using dominant hand, use a sterile cotton-tipped applicator and/or sterile gauze pad to clean the stoma-site. 14. Using dominant hand, moisten a sterile gauze pad with the sterile solution. Squeeze out the excess liquid. Then clean trach/neck area 3-4 inches around in circular motion from inner to outer, clean face plate, outer cannula and pat dry thoroughly with additional sterile gauze; 16. Instruct assistant to don clean gloves and hold tracheostomy tube in place to prevent expulsion during tie replacement.Record review of the facility's Enhanced Barrier Precautions policy, dated 11/24/25, revealed Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 3. Implementation of Enhanced Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: A. Dressing; B. Bathing, C. Transferring; D. Providing hygiene; E. Changing linens; F. Changing briefs. G. Device care or use. H. Wound care.Record review of the CDC: Long-Term Care Facilities (LTCFs): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: A. Wounds or indwelling medical devices, regardless of MDRO colonization status; B. Infection or colonization with an MDRO. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

Based on interviews and record reviews, the facility failed to provide or obtain laboratory services to meet the needs of its residents for of 1 of 5 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure Resident #1's Keppra (a medication used to treat seizures) level was drawn every three months to ensure Resident #1 was at a therapeutic level. This failure could place residents at risk of not receiving needed laboratory services and not having medications managed at a therapeutic level. The findings included:Record review of Resident #1's face sheet, dated 06/22/2026, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] with a readmission on [DATE]. Pertinent diagnoses included Epilepsy, not intractable, without status Epilepticus (a form of epilepsy [seizure disorder] where seizures were controlled with medication and did not involve prolonged or continuous seizures).Record review of Resident #1's Annual MDS assessment, dated 04/16/2026, revealed Resident #1 had a BIMS score of 00, which indicated severely impaired cognition. Further review of the MDS assessment also revealed Resident #1 had a seizure disorder or epilepsy. Record review of Resident #1's comprehensive care plan, revised 10/13/2021, revealed Resident #1 had a seizure disorder. Interventions included: give seizure medications as ordered by the doctor; monitor labs and report any sub therapeutic or toxic results to the doctor. Record review of Resident #1's physician order summary dated 05/25/2026 revealed a laboratory order for a Keppra level every 3 months. Order date was 11/10/2023. Record review of Resident #1's active physician order summary dated 06/22/2026 revealed an order to discontinue all routine labs; please call Hospice services with any questions or concerns, changes in condition, fall or absent vitals. Order date was 06/10/2026. Record review of Resident #1's physician orders revealed Resident #1 had been on Keppra since 2021, with the most recent change or revision to the order on 06/04/2026, Levetiracetam (Keppra) 500MG / 5ML, give 5ML by mouth four times a day related to Epilepsy.Record review of Resident #1's lab results revealed the last Keppra level was drawn on 12/20/2025.In an interview on 06/22/2026 at 4:13 PM, Resident #1 did not recall when the last time he had a seizure was, as well as was confused about what medications he took. Resident #1 was only concerned with getting more food and snacks. In an interview on 06/23/2026 at 1:15 PM, ADON-B stated Resident #1 had been admitted to hospice this month, which was why all his lab work had been discontinued. She stated she was not sure how often labs were supposed to be drawn to monitor epilepsy medications or what the therapeutic ranges were supposed to be for the medications Resident #1 was on. ADON-B stated since Resident #1's last Keppra level was checked on 12/20/2026, he should have had lab work checked again sometime in March 2026 and June 2026. ADON-B stated if his Keppra levels were not in a therapeutic range it could have contributed to him having seizures, and the labs should have been drawn every three months as ordered. ADON-B stated Resident #1 had not had any seizures recently that she was aware of. In an in interview on 06/23/2026 at 1:56 PM, ADON-A stated Resident #1's last Keppra level was in December 2025, so the next one should have been in March 2026. ADON-A stated everyone was different, so he was not sure if Resident #1 needed to be in the therapeutic range for his Epilepsy medication to work, but being at a subtherapeutic level could have possibly caused Resident #1 to have a seizure. In an interview on 06/24/2026 at 10:05 AM, the DON stated Resident #1's labs should have been checked to ensure his Epilepsy medication was at a therapeutic level because if the medication was not at a therapeutic level, it could have possibly contributed to Resident #1 having seizures. The DON stated Resident #1 had not had any seizures since the seizure like activity when he was transported to the hospital in May 2025. The DON stated she had already called Resident #1's Hospice company and got an order to restart labs to assess the therapeutic levels of Resident #1's Epilepsy medication since all of his routine labs had been discontinued after being admitted to hospice this month. Record review of the facility's Laboratory Services and Reporting policy, implemented 04/08/2024, revealed Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.The facility failed to ensure all kitchen staff wore hair and beard covers while assisting in the kitchen during lunch on 06/24/2026. This failure could place residents at risk for food contamination and food borne illness. The findings included: In an observation of the dining room and kitchen on 06/24/2026 at 12:27 PM, the DM was observed in the kitchen talking to and assisting another kitchen staff who was preparing and setting up lunch trays for residents. The DM had hair on his head and a beard, but he did not have a hairnet or beard cover on to prevent hair or facial hair from falling into residents' dishes or food. In an interview on 06/24/2026 at 1:34 PM, the DM he knew he was supposed to wear hairnets and beard covers while in the kitchen. The DM stated he had just gone out the back entrance to do something and was coming back in the back door, and there were no hairnets or beard covers at the back entrance where he usually kept them, so he was walking through the kitchen to grab one from the front entrance. The DM stated if a hair or beard cover was not worn while in the kitchen, hair could have fallen into the resident's food and caused cross contamination.In an interview 06/24/2026 at 2:13 PM the Administrator stated the DM and kitchen staff knew they were supposed to wear hair and beard covers while in the kitchen, even if the staff were just walking from one entrance of the kitchen to the other entrance. Loose hairs could fall into the residents' food or dishes if hair covers were not worn. He stated he had already started an in-service today (06/24/2026) regarding covering hair and facial hair while in the kitchen.Record review of the facility's Employee Sanitation Policy, dated 10/01/2018, revealed Policy: The Nutrition and Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 3. B. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: 2-4 Hygienic Practices 2Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination (2) Where it is not exposed to splash, dust, or other contamination.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1's bowel and bladder documentation was charted in PCC (the electronic record and charting system) for the dates of 06/20/2026 and 06/21/2026.This failure could place residents at risk for improper care due to inaccurate or incomplete assessments and records.The findings included:Record review of Resident #1's face sheet, dated 06/22/2026, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] with a readmission on [DATE]. Pertinent diagnoses included Chronic Kidney Disease Stage 2 (also called chronic kidney failure, involves a gradual loss of kidney function).Record review of Resident #1's Annual MDS assessment, dated 04/16/2026, revealed Resident #1 had a BIMS score of 00, which indicated severely impaired cognition. Further review of the MDS assessment also revealed Resident #1 was always incontinent of both bladder and bowel, and he required substantial or maximal assistance with toileting hygiene.Record review of Resident #1's comprehensive care plan for ADL self-care performance deficit related to confusion, revised 10/22/2021. Interventions, revised 04/23/2026, revealed Functional Performance: Toileting Hygiene: Resident #1 required dependent assistance for toileting hygiene. Record review of Resident #1's bladder elimination documentation from 06/09/2026 - 06/22/2026 revealed the dates of 06/20/2026 and 06/21/2026 were missing from the documentation. Record review of Resident #1's bowel elimination documentation from 06/09/2026 - 06/22/2026 revealed the dates of 06/20/2026 and 06/21/2026 were missing from the documentation.In an in interview on 06/23/2026 at 1:56 PM, ADON-A stated the CNAs were supposed to document the residents' bowel movements and incontinent episodes on the care task in PCC. After checking in PCC, ADON-A stated the documentation for the 20th and 21st of this month (June) were not there, but they should have been. He stated the charge nurses were ultimately responsible for following up to make sure the CNAs were documenting the care tasks performed on their shift.In an interview on 06/23/2026 at 2:47 PM, LVN-D stated she worked Saturday and Sunday (06/20/2026 and 06/21/2026) as a charge nurse and a medication aide on the 400 hall. She stated the CNAs documented the bowel and bladder notes in PCC. LVN-D stated it was ultimately the charge nurse's responsibility to check to make sure it was document. LVN-D stated she was busy helping the CNAs and passing medications, so she had not had time or a chance to check if the CNAs completed their charting, but the charting should have been completed so the residents' bowel patterns were known. In an interview on 06/23/2025 at 4:33 PM, CNA-C stated she had worked the previous weekend. She stated she documented bowel movement and incontinent briefs in the bowel and bladder section of PCC, and if there were any urinary symptoms, she reported the symptoms to the nurse. She was unsure why they were not documented for the previous weekend.Record review of the facility's Documentation in Medical Record policy, implemented 10/24/2022, revealed Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observation, interview and record review, the facility failed to ensure each resident had the right to dignified existence in a manner and an environment which promoted maintenance or enhancement of quality of life for 1 (Resident #1) of 5 residents reviewed for dignity.The facility failed to ensure CNA-A received permission from Resident #1 and/or the Responsible Party prior to completely shaving off Resident #1's facial hair. This failure could place residents at risk of feeling uncomfortable, disrespected, or embarrassed, and could decrease the residents' self-esteem and/or diminish their quality of life.The findings included:Record review of Resident #1's face sheet dated 05/12/2026 revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Metabolic Encephalopathy (a condition in which brain function was disturbed either temporarily or permanently due to different diseases or toxins in the body) and Acute Respiratory Failure with Hypoxia (a condition in which a person did not have enough oxygen in the blood or body). Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMs score of 05, which indicated severely impaired cognition. The MDS also indicated Resident #1 needed substantial or maximal assistance with showering or bathing, and partial assistance with shaving. Record review of Resident #1's Care Plan Report revealed a care plan for ADL self-care performance deficit related to confusion, initiated 04/08/2026, with interventions to include ask the RP for preference prior to beard grooming, required extensive assistance for bathing, showering, dressing, toileting and personal hygiene.Record review of a written statement by CNA-B, dated 04/23/2026, revealed CNA-B asked Resident #1 if he wanted her to trim his beard, and he did not refuse or tell her to stop.An interview on 05/12/2026 with Resident #1 was unable to be obtained due to he was in a new facility. In an interview on 05/12/2026 at 10:31 AM, a family member stated Resident #1's beard was shaved completely off in his sleep. He had grown and worn his beard for many years, and he never shaved it. She stated his beard defined him, and he would never have given permission for anyone to shave it completely off. She stated she tried to discuss the situation with facility staff, but they thought it was funny and laughed at her. She stated she attempted to speak to the Administrator multiple times about the situation, but he was always in a meeting or gone to lunch, and he could not make time to meet with her. She stated she was able to speak to a male ADON in the facility, but he too laughed about the situation and thought it was funny. She stated no one took her or Resident #1 seriously, and they were upset about the situation. In an interview on 05/12/2026 at 1:48 PM, CNA-B stated she remembered Resident #1 because he had refused his shower the day of the incident but agreed to a bed bath. CNA-B stated she remembered asking him about trimming his beard because it had oatmeal in it after breakfast. She first stated she asked if she could trim and clean up the beard, then stated she actually asked if he wanted the beard shaved off. She stated Resident #1 had told her to shave the beard but leave the mustache, and after it was shaved Resident #1 said thank you. CNA-B stated Resident #1 never complained about the beard being shaved off until after his family arrived to the facility, and the family became really upset. In an interview on 05/12/2026 at 2:35 PM, CNA-A stated prior to the earlier observation today, she had called a family member prior to showering a resident to see if the family member wanted her father shaved. She stated some residents cannot make this decision themselves depending on their cognitive status, so the family or RP should be contacted, and some family members would just like to be asked prior to shaving residents because sometimes the family member liked to do it themselves. In an interview on 05/12/2026 at 3:17 PM, the Administrator stated he felt with a BIMS of 05, Resident #1 had the cognitive capacity to make decisions regarding his care, such as shaving his beard, but he felt like he had not had the cognitive capacity to make major decisions or health care decisions, such as signing a DNR, and the RP would have needed to be notified in those cases or circumstances.In an observation on 05/13/2026 at 11:20 AM CNA-A was observed getting residents prepared for showering, bathing, and ADLs. CNA-A was overheard telling another staff member she had already reached out to this specific residents' family member to see if it was okay if they shaved the resident prior to his shower, and CNA-A stated the family member had given her the okay to shave the resident. In an interview on 05/13/2026 at 2:20 PM, the ADON stated Resident #1 seemed to have the appropriate cognitive status with answering questions regarding his care, but based on his BIMS score, he would not have been able to make major decision regarding care such as DNR or big medical decisions, so probably should have contacted the RP.Record review of the facility's Facial Hair and Long Hair on Men In-Service, dated 04/23/2026, revealed Do not shave, trim, or cut hair without checking with the family first, even if the patient agreed or asked for it.Record review of the facility's admission Agreement, no date identified, revealed Resident Rights: Rights of Elderly Individuals (Human Resourced Code, Title 6, Chapter 102).Record review of Human Resourced Code, Title 6, Chapter 102, Rights of the Elderly, revealed (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this stated and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. (b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means the elderly individual: (2) has the right to be free from abuse, neglect, and exploitation; and (3) if protective measures are required, has the right to designate a guardian or representative to ensure the right to quality stewardship of the individual's affairs.

Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident #1) of 5 residents reviewed for comprehensive assessment accuracy and timing.The facility failed to complete Resident #1's comprehensive admission assessment by 03/08/2026 after admission to the facility.This failure could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings included:Record review of Resident #1's face sheet, dated 04/08/2026, revealed a [AGE] year-old female with an admission date of 02/23/2026. Admitting diagnosis was Cellulitis of Right Lower Limb (a bacterial infection which typically affects the inner layer of the skin).Record review of Resident #1's admission MDS assessment, dated 02/25/2026, revealed an admission date of 02/23/2026. Resident #1 had a BIMS score of 06, indicating severely impaired cognition. The MDS also revealed the admission assessment was completed on 03/11/2026 and signed as completed by the DON on 03/11/2026. Record review of Resident #1's baseline care plan was initiated on 02/23/2026, but the comprehensive care plan had not been completed since Resident #1 discharged prior to comprehensive care plan being due. In an interview on 04/08/2026 at 3:40 PM, the MDS Nurse stated the admission MDS assessment should have been completed within 14 days of admission, and she was not sure why Resident #1's admission MDS assessment was not completed in the correct time frame. She stated it should have been completed by 03/08/2026 but must have been overlooked by accident. The MDS Nurse stated she was the one who assessed the residents and collected the data to input for the MDS assessments. She stated the MDS was also what triggered the different areas of the care plan, and if the MDS was not completed timely it could have possibly caused the care plan to not be completed timely as well. She stated she was ultimately responsible for making sure of the accuracy and timeliness of the MDS assessment, and the DON was the one who signed when the MDS assessment was completed and ready to be submitted.In an interview on 04/08/2026 at 3:51 PM, the DON stated the MDS nurse completed the MDS assessment, but she was the one who then signed it was completed and ready to be submitted. She stated the admission MDS for a new resident should be completed within 14 days, so Resident #1's admission MDS should have been completed by 03/08/2026, and she was unsure why it had not been completed by correct date. The DON stated the MDS assessment was utilized to help develop the care plan and was utilized for billing purposes as well, and if not completed accurately or timely, it could affect the accuracy or timeliness of the care plan. Record review of the facility's Assessment Frequency / Timeliness policy, dated 10/24/2022, revealed Policy Explanation and Compliance Guidelines: 1. The MDS Coordinator will be responsible for tracking due dates for all MDS assessments. 2. The comprehensive admission assessment will be completed within 14 days after admission.

Based on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility did not include Resident #1's mechanically altered diet (modified texture and consistency of food and liquids such as mechanical soft or purred diet) on her care plan. This failure could place residents at risk for not receiving a safe and appropriate care.The findings include: Record review of Resident #1's face sheet, dated 08/21/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 08/16/25. Resident #1 had diagnoses which included: fistula of vagina to large intestine (abnormal connection that allows gas, stool and other contents from the large intestine to leak into the vagina), malignant neoplasm (cancer) of unspecified ovary, and anorexia nervosa (eating disorder), unspecified. Record review of Resident #1's Medicare 5 day Minimum Data Set assessment, dated 07/04/25, revealed Resident #1 had a BIMS score of 11, which indicated she was moderately cognitively impaired. Resident #1's MDS indicated she was on a mechanically altered diet that required a change in texture of food or liquids on admission and while a resident at the facility. Record review of Resident #1's initial nursing evaluation with an effective date of 07/02/25 reflected she was on a mechanically altered diet. Record review of Resident #1's order summary report reflected she had an order for mechanical soft texture and regular liquids consistency from 07/02/25 until 07/25/25 when it was discontinued and was upgraded to a regular texture and regular liquid consistency diet from 07/25/25 until 08/11/25. Resident #1 had an order for pureed texture and regular liquids started 08/11/25 until it was discontinued on 08/16/25. Record review of Resident #1's initial baseline care plan dated 07/02/25 reflected her diet ordered was .mech [mechanical] soft, thin liquids and was marked as Yes under question that asked, Mechanically Altered? Record review of Resident #1's nursing noted reflected a note dated 08/11/25 that stated Resident #1's responsible party had notified RN A of Resident #1's request to change her diet texture to puree. Record review of Resident #1's closed comprehensive care plan, with a closed date of 08/18/25 did not reflect Resident #1's mechanically altered diet or food texture and liquid consistency. During an interview with MDS Nurse B on 08/21/25 at 3:05pm she stated she was responsible for completing the comprehensive care plan for Resident #1. MDS Nurse B stated she had reviewed Resident #1's care plan and it did not include her diet. MDS Nurse B stated it was best to include residents diets and altered texture diets on their care plans and stated she should have put a diet on Resident #1's care plan. MDS Nurse B stated she did not have a valid reason as to why Resident #1's diet was not include don her care plan. MDS Nurse B stated it was initially important to include diets on residents care plans to notify staff that they are on a mechanically altered diet. MDS Nurse B stated the care plans had to be signed by an RN but she was not sure about how often they were being monitored. MDS Nurse B stated she had been trained over developing a care plan and what it should include., MDS Nurse B did not recall an exact date of her last training but stated they had calls every Friday with their corporate team where they stressed the importance of care planning. MDS Nurse B was asked how not including a residents diet on their care plan could negatively impact them and stated she understood the importance of it but stated there were plenty of other areas that staff could find that information that was accurate, good, safe and quick for their diets in question. During an interview on 08/21/25 at 3:25pm with the Regional MDS Nurse, she stated every Friday she completed education calls. The Regional MDS Nurse stated on 05/05/25 she was at the facility and provided a training over care areas that had to be care planned including nutrition and where to care plan diets. The Regional MDS Nurse stated MDS Nurse B had received the training. The Regional MDS Nurse stated she was unable to find any documentation of the education that was provided on 05/05/25. During an interview with the DON on 08/21/25 at 3:42pm she stated MDS Nurse B was responsible for completing Resident #1's care plan. The DON stated care plans should include the resident's diets and stated she had reviewed Resident #1's care plan and it did not include her diet. The DON stated she did not know why Resident #1s care plan did not include her diet. The DON stated it was important to include resident's diets on their care plans so that everyone could be aware of it. The DON stated she reviewed and monitored the care plans to ensure they had all required information. The DON stated care plans should be monitored daily and stated she performed monthly audits on everything and stated any new changes should have been updated on the care plans. The DON stated her and MDS Nurse B had both been trained by the Regional MDS Nurse over developing a care plan and what should be included and stated her last training was on 07/15/25 and MDS Nurse B last training was on 05/05/25. The DON stated they did not have any documentation for those trainings. The DON stated not including a resident diet on their care plan could negatively impact them because they could miss a diet texture. During a continued interview on 08/21/25 at 3:42pm with the DON she stated she did not have any documentation to provide for the training her and MDS Nurse B had received over care plans by the Regional MDS nurse on 05/05/25 and 07/15/25. At this time the DON provided an Inservice she had started on 08/21/25 that included the DON and MDS Nurse B and covered, completing care plans accurately and reviewing [and] updating daily [with] any new orders, changes in condition/ADLS Record review of facility policy titled, Comprehensive Care Plans with an implementation date of 10/24/22 included the following verbiage, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. and 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record reviews the facility failed to ensure that drugs and biologicals for Resident #1 were received and counted appropriately for 1 of 4 residents. A narcotic medication for Resident #1 was not received and counted appropriately by RN A when Resident #1 admitted to the facility. The narcotic count for medication Oxycodone-Acetaminophen Oral Tablet 10-325 MG was short by 15 pills.This failure could result in being in pain.Findings included: Record review of Resident #1’s face sheet dated August 5, 2025, revealed Resident #1 admitted on [DATE]. Resident #1 had medical diagnoses of Cirrhosis of the liver (chronic liver damage), Other Psychoactive substance abuse, Hypertension (High Blood Pressure), Hepatitis C, and Repeated falls. Review of Resident #1’s admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS (Brief Interview Mental Status) score of 05 which indicates severe cognition impairment. Record review of Resident #1’s care plan, undated, revealed Resident #1 had chronic pain due to liver cirrhosis. Record review of Resident #1’s physician orders dated August 5, 2025, included Oxycodone-Acetaminophen Oral Tablet 10-325 MG by mouth every 4 hours as needed for Pain with a start date of July 10, 2025. During an interview on August 5, 2025, at 1:35p.m., LVN A verbalized she was giving report to the oncoming nurse on July 10, 2025, and they (she and the oncoming shift nurse) were waiting on narcotics from the hospice nurse for Resident #1. LVN A stated “RN A told me she would count the narcotics when they arrived”. I had already signed in some other medications Resident #1 brought from home. LVN A stated she was going off shift and RN A was coming on shift when the narcotics arrived, but I never opened or saw the narcotics. LVN A stated she did not think this resident was abused or neglected due to Resident #1 never being without medication. LVN A stated we (the facility staff) changed the way we receive medication, and we have to ensure we count the medication with whomever drops off the medication and we have them sign our paperwork also. It has always been the policy to have 2 staff members sign for narcotic medication. During an attempt to reach Resident #1 on August 8, 2025, this investigator was hung up on two times. This occurred at 2:00p.m and 2:05p.m. During an interview on August 8, 2025, at 2:30p.m., LVN B verbalized he counted the narcotic medication cart when he came on shift on July 11, 2025. LVN B stated the off-going shift nurse had Resident #1's medication in pill bottles and when he counted the narcotics named Oxycodone-Acetaminophen Oral Tablet 10-325 MG the count was off by 15 pills. LVN B stated he notified the ADON and DON that the narcotic count was off. LVN B stated the DON and ADON took the medication and recounted the medication and started an investigation. LVN B stated he was not sure what happened after they started investigating the missing medication. During an interview on August 8 ,2025 at 2:40p.m., RN A stated she did receive the Oxycodone-Acetaminophen Oral Tablet 10-325 MG from the hospice nurse, and she did lock them up but did not count them. RN A stated she took report from the off going staff member (LVN A) started her shift. RN A stated she received a pill bottle from the hospice nurse and took the count listed on the bottle as the amount of narcotics in the bottle (the count was 60). RN A stated she knew she should have counted them, but she did not count the medication. RN A stated she did not know how to answer the question of if its abuse or neglect for Resident #1. RN A stated Resident #1 was never without her medication and was never in pain. RN A stated she did not follow proper policy and protocol. During an interview on August 8, 2025, at 3:00p.m., the Director of Nursing (DON) stated she was notified by LVN B that the narcotic medication labeled Oxycodone-Acetaminophen Oral Tablet 10-325 MG count was off by 15 pills for Resident #1. The DON stated she immediately took the bottle of medication and tried to find the missing pills. The DON stated she notified the Administration and started an investigation. The DON verbalized the investigation included interviewing staff, calling hospice, placing staff on suspension, doing in-services on narcotic medication, reviewing Resident #1's entire clinical record, reviewing narcotic logs, and providing support to leadership during the process of investigating. During an interview on August 8, 2025, at 3:15p.m., the Administrator stated he was made aware the narcotic medication labeled Oxycodone-Acetaminophen Oral Tablet 10-325 MG was missing the morning of July 11, 2025, by the DON. The Administrator stated I called the person who delivered the medication, the pharmacy, and the DON for Hospice. The Administrator stated we (staff involved in the investigation) found out that this medication was left at the Hospice office for over 24 hours. The Administrator stated his facility staff nurse (RN A) trusted the pharmacy count and she did not count the actual medications. The Administrator stated policy and procedure was not followed. The Administrator stated the staff were placed on suspension and we have updated our policy and process for receiving medication. The Administrator stated we have also updated staff on the policy and now we request blister packs from all our pharmacies and Hospice companies. The Administrator stated I do not think this resident was abused or neglected and the resident was never in pain because she was never out of medication. A review of the facility policy named “Medication Policy, subsection Receiving Controlled Substances” dated October 1, 2019, revealed “At the time of delivery, the licensed nurse will verify the controlled substances received in the presence of the driver. The information on the manifest delivery log is correlated and both copies are signed indicating delivery and receipt of the individual controlled substances has been accomplished”.

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 for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure all food was labeled, dated, and not expired in refrigerators #1 and #2. 2. The facility failed to ensure all food was labeled, dated, and not expired in freezers #1 and #2. 3. The facility failed to ensure all refrigerators and freezers had internal thermometers. 4. The facility failed to ensure the chest-type milk refrigerator was clean and sanitized. 5. The facility failed to ensure rotted tomatoes were not stored with fresh tomatoes. 6. The facility failed to ensure dry goods were dated, labeled, sealed, and not expired. 7. The facility failed to ensure the meat slicer and roasting pans were clean and sanitized. 8. The facility failed to ensure the steamer oven was clean and sanitized. 9. The facility failed to ensure the dumpster side doors remained closed at all times. 10. The facility failed to ensure personal items were not kept on a prep table. 11. The facility failed to ensure a spatula was not chipped. These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on 05/05/25 beginning at 10:00 AM revealed 1, half-full 4-quart container of what appeared to be sliced cheese, and 1, half full 4-quart container of what appeared to be shredded cheese with the lids ajar, unlabeled, and undated in refrigerator #1. There were 2, 4-quart containers of what appeared to be sliced meat unlabeled and undated in refrigerator #1. There were 3 pre-made plates of salad and 3 pre-made bowls of salad unlabeled and undated in refrigerator #1. There was a 1-quart container of an unknown substance unlabeled and undated in refrigerator #1. There was a cut onion loosely wrapped in plastic, not sealed, unlabeled and undated in refrigerator #1. There were 2, 1-gallon containers with manufacturer labels of Dijon mustard on one and Cole slaw dressing on the other that had crusty substances around the lids and black furry dots and clumps on the outsides of the containers in refrigerator #1-both containers expired on 07/2024. There were 2 trays of beverages that were unlabeled and undated; 1 tray had 15 beverage cups filled with some red and some brown liquids in them, the other tray had 17 beverage cups with various liquids in them; some with a thick white substance appearing to be milk, some with a red substance, and others with a brown substance in refrigerator #1. There was an unknown substance wrapped in foil that was unlabeled and undated in refrigerator #1. There was a tray with 20 small cups of a thick yellow substance, unlabeled, undated and approximately half of them had lids ajar in refrigerator #2. There were 5 slices of pie and 7 small cups of what appeared to be cut fruit unlabeled and undated in refrigerator #2. There were 7, 4-quart containers partially full of various substances that had no use-by dates; 1 was labeled cranberry sauce and 1 was labeled tomato sauce. The other 5 containers were unlabeled and undated. There was a 2-pound opened bag of cheese that was not sealed in refrigerator #2. There were 2, 1-gallon jugs of an unknown dark brown liquid that were unlabeled and undated in refrigerator #2. There was a 1-gallon bag labeled pureed egg that was undated. There was a 4-quart container of a yellow substance that was unlabeled and undated in refrigerator #2. There was a mostly empty 25-pound container with a manufacturer label of hard cooked peeled eggs and the lid ajar. It was undated. There was a take-out container with hand-written sausage and egg that was undated in refrigerator #2. There were two bowls of an unknown substance that were unlabeled and undated in refrigerator #2. There was no internal thermometer in refrigerator #2. There was a removable black substance on the entire gasket of the lid to the chest-type milk refrigerator and ice accumulation on all four of the inside walls. There was condensation dripping from the top of the chest-type milk refrigerator where the lid met the chest. The bottom of the chest-type milk refrigerator was dirty and a reddish-brown substance on places of the metal floor and metal grate above the floor of the chest-type milk refrigerator. There was a large, partial bag of French fries with frost on them and on the inside of the bag, open to air, unlabeled and undated in freezer #1. There was a 29.7-pound box of frozen biscuits open to air, unlabeled and undated in freezer #1. There was 3, 2-gallon bags of what appeared to be English muffins, unlabeled and undated in freezer #1. There were 17 large beverage glasses on a tray filled with what appeared to be ice. The ice in the glasses had frost on them. The tray nor the glasses were labeled or dated in freezer #1. There was a 10.5-pound box with a manufacturer label of Salisbury steak that was open to air and the steaks inside were shriveled in freezer #2. There was no internal thermometer in freezer #2. There was a large, mostly empty box of fresh tomatoes that had what appeared to be rotten tomatoes open and dripping onto fresh tomatoes in the kitchen. There was an opened 28-ounce box with a manufacturer label of instant breakfast cereal that was undated and not sealed properly, leaving it open to air in the dry storage area. The covered meat slicer had food debris on the blade, the cutting platform, and the slider platform. The plastic cover on the meat slicer was dusty. There was a rubber spatula that had missing chunks of it around the edges and crevices worn into both sides. There were dirty roasting pans on the shelf of the steamer table. The oven-type steamer had a thick, yellow-white substance caked on the bottom and all four sides. The substance was flaking and floating in the water of the oven-type steamer. The dumpster side doors were open or partially open on all days of the survey from 05/05/25-05/07/25. Return observation of the kitchen on 05/06/25 at 04:21 p.m. revealed the steam oven still had a flaking yellow-white substance on the sides and bottom with floating debris in the water. Return observation of the kitchen on 05/07/25 at 11:30 a.m. revealed the steam oven still had a flaking yellow-white substance on the sides and bottom with floating debris in the water. In an interview with the FSS on 05/05/25 at 10:30 a.m. during the initial tour, she stated she did not know what the used-by dates were for any of the unlabeled and undated containers in Refrigerator #1, Refrigerator #2, Freezer #1, or Freezer #2. She said she did not know why the labels on the food containers only had the received dates on them. She said she received shipments and labeled food and containers with the received dates only. She said she and whoever placed food in the refrigerators and freezers was responsible for writing the correct dates and their initials on labels, including use-by dates. She said using undated food could cause the residents to get sick because of staff would not know how old the food was and because of cross-contamination. She said staff should know to make sure lids were tight on the containers in the refrigerators, but it was her responsibility to make sure the lids were tight on the containers. The FSS said the black furry dots and clumps on the outsides of the 1-gallon containers in Refrigerator #2 was mold. She said she was unaware of the mold and the expiration dates on the 1-gallon containers. She said she was responsible for checking the refrigerators and freezers for cleanliness. She said the open boxes of food in the freezers were probably freezer burned. She said she did not know who left them open or why. She said they would have to dispose of all the ruined food. The FSS stated the steam oven was cleaned weekly. The FSS said she was not aware rotten tomatoes were in the same box as fresh tomatoes. She said rotten tomatoes could attract gnats, ants, and roaches and could cross contaminate the good tomatoes. She said the entire box should be discarded. The FSS stated the contents of the unsealed container of instant breakfast cereal in the dry storage room could be contaminated by things in the air, moisture, or insects. She said the container of instant breakfast cereal could also taste funny and make residents not want to eat it or make them sick. She said she did not know why some of the refrigerators and freezers had more than one internal thermometer and others did not have any and she would have to speak to the kitchen staff about it. She said all the refrigerators and freezers had to have internal thermometers because there was no way to compare the digital reading on the exterior with an internal thermometer for accuracy. She said temperatures inside the refrigerators and freezers were important to make sure they were working properly and keeping foods the kitchen served from being bad. The FSS said the chest-type milk refrigerator had mold all around the gasket and did not know that it could affect the seal. She said she did not know how long it had been since the milk refrigerator had been cleaned and it was not on the cleaning schedule. She said she did not know if a bad seal could cause ice build-up on the inside walls of the chest-type milk refrigerator. She said the meat slicer was cleaned after each use. She said the meat slicer did not look like it had been cleaned. She said they did not use it very often, so she did not know when it was cleaned last or who used it last. She said the bits of meat on the meat slicer could be growing bacteria and could cause some real problems with residents getting sick from it. The FSS said she had not noticed the dirty roasting pans on the shelf below the steam table because they did not use them very often. She said they should be clean and were not on the cleaning schedule. The FSS said the chipped spatula should be thrown out because the pieces probably got in the food and could be bad for the residents. The FSS said the doors on the dumpsters were supposed to be closed unless it was being used. She said the kitchen was not the only department that used them. She said if they were already open, no one would bother to close them. She said open doors on the dumpsters could attract rodents. The FSS said she did not know who put their personal items on a prep table in the kitchen. She said the kitchen staff had a designated area for their things. She said she would have in-services about everything. Training, cleaning schedules, and kitchen policies requested at this time. Cleaning schedules were not received. In an interview with the COOK on 05/05/25 at 11:30 a.m., he said everything in the refrigerators and freezers and storage room should be labeled, dated, initialed, and have the use-by date on them. He said everyone was responsible, including himself. He said they (kitchen staff) all knew what was in there and when it was put in there. He said nothing when asked about the mold on the 1-gallon containers. He said there was a cleaning schedule and the meat slicer, and roasting pans were not on the schedule. He said he had not used the meat slicer because they usually got pre-cut meat. He said he did not know who used it last. He said personal items were not allowed in the kitchen. He said he did not know who or why someone would do that. He said personal items on the prep table caused cross contamination and could make residents sick if whoever it was did not wash their hands before touching items the residents would be touching. In an interview with the RD on 05/06/25 at 11:30 a.m., she said the kitchen followed a cleaning schedule. She said she monitored hand washing and service when she was at the facility every 2 weeks or so and as needed. She said she was always available to kitchen staff to answer any questions. She said she did not check labeling of food in the refrigerators or freezers. She said the FSS conducted in-services. Record review of In-services: 02/07/25-Deep Cleans of all areas, 03/21/25-Report any AC issue on electronic reporting system, 04/08/25-Coffee Temp. Record review of the facility policy, Food Storage revised 06/01/19: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP (Hazard Analysis Critical Control Point) guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. c. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 2. Refrigerators: d. Date, label and tightly seal all refrigerated foods using clean, covered containers .e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. h. Place a thermometer inside refrigerators near the door .Check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41F or below. 3. Freezers: e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. h. Place a thermometer inside freezers near the door .Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0F or below. Record review of the facility policy, General Kitchen Sanitation dated 10/01/18: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US food Codes in order to minimize the risk of infection and food-borne illness. Procedure: 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of the facility policy, Steamers dated 10/01/18: Policy: The facility will maintain steamers in a clean and sanitary manner to minimize the risk of food hazards. The steamers will be cleaned after each use. Record review of the facility policy, Meat Slicer dated 10/01/18: Policy: The facility will maintain the meat slicer in a sanitary manner to minimize the risk of food hazards. The meat slicer will be cleaned after each use.

Based on interviews and record reviews, the facility failed to a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 1 of 5 residents (Resident #83) reviewed for Preadmission Screening and Resident Review screenings. The facility failed to ensure Resident #83's PASRR L1 screening dated 08/26/21 accurately reflected his diagnoses of mental illness. There was no evidence that Resident #83 was referred to a Level 2 PASRR Screening and Evaluation. This failure could affect residents by placing them at risk for not receiving needed treatments and services. Findings included: Record review of Resident #83's face sheet revealed a [AGE] year-old male with an admission, original and initial date of 08/27/21. His principal diagnosis was stroke and secondary diagnoses were alcohol abuse and kidney failure. Diagnoses included major depressive disorder, recurrent, moderate dated 06/07/22, and anxiety disorder dated 06/07/22 and 12/08/21. Post-Traumatic Stress Disorder, Chronic dated 09/15/21, mood (affective) disorder dated 04/21/25, dementia, unspecified severity, with agitation dated 01/24/23, dementia dated 04/25/23, insomnia, altered mental status, and restlessness and agitation dated 04/21/25. Record review of Resident #83's admission MDS report dated 08/30/21 revealed a BIMS score of 06 indicating severe cognitive impairment. Section D: Mood indicated he had little interest or pleasure in doing things, felt tired or had no energy nearly every day. He felt down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much half or more of the days. He had a poor appetite for several days. He was on a mechanically altered diet. He was not steady and only able to stabilize with staff assistance. He required staff assistance with toileting, dressing, footwear, showering and positioning, personal hygiene, and set-up with oral hygiene and eating. He could sit in a wheelchair. He was frequently incontinent of bladder and bowel. Record review of Resident #83's quarterly MDS report dated 04/22/25 revealed a BIMS score of 00 indicating severe cognitive impairment. His cognitive skills were severely impaired for daily decision making. His inattention was continuous. He had physical and/or verbal behavioral symptoms directed toward others every 1-3 days. He was dependent on staff for all ADL's. He was on a mechanically altered diet. He was always incontinent of bladder and bowel. His active diagnoses were stroke, mood (affective) disorder, insomnia, altered mental status, restlessness and agitation, encounter for palliative care, cognitive communication deficit, insomnia, and alcohol abuse. He was taking antianxiety, antidepressant, and hypnotic medications. He was receiving hospice care. Record review of Resident #83's PL1 from a local hospital dated 08/26/21 was negative for MI (mental illness), ID (intellectual disability), and DD (developmental disability). There were no other PL1 screenings for Resident #83. Record review of Resident #83's Care Plan dated 08/29/21 revealed he has an ADL self-care performance deficit r/t Confusion, Dementia Date Initiated: 09/02/21 Revision on: 09/02/21. He had a behavior problem of abusive language, threatening behavior, rejection of care, and will push staff related to PTSD, dementia, yelling, screaming, pushing, and grabbing Date Initiated: 05/09/22 Revision on: 08/08/22. He had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia Date Initiated: 06/07/22 Revision on: 06/07/22. He had a history of actual falls and was at a high risk for further falls. Confusion, poor safety awareness, Deconditioning, anxiety, use of psychoactive medications. Will pull his floor mat onto his bed. Date Initiated: 09/02/21 Revision on: 05/05/25. He used anti-anxiety medications r/t anxiety disorder and mood disorder. Date Initiated: 10/22/21 Revision on: 03/12/25. He used antidepressant medication r/t Depression, Insomnia Date Initiated: 10/22/21 Revision on: 04/28/25. He had a terminal prognosis r/t cerebral infarction (stroke) Date Initiated: 10/31/22 Revision on: 10/31/22. Record review of Resident #83's Care Plan dated 04/16/25 revealed the revision date for a history of actual falls and was at a high risk for further falls. Confusion, poor safety awareness, deconditioning, anxiety, use of psychoactive medications. Will pull his floor mat onto his bed. Date Initiated: 09/02/21 Revision on: 03/12/25. He was on sedative/hypnotic therapy r/t Insomnia Date Initiated: 09/02/21 Revision on: 09/26/22. Record review of Resident #83's Form 1012 (Mental Illness/Dementia Resident Review) dated 02/02/23 revealed Yes, the individual has a primary diagnosis of dementia as defined above. The physician signs and dates the form attesting to the dementia diagnosis. Complete Sections D and E of the form. File the form in the resident's medical record. The Form 1012 Indicated the PL1 was dated 08/26/21. Section C. of the Form 1012 indicated Resident #83 had a Mood Disorder (Major Depression) The Form 1012 did not indicate Resident #83 had an anxiety disorder or any other disorder (such as PTSD). Section C instructed If all the responses are No, physician signs and dates the form. A new PL 1 is not needed at this time. Complete Sections D and E. If any of the responses are YES, the nursing facility needs to complete a new PL 1 and Sections D and E of the form. A full PASRR Evaluation will be conducted after the nursing facility submits the new positive PL 1. Section D of Resident #83's Form 1012 had The PL 1 remains negative and no new PL 1 needs to be completed. The nursing facility files the completed form in the resident's chart selected, but not A new positive PL 1 was submitted on _______ according to the instructions in Section C with DLN Driver's License Number). Resident #83's Form 1012 was signed by the MDS nurse on 02/02/23. Record review of Resident #83's Psychiatric Subsequent assessment dated [DATE] indicated he had diagnoses of: Primary Treating Diagnosis: Generalized anxiety disorder. Secondary Treating Diagnosis: Insomnia due to other mental disorder. Tertiary Treating Diagnosis: Major depressive disorder, recurrent, moderate. Reason for Referral: Anxiety, Agitation, Alcohol or Substance Abuse, Previous Mental Health Diagnosis: fidgety, pacing, intruding roommates' space, Other: PTSD. In an interview with the MDS on 05/06/25 at 5:28 PM, she said Resident #83's PASRR L1 dated 08/26/21 was negative and the person who worked at the facility before her, quit, so she had been catching things up, and that was why Resident #83's Form 1012 dated 02/02/23 had taken 2 years to send. She said she checked the Form 1012 Section C yes for Mood Disorder (Major Depression) and signed the form. She said she missed the part of the instructions where the Form 1012 stated, If any of the responses are yes, the nursing facility needs to complete a new PL1 and sections D and E of the form. A full PASRR Evaluation will be conducted after the nursing facility submits the new positive PL1. She said she misread Section D of the Form 1012 and filled in the circle that stated, The PL1 remains negative and so no new PL1 needs to be completed. The nursing facility files the completed form in the resident's chart. She said her signature was on the Form 1012 and said she would submit another PL1 now. She said Resident #83 had declined since his admission. Policy for PASRR was requested at this time. In an interview with the ADM on 05/07/25 at 8:55 AM, he said the facility did not have a policy on PASRR.

Based on record review and interview the facility failed to ensure that each resident recieved adequate supervision and assistance to prevent accidents for one resident (Resident #3) of six resident reviewed for supervision. The facility did not implement Resident #3's comprehensive care plan and did not transfer Resident #3 with a 2-person assisted Hoyer (mechanical lift) transfer as reflected on Resident #3's comprehensive care plan. This deficient practice could place residents at risk for not receiving appropriate treatment and services. The findings were: Record review of Resident #3's face sheet, dated 04/14/23, revealed a [AGE] year-old female with an admitted [DATE] with diagnoses which included: Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), unspecified, contracture ( tightening or shortening) of muscle, multiple sites, age-related osteoporosis (bone disease that develops when bone mineral density and bone mass decrease) without current pathological fracture (break caused by preexistent issue like a disease), and dysphagia (difficulty swallowing), unspecified. Record review of Resident #3's quarterly MDS assessment, dated 02/07/23, revealed Resident #3 had a BIMS score of 0, which indicated severe cognitive impairment. Resident #3's quarterly MDS dated [DATE] reflected she was total dependent for bed mobility and total dependent for transfers with 2-person physical assist. Record review of Resident #3's care plan, obtained on 04/14/23, revealed a focus of Resident #3 has an ADL self-care performance deficit related to Alzheimer's, with an initiated date of 02/11/21. Associated interventions stated, TRANSFER: the resident requires TOTAL ASSIST X 2 (2 person) Hoyer staff to move between surfaces as necessary., with an initiation date of 02/11/21. Record review of Resident #3's documented tasks of ADL-Transferring, revealed Resident #3 was transferred with 1-person physical assist on 03/17/23, 03/18/23, 03/19/23, 03/22/23, 03/27/23, 03/28/23, 03/30/23, and 03/31/23 by CNA A. Documentation identified CNA B had transferred Resident #3 with 1-person physical assist on 03/23/23 and 03/29/23 and CNA C transferred Resident #3 with 1-person physical assist on 03/26/23. Documentation identified CNA D had transferred Resident #3 with 1-person physical assist on 03/25/23 and CNA E had transferred Resident #3 with 1-person physical assist on 03/20/23, 03/21/23, and 03/24/23. Record Review of Resident #3's nursing notes dated 03/30/23 at 12:42pm reflected LVN F was notified that Resident #3 had left knee pain while getting ready for breakfast. This nursing note continues to describe LVN F's assessment of Resident #3 stating upon further assessment pain was noted to Resident #3's left knee when bending knee at a slight angle. Resident #3 was administered pain medication that was identified to have helped subside pain. A few hours later LVN F checked on Resident #3 again and identified slight pain remained. Nurse practitioner was notified and had X rays ordered for Resident #3. Record review of Resident #3's radiology report with an examination date of 03/31/23 at 12:00pm revealed Resident #3 was identified to have a fracture of the left distal femur with soft tissue swelling. Record review of Resident #3's nursing notes reflected she was sent out of facility to the hospital for evaluation and treatment of fracture to left femur on 03/31/23 and had not returned as of 04/14/23. Record review of Resident #3's CAT (computed axial tomography) scan of left lower extremity without contrast revealed Resident #3 had a comminuted fracture identified involving the distal left femur. Record review of Resident #3's CAT (computed axial tomography) scan of right lower extremity without contrast revealed Resident #3 had a comminuted fracture identified involving the distal right femur between the stem of the stem of the femoral intramedullary rod and the femoral component of the knee prosthesis. An observation of staff transferring Resident #3 was not possible due to Resident #3 not being in the facility. During an interview with the Administrator on 4/09/23 at 3:30pm she stated Resident #3 had been discharged from facility. During an interview with the LVN F on 04/09/23 at 1:55pm he stated CNA A notified him of Resident #3 having some pain while she was getting her ready for breakfast. LVN F stated Resident #3 was able to notify him of pain with facial grimacing and by verbalizing no no no and ah ah ah when he was attempting to bend her left knee. LVN F stated while he was assessing Resident #3's knees he touched and bent residents left knee a little bit and stated Resident #3 was grimacing and making a sound like ah ah. LVN F stated he administered Tylenol and came back a couple hours later and stated Resident #3 was not in as much pain, so he tried to bend Resident #3's left knee again but stated Resident #3 continued to make noises. When LVN F was asked if he knew how Resident #3 fractured her femur he stated, he did not know the findings. During an interview on 04/14/23 at 4:08 p.m., CNA A stated she had worked with Resident #3 and stated she was responsible for Resident #3's transfers when working with her. CNA A reviewed Resident #3's tasks of ADL-Transferring and confirmed she had documented she transferred Resident #3 with 1-person physical assist on 03/17/23, 03/18/23, 03/19/23, 03/22/23, 03/27/23, 03/28/23, 03/30/23, and 03/31/23. CNA A stated there had been times her and her partner would perform a 2 person transfer for Resident #3. CNA A stated there had been times when Resident #3 was willing to help, and CNA A would use a gait belt and transfer Resident #3 herself as a single person transfer. CNA A stated she did not use a Hoyer lift when transferring Resident #3 because she was not aware Resident #3 was a Hoyer transfer. CNA A stated she did not know Resident #3 was a Hoyer transfer until recently when the DON made her aware this month (April 2023). CNA A stated Resident #3's care plan recently started reflecting she was a Hoyer lift and stated she had not seen it. CNA A stated she was not following Resident #3's care plan because Resident #3 was helping her, and CNA A would just transfer her. CNA A stated she should have looked more at the kiosk (Kiosks include Kardex system that show resident care plans) to see if Resident #3 was a Hoyer lift. CNA A stated she had been trained on transfers and following residents' care plans. CNA A stated the DON and ADON monitored her several times and observed her complete transfers to ensure she was providing appropriate care. CNA A stated she did not know how Resident #3 fractured her femur, however she stated not following a resident's care plan and performing incorrect transfers could cause residents to have bruises, skin tears, broken bones and could cause death if they fell . During an interview on 04/14/23 at 4:40 p.m., CNA B stated she had worked with Resident #3 and stated CNAs were responsible for completing resident transfers. CNA B reviewed Resident #3's tasks of ADL-Transferring and confirmed she had documented she transferred Resident #3 with 1-person physical assist on 03/23/23 and 03/29/23. CNA B stated she would transfer Resident #3 as a 2 person transfer and a gait belt and did not know why she documented she had completed a 1-person transfer. CNA B stated she did not use a Hoyer lift when transferring Resident #3. CNA B stated Resident #3's care plan reflected transfers as pretty much 2 person or 1 person. CNA B stated now Resident #3's care plan reflected, 2 person transfers with Hoyer. CNA B stated she was not following Resident #3's care plan because she did not know Resident #3 was a 2-person Hoyer transfer. CNA B stated she had been trained on transfers and following resident care plans. CNA B stated the hall nurses and ADON walked down the halls and would monitor if we are doing everything the right way. CNA B stated not following a resident's care plan and performing incorrect transfers could have a lot of negative effects, stating, we could injure them. CNA B was asked if she knew how Resident#3 fractured her femur and she stated, I don't know how she got those fractures. Could be through miss transferring her or she has her days when she's trying to get up, I don't know. During an interview on 04/14/23 at 6:00 p.m., CNA C stated she had previously worked with Resident #3 and stated CNAs were responsible for completing resident transfers. CNA C was unable to review Resident #3's tasks of ADL-Transferring due to interview being conducted via telephone. CNA C explained that her documentation reflected she transferred Resident #3 on 03/26/23 as a 1-person transfer. CNA C stated she would transfer Resident #3 as a 2 person transfer and would use a gait belt and stated she probably meant to click on 2-person transfer when documenting. CNA C stated she did not know Resident #3 was a Hoyer transfer and stated she did know that Resident #3 was a Hoyer transfer now. CNA C stated she had been trained on transfers and following residents' care plans. CNA C stated she was monitored with in-services and meetings to ensure she was following care plans and providing appropriate care. CNA C stated not following a resident's care plan and performing incorrect transfers would put herself and the resident at risk for falls and skin tears. During an interview on 04/14/23 at 6:30 p.m., CNA D did not recall working with Resident #3. During an interview on 04/14/23 at 4:40 p.m., CNA E stated she had worked with Resident #3 and stated she was responsible for completing Resident #3's transfers. CNA E was unable to review Resident #3's tasks of ADL-Transferring due to interview being conducted via telephone. CNA E explained that her documentation reflected she transferred Resident #3 with 1-person physical assist on 03/20/23, 03/21/23, and 03/24/23. CNA E stated she had been transferring Resident #3 as a 1 person transfer and stated she had not used a Hoyer when she transferred Resident #3. CNA E stated she was not following the care plan for Resident #3 because she was not aware Resident #3 was a Hoyer transfer. CNA E stated Resident #3's care plan now reflected she was a Hoyer transfer, CNA E stated she had been trained on transfers and following residents' care plans. CNA E stated the ADON and DON were assigned to each hall and would keep up as far as who is 1 or 2 person transfers. CNA E also stated the ADON and DON would make sure their POC (a mobile-enabled app that runs on wall-mounted kiosks that enable care staff to document activities of daily living) was correct. CNA E stated not following a resident's care plan and performing incorrect transfers could have negative effects on residents such as broken bones. CNA E was asked if she knew how Resident #3 fractured her femur with CNA E stating, I think it was a fall, or they dropped her or she fell off the bed. During an interview on 04/14/23 at 6:46 p.m. the DON stated Resident #3's care plan and Kardex (location for CNAs to view plan of care) reflected Resident #3 was a Hoyer lift. The DON stated there were staff members who had been transferring Resident #3 and did not know she was a Hoyer transfer. The DON stated staff did not know Resident #3 was a Hoyer lift previously because the kiosk system that the CNA's use was not reflecting that Resident #3 was Hoyer transfer. The DON stated she completed an audit on all Hoyer transfers and had corrected them by adding a custom task to state Hoyer transfer on the Kardex system. The DON stated staff was asking Resident #3 to hug them and were using gait belts to transfer her as a 1 person transfer and without use of Hoyer. The DON stated staff was not following Resident #3's care plan and stated staff said they were transferring Resident #3 that way because she was able to follow commands to hug staff and was not buckling and was able to bear weight based on what nursing staff told the DON. The DON reviewed Resident #3's documented tasks of ADL-Transferring, and confirmed Resident #3 was documented as transferred with 1-person physical assist on 03/17/23, 03/18/23, 03/19/23, 03/22/23, 03/27/23, 03/28/23, 03/30/23, and 03/31/23 by CNA A. The DON reviewed and confirmed CNA B documented she transferred Resident #3 with 1-person physical assist on 03/23/23 and 03/29/23. The DON reviewed and confirmed CNA C documented she transferred Resident #3 with 1-person physical assist on 03/26/23. The DON reviewed and confirmed CNA D documented she transferred Resident #3 with 1-person physical assist on 03/25/23. The DON reviewed and confirmed CNA E documented she transferred Resident #3 with 1-person physical assist on 03/20/23, 03/21/23, and 03/24/23. The DON stated all nursing including the ADON, the MDS nurse and the DON were responsible for educating and supervising nursing aides on resident care plans and to ensure they were providing appropriate care to residents. The DON stated she monitored and ensured staff were providing appropriate care to residents and following their care plans by doing walking rounds, in-services, spot checks and having the MDS nurse do ADL training with staff. The DON stated staff had been recently in-serviced staff over transfers. Documentation was reviewed by this surveyor and confirmed in services completed on 03/31/23. The DON stated not following a resident's care plan and doing incorrect transfers could have negative effects on residents such as injuries from skin tears to fractures. Record review of the facility's policy titled, Comprehensive Care Plans with an implementation date of 10/24/22 revealed a section titled, Policy: that reflected, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The section titled ,Policy Explanation and Compliance Guidelines: reflected, 8.Qaulified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from abuse for one of three residents (R #1) reviewed for abuse. 1. The facility failed to develop and implement effective interventions to address R #2's physically aggressive behaviors after R #2 physically assaulted R #1 on 03/15/20 and then again on 03/27/20. R #1 was punched on the shoulder and/or face on two separate occasions by R #2, sustaining pain to her left shoulder, which required an x-ray. R #1 sustained pain to her shoulder and facial bruising to the left side of her face. R #1 stated and displayed signs of being fearful of R #2. 2. The facility failed to develop and implement effective interventions to address R #1's behaviors, such as provocation, physical aggression, and resistance to care. 3. The facility failed to identify R #2's two separate acts of physical aggression towards R #1 as acts of abuse, instead, the facility identified the acts as behaviors. 4. The Administrator, who was the Abuse Coordinator did not identify R #2 punching R #1 on 03/15/20 and then again on 03/27/20 as abuse therefore, the incidents were not reported as acts of abuse. The Abuse Coordinator did not thoroughly investigate the first incident and missed the identification of R #1's fear of and anger for R #2, all of which contributed to a second incident of physical abuse 5. The facility failed to protect R #1, allowing R #2 ongoing access to R #1. R #1 expressed changes in behavior of increased agitation, aggression, and provocation whenever R #2 was in sight. 6. The facility failed to assess R #1's psychosocial effects after she was the recipient of two separate incidents of physical abuse and allowed the perpetrator, R #2, to remain in the near vicinity of R #1. An Immediate Jeopardy (IJ) situation was identified 04/07/20. While the IJ was removed on 04/09/20 at 4:42 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices of the facility's failure to intervene after abusive incidents could result in further abuse and injury. The findings included: Record review of R #1's Face Sheet dated 04/06/20 documented a [AGE] year-old female admitted [DATE] with the [DIAGNOSES REDACTED]. Record review of R #1's Comprehensive Care Plan dated 01/20/20 documented: -(R #1) is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) cognitive deficits . -(R #1) is an elopement risk/wanderer r/t history of attempts to leave facility unattended, Impaired safety awareness, resident wanders aimlessly -(R #1) resides in the secure unit due to wandering, she is new to facility and has been packing and unpacking belongings . -(R #1) has impaired cognitive function/dementia or impaired thought processes r/t dementia -(R #1) uses antidepressant medication r/t poor adjustment to admission [MEDICATION NAME] and [MEDICATION NAME] PATCH . The resident uses anti-anxiety medications ([MEDICATION NAME]) r/t anxiety disorder . The resident uses antipsychotic medications [MEDICATION NAME] . Monitor/record occurrence of/for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. Record review of R #1's Quarterly Minimum (MDS) data set [DATE] documented she: -had adequate hearing and clear speech -understood others and made self-understood -had a brief interview of mental status score of 4-severely impaired -required supervision for bed mobility, transfers, dressing, and limited assistance for personal care -had physical behavioral symptoms towards others and other behavioral symptoms not towards others that occurred 1-3 days. Record review of R #1's Nursing Progress Notes and Change in Condition Communication Form dated 03/15/20 documented 10:16 PM- SN (Skilled Nurse) notified by CNA (Certified Nurse Aide) that resident received physical aggression and was physical towards another resident (R #2). Upon entering the secured unit SN was informed that resident was in her room. Upon entering resident's room, she was observed sitting on her bed. SN asked resident what happened, and she stated (she) and another resident were arguing when he hit her on her shoulder and she then bit his hand. SN asked resident if she had any pain and resident denied. SN assessed both of resident's shoulders and no redness or discoloration was observed. Vitals were . SN notified DON (Director of Nurses), RP (Responsible Party), and MD (Medical Doctor). No new orders received from MD. RP aware and no concerns at this time. SN placed resident on 72-hour (hr) critical behavior monitoring every hour. Resident remains in her room. Safety has been maintained, will continue to monitor. Record review of R #1's Incident/Accident Report dated 03/15/20 documented 10:30 PM- SN notified by CNA that resident received physical aggression and was physical towards another resident. Upon entering the secured unit SN was informed that resident was in her room. Upon entering resident's room, she was observed sitting on her bed. SN asked resident what happened, and she stated she and another resident (R #2) were arguing when he hit her on her shoulder, she then bit his hand. SN asked resident if she had any pain and resident denied. SN assessed both of resident's shoulders and no redness or discoloration was observed . SN notified DON, RP, and MD. No new orders received from MD. RP aware and no concerns at this time. SN placed resident on 72-hour critical behavior monitoring every hour. Resident remains in her room. Safety has been maintained. Will continue to monitor. Residents separated. Resident assessed, all appropriate parties notified. Upon investigation this resident was observed in her room sitting on her bed. Resident noted to be upset saying a man hit her on her shoulder and she bit him back. Noted bilateral shoulders with redness, bruising at present. Shoulders will be monitored. Resident denies being fearful of other resident at present. CNA will help separate and continue to monitor for further behaviors. Resident offered pain medicine. RP and MD notified of incident. Behavior monitoring for residents hourly X 72 hours. In an interview with CNA A on 04/06/20 at 4:05 PM, she stated the day following the incident (03/16/20), R #1 told her she was afraid of R #2, she (R #1) said she did not want him around. CNA A said R #1 put a chair and wheelchair to block the doorway to her room to keep him (R #2) from coming in the room. CNA A said she (R #1) stayed distant, she stayed in her room for a couple of days behind the privacy curtain. CNA A stated, She did not want to be next to him (R #2) at all. Then a couple of days later she would constantly follow (R #2) with her eyes and purposely walk in front of (R #2), staring him down. Record review of R #1's Acute Care Plan dated 03/15/20 documented Behavior - Problem: Physical aggression/combativeness related to unknown .Approach: Reorient and redirect to self; Notify MD/RP of any changes in behavior; one-hour behavior monitoring for 72 hours. The care plan did not include any interventions in attempt to prevent incidents of physical aggression from re-occurring or what actions to implement should the aggression occur again. Record review of R #1's Nursing Progress Notes dated 03/18/20 documented 1:24 PM - 72-hour behavior (monitoring). Resident, this 6-2pm shift not having aggressive behaviors. SN placed call to daughter regarding approx. 1in. x 1in. discoloration to left shoulder . Resident at this time is able to perform full range of motion in all extremities with no non-verbal signs of pain nor is pain verbalized. Resident able to make needs known. Behavioral monitoring continued. Record review of R #1's left shoulder x-ray result, for a [DIAGNOSES REDACTED].#1 did not have a fracture. Record review of R #1's Nursing Progress Notes dated 03/23/20 documented 3:51 PM - Par meeting held IDT (interdisciplinary team)-Res had combative behaviors throughout the day with staff care at intervals. New onset of resisting care. Res was not easily redirected . Record review of R #1's Social Services Progress Note dated 03/24/20 documented 2:50 PM - Resident with recent changes in behavior including increased agitation. Current precautions in place in this facility are restricting visitors and resulting in some disruption to (R #1's) daily routine. Will continue to monitor and offer support as needed. This note documented changes in behavior with increased agitation but did not address R #1's psychosocial needs, her fear or her feelings towards her aggressor (R #2). Record review revealed there was no Social Services note regarding the 03/15/2020 altercation with another resident. In an interview with the Social Worker (SW) on 04/07/20 at 10:05 AM, she said the IDT did not further explore or investigate R #1's increased agitation and resisting of care. The SW said R #1's behaviors could have been a result of R #2 being within her line of sight, possibly being fearful and angry at R #2 for punching her. Record review of R #1's Nursing Progress Notes dated 03/26/20 documented 1:37 PM - resident continues with agitation and verbal aggression towards other residents in the unit. Resident believes another male resident is after her, unable to redirect due to impaired cognition. Resident continues with delusions, resident closely monitored, SN notified MD of current behavior. Pending response at this time. RP notified, will continue to monitor. Record review of R #1's Nursing Progress Notes dated 03/26/20 documented 2:04 PM - new orders from (physician) received to decrease PRN [MEDICATION NAME] to 0.5mg prn every 6 hours and to increase Trazadone to 50 mg tid. SN notified RP. Will continue to monitor. Record review of R #1's Nursing Progress Notes and Change in Condition Communication Form dated 03/27/20 documented 9:42 PM - SN notified by CNA that resident had received physical aggression from another resident. Upon assessment resident was observed sitting in chair in her bedroom. SN assessed resident and observed a hematoma to the top of her left eyebrow. Resident noted with bruising/discoloration from fall that previously happened. Resident verbalized pain to area and PRN Tylenol was administered. SN asked resident what happened, and she stated she was hit in the face. CNA stated that she witnessed another resident (R #2) hit (R #1) twice on her temple and side of the eye and she immediately separated the two and called for assistance of other CNA and notified SN. Upon assessment, no other injuries were apparent. Vitals at the time of incident were . SN notified (physician) and no new orders. DON was notified. RP notified, no concerns or issues at this time. SN initiated 72-hour critical behavior monitoring hourly, and neuro checks x72 hours. Resident remained in room, safety maintained, will continue to monitor. Record review of R #1's Incident/Accident Report dated 03/27/20 documented 9:30 PM - .SN asked resident what happened, and she stated she was hit in the face. Upon investigation this resident was observed by CNA being hit on the left eye by another resident. Residents were both separated immediately. This resident (R #1) resides on the dementia unit and is able to state what occurred, oriented X1. Ice pack applied, and neuro checks were monitored. Prior to this incident resident had sustained a fall and noted with bruising discoloration to left side of eye (fall occurred on 03/20/20) RP and MD notified of incident. PRN adjustment for physical aggression, on 03/26/20 with new order for [MEDICATION NAME] 0.5 mg PRN (as needed) every 6 hours. Will continue to monitor. Resident denies being fearful of other resident at this time. After resident's family gave consent, resident was trialed outside the unit as an intervention. She did well for 4 hours then resident was observed ambulating down the hallway asking for way out of the facility. Resident required redirection but asked a second time how to get out of the building. Was then assisted back to the unit for safety. Due to recent restrictions related to COVID-19 resident is not a candidate to be out of the unit or for transfer to another facility and family cannot care for her at home at this time. Record review of R #1's Accident Investigation Report - Witness Interview documented by CNA B dated 03/27/20 documented A physical altercation between (R #1) and (R #2). I was assisting a resident in her room when I heard yelling. I ran out and saw (R #2) punching (R #1) twice, once near her temple and again her eye. I stepped between them and (R #2) grabbed my hand. He would not respond to his name and was intently staring at (R #1). I yelled his name loudly and he asked me who I was. I told him my name and that he was hurting me. He immediately let go of my hand and said he was sorry. Record review of R #1's Nursing Progress Notes dated 03/28/20 documented 10:24 AM - 24 hour follow up physical aggression received, resident stable, no s/s of distress, resident continues with contusion to left upper brow and temple. Resident medicated with PRN pain medication for complaints of general pain. Resident alert, watching tv in common room, will continue to monitor . The 03/27/20 incident was the second incident of abuse, there was no documentation of any other interventions to protect R #1 from R #2, other than will continue to monitor. Record review of R #1's Nursing Progress Notes dated 03/30/20 documented 10:41 AM - 72-hour behavior monitoring. Patient is alert with discoloration to the left eye. Patient voiced that she has pain to the site. Ice pack and PRN medication administered. No signs of aggressive behaviors or fearful behavior noted. Record review of R #1's Physician order [REDACTED]. Observation of R #1 on 04/06/20 at 10:19 AM revealed she had purple discoloration beneath her left eye, on her left temple, down to her left cheek. R #1 was sitting in a chair in the common area of the secured unit watching television. At 10:21 AM, CNA D asked R #1 if she would like to go to the bathroom, R #1 said yes, and she ambulated to her room using a rolling walker. R #1 walked out of the bathroom and ambulated to her bed and sat on the edge of her bed. The privacy curtain was pulled around R #1's bed. R #1 frequently looked around the privacy curtain towards the hallway. When asked what R #1 was looking for, R #1 said Ese viejo (that man). Record review of R #1's Nursing Progress Notes dated 04/03/20 documented 11:44 AM - notified RP of resident (R #1) aggressive behavior towards male resident (R #2). Resident was observed attempting to hit resident (R #2) with walker. Male resident was not engaged in any behavior prior to resident's aggression. SN separated residents, will continue to monitor. There was no evidence the facility took any further action other than resident separation. Interview with R #1 on 04/06/20 at 10:26 AM revealed she was alert to self, able to correctly state her name, stating she was not in her home but was unable to state her current location and time. R #1 was sitting on the edge of her bed with the privacy curtain pulled all the way around her bed. R #1 stated she was hit by a male resident, whom the only description she gave was a white man with no teeth. R #1 stated the male resident entered her room when it was still somewhat dark outside since she could see outside her window. R #1 said she was lying down on her right side, in bed, when the male resident entered her room and began pulling down her bed sheets. R #1 stated she yelled at him to leave her room and he kept telling her Shhh and called her Mammacita. R #1 said she held on to her sheets tightly as he tried to pull them off. R #1 said as she began to sit up, the male resident hit her in the face twice using his closed right fist. R #1 said she fell back on the bed when she got hit. R #1 said she pushed him with her walker and kicked him in his groin. R #1 said after that, she stood up and began to walk forward when he cornered her to the wall and hit her again on her left shoulder, using his closed fist. R #1 said she bit R #2's hand just before someone came into the room and escorted R #2 out. R #1 said her left eye, left temple, and right temple hurt. Further inspection of R #1's face revealed she had a slight raised area to her right temporal region. R #1 also complained of pain to her left shoulder. R #1 said she felt drunk from lack of sleep because she did not sleep well at night. When asked why she did not sleep well, R #1 said she was afraid the man was going to come back and hurt her again. R #1 said she hated that man for hitting her and was afraid of him. R #1 said the man continued to live in the facility because she was told the man had a right to live there. R #1 could not recall who or when she was told that. R #1 said she wanted her curtain pulled all the way around her bed so He don't see me when he is walking back and forth. Record review of R #1's Comprehensive Care Plan revised 04/06/20 documented The resident is/has potential to be physically aggressive related to dementia and depression. Due to resident's past history from family, resident has some issues with men. Can become aggressive with staff and at times other residents Interventions: Analyze times of day, places, circumstances, triggers, de-escalating behavior and document; Anticipate resident needs; Provide physical and verbal cues to alleviate anxiety. This revision of R #1's care plan was completed by the facility after the surveyor had started the investigation, while the survey was in progress. In an interview with the DON on 04/07/20 at 10:40 AM, she said R #1 did not have any other revisions to her care plan that specifically addressed effective interventions to prevent further behaviors, prior to the revision on 4/6/20. Observation of R #1 on 04/07/20 at 10:20 AM revealed she sat on the couch in the secured unit's common area, behind R #2. Both R #1 and R #2 kept to themselves and watched television. At 10:24 AM, R #2 stood up and ambulated down the hallway towards his room. R #1 continuously stared at R #2 until R #2 was no longer in sight. R #2: Record review of R #2's Face Sheet dated 04/06/20 documented an [AGE] year-old male admitted [DATE] with the [DIAGNOSES REDACTED]. Record review of R #2's Admission Minimum (MDS) data set [DATE] documented he: - had minimal difficulty hearing and clear speech -had a brief interview of mental status score of 4- severely impaired -had inattentive fluctuating behavior -required limited assistance for bed mobility; extensive assistance with one-person physical assist for transfers, dressing, toilet use, and personal hygiene. Record review of R #2's Comprehensive Care Plan dated 03/03/20 documented: -The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits - The resident has an ADL self-care performance deficit r/t dementia . - The resident has a behavior problem (R #2) will urinate where ever he can. Corners trash cans closets and other residents' rooms. (R #2) is to be monitored when up and ambulating . - The resident is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities . - The resident has impaired cognitive function/dementia or impaired thought processes r/t altered cognitive status . Record review of R #2's Nursing Progress Notes and Change of Condition Communication Form dated 03/15/20 documented 10:53 PM - SN notified by CNA resident was physical towards another resident (R #1) and then received physical aggression. Upon entering the secured unit resident was observed standing in the living/common area. SN approached resident and asked resident to see his right hand. upon further assessment resident was observed with discoloration/bruising. SN asked resident what happened and resident unable to verbalize. SN asked resident if he was in any pain and resident stated no. SN then assisted resident back to his room, assisted with toileting needs, and assisted resident to bed . resident remains in bed at this time. Safety maintained. DON notified, RP notified, no concerns at this time. On call for (physician) was notified new order for UA (urine) C&S (culture & sensitivity) and (lab). Oncoming 10-6 nurse aware of new orders. Orders have been transcribed, lab slip placed in binder. SN placed resident on 72- hour critical behavior monitoring, will continue to monitor. There was no documentation of any interventions put in place to prevent incident re-occurrence or protection. Record review of R #2's Acute Care Plan dated 03/15/20 documented Behavior - Problem: Physical aggression/combativeness related to unknown .Approach: Reorient and redirect to self; Notify MD/RP of any changes in behavior; 72-hour behavior monitoring. The care plan did not include any interventions in attempt to prevent incidents of physical aggression from re-occurring or what actions to implement should the aggression occur again. Record review of R #2's Nursing Progress Notes dated 03/16/20 documented 5:24 PM - resident 24-hour follow up behavior. Resident observed walking throughout hallway no s/s of pain. No s/s of anxiety or distress. Safety has been maintained. Resident remains on 72-hour critical behavior monitoring, will continue to monitor. Record review of R #2's Nursing Progress Notes and Change in Condition Communication Form dated 03/27/20 documented 8:50 PM - SN notified by CNA at approx. 4:30 PM that resident was physically aggressive towards another resident (R #1). Upon entering 500 hall, resident was observed sitting at desk at the end of the hall eating his dinner. Resident observed with no s/s of anxiety/distress or pain/discomfort. SN assessed resident and no injuries were present .CNA stated that she saw resident walking down hall towards dining area while assisting another resident in her room and when she entered dining area resident was physically hitting another resident (R #1), CNA stated that she witnessed him hit (R #1) twice on her temple and side of the eye and she immediately separated the two and called for assistance of other CNA and notified SN. SN initiated 72-hr. critical behavior monitoring hourly. Nurse Practitioner (NP) was notified and new order for [MEDICATION NAME] 0.5 mg every 12hrs. PRN x2weeks was received. SN transcribed order and faxed it over to pharmacy. new order also received to have (psychological) services evaluate and treat . DON notified of incident and all new orders. RP was also notified, no concerns at this time. Safety has been maintained. Will continue to monitor. Record review of R #2's clinical record including physician's orders [REDACTED]. Record review of R #2's Accident Investigation Report - Witness Interview documented by CNA B dated 03/27/20 documented A physical altercation between (R #1) and (R #2). I was assisting a resident in her room when I heard (R #1) yelling. I ran out and saw (R #2) punching (R #1) twice near her temple and eye. I stepped between them and (R #2) grabbed my hand as I stopped (R #2) from hitting (R #1). R #2 was staring at (R #1) intently. I had to yell to get his attention. He let go of my hand and I walked him away from (R #1) who was calling (R #2) names. Record review of R #2's Nursing Progress Notes dated 03/28/20 documented 10:14 AM - 24-hour follow up physical aggression initiated. Resident continues with agitation at beginning of shift, SN administered prn medication for anxiety. Resident redirected, resident with SN at nurses' station reading magazines and drinking coffee. Resident calm, no anxiety observed . Observation of R #2 on 04/06/20 beginning at 10:21 AM, revealed he independently ambulated back and forth in the hallway, the same hallway R #1's room was located. In an interview with R #2 on 04/06/20 at 11:45 AM, he correctly stated his name. R #2 was not able to correctly state the day/time or place. R #2 said he was well taken care of and did not have issues or feared anyone in the facility. R #2 denied getting into any verbal or physical confrontations with anyone in the facility. In an interview with CNA A on 04/06/20 at 4:05 PM, she stated On 03/15/20 after dinner, (R #1) said she was going to her room to get ready to go to bed. CNA A said (R #2) had already been agitated that afternoon. CNA A explained she was documenting on the tracker when she heard thumps. CNA A said the tracker was located approximately a couple of feet adjacent to R #1's room. CNA A stated she went to find where the thump came from and heard some voices coming from R #1's room. CNA A said she walked into R #1's room and saw R #2 had R #1 pinned between the wall and the closet and he was hitting her with his right hand, closed fist on her right shoulder. CNA A said R #1 was trying to block R #2's hits. CNA A stated she immediately intervened and blocked some of the punches. CNA A explained CNA B was in the shower room and Licensed Vocational Nurse (LVN) C was working the other hall when the incident happened. CNA A said R #2 made a comment a couple of hours earlier before the incident happened, saying That son of a b**** needs to be hit, referring to R #1. CNA A said the next day on 03/16/20, R #1 had bruising on her left shoulder and stated R #2 punched R #1 on her left shoulder and that he choked her. CNA A said she never saw R #2 choking R #1 but the following day she had bruise marks on her neck. I felt bad for her. (There was no documentation of bruising to R #1's neck in R #1's clinical record). CNA A said she did not inform a nurse of R #1's neck bruising because she thought the nurse already saw it when she assessed R #1. CNA A stated they were told to ensure both residents avoided contact with each other, which was difficult because it was a small area. CNA A also said they were told to monitor their (R #1 and R #2's) behaviors. CNA A said R #1 had a bruise to her left eye from a fall she had prior to the assault from R #2 however, R #1's left eye bruising worsened and grew in size. CNA A said on 03/27/20, prior to 9:00 AM, she was in the bathroom and when she arrived at the scene, she saw R #1 upset, sitting on the couch. CNA A said CNA B told her she witnessed R #2 punch R #1 on the face a couple of times. When asked if she was aware if R #2 had hit or hurt any other resident, CNA A said on 03/15/20, prior to R #2 hitting R #1 in her bedroom, she witnessed R #2 hit R #3 on her back while CNA A was escorting R #3 to the common area. CNA A said she redirected R #2 which was successful. CNA A said R #3 denied any discomfort. CNA A said she told LVN C of the incident but did not report the incident to the Abuse Coordinator. Record review of R #3's nursing progress notes and incident/accident reports dated 03/2020 revealed no documented incident of R #2 hitting R #3. In an interview with CNA B on 04/06/20 at 5:07 PM, she said on 03/15/20, she worked in the secured unit but did not witness the incident involving R #1 and R #2 because she was in the shower room. CNA B said CNA A told her that R #2 went to R #1's room and punched her on the shoulders. CNA B said R #1 stated that she bit R #2's hand. CNA B said before R #1 and R #2 got into the altercation, they kept staring at each other throughout the day and she recalled R #2 made a comment saying, That son of a b**** needed to be hit. CNA B said R #2 was staring at R #1 when he made the comment. CNA B said on 03/27/20, she was in a room helping another resident while CNA A went on break. CNA B said she was the only staff in the secured unit when she saw R #2 push a television tray and was pushing it down the hallway. CNA B said she suddenly heard R #1 yelling at R #2 and found both residents in the back area and witnessed R #2 hit R #1 twice on the left side of her face with his closed hand. CNA B said R #1 was also trying to hit R #2 but was unsuccessful because CNA B's arm was in the way and the television tray was between the two residents keeping R #1 from being within R #2's reach. CNA B said she grabbed R #2's hands and R #2 held on to her wrists. CNA B said she could not re-direct R #2 until she yelled his name loudly. CNA B said she told R #2 he was hurting her and he replied he was sorry for hurting her hand. CNA B stated R #2 seemed to think everyone in the unit was a man and sometimes referred to the unit as the barracks. CNA B said R #2 frequently confused R #1 as a man. CNA B said sometimes R #1 would instigate things such as stand in front of R #2 or she would say a comment towards him. CNA B said R #1 seemed to have anger towards R #2 because she remembers him hitting her. When asked what interventions she had been trained to implement when R #1 or R #2 display their behaviors, CNA B said We just re-direct. Interview with SW on 04/07/20 at 10:05 AM revealed she was informed of R #1 and R #2's physical altercations during the morning meetings. The SW said she spoke to the nurse and reviewed the nursing notes about the incidents. The SW said she had a basic conversation with both residents after the second incident. When asked to explain what a basic conversation meant, the SW said she asked each one if they were okay, if everything was okay and they both seemed fine. I just asked how they were feeling and if anything was wrong, the conversation did not go very far with either one of them. When asked if she spoke to R #1 and R #2 about the incidents and their feelings regarding the incident and each other, the SW said There was no conversation about the actual altercations. I asked if they were doing okay this morning and feeling alright, I did not ask them if they were comfortable or if they were fearful because I did not want to put that into their head. We felt (R #2) was a trigger for (R #1) which agitated (R #1) and showed aggression. I've seen her since the incident and she did not seem fearful or reserved. No, I did not specifically ask her how she felt about R #2 or if she feared anyone. At 10:20 AM, the SW and the surveyor visited R #1 in her room. The SW stated she did not understand Spanish and R #1 was primarily Spanish speaking. The SW asked CNA E to translate for her. When asked how she received her facial bruising, R #1 said A man (pointing to the hallway) that is over there hit me with his hand. His hand was closed (Resident demonstrated a closed fist). I feel very angry that he did that because no man should hit a woman. I feel angry and with disconfianza (distrust) and (am) scared. R #1 said the staff removed the male resident away from her and got mad at him for hitting her but he's still here. Observation of R #2 on 04/07/20 at 10:25 AM while the surveyor exited R #1's room revealed R #2 wandered throughout the secured unit hallway walking back and forth, past R#1's room each time. In an interview with the SW on 04/07/20 at 10:26 AM, she said she was not aware of R #1's feelings of anger, distrust and fear. In an interview with LVN C on 04/07/20 at 12:18 PM, she said she did not recall being told of R #2 hitting any another resident other than R #1. In an interview with the DON on 04/07/20 at 10:40 AM, when asked if R #1 and R #2's altercations were reported to the State agency, the DON said It was not reported to the stat (TRUNCATED)

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibited and prevented the abuse of residents for one Resident (R#1) of three residents reviewed for abuse, in that: 1. The facility failed to develop and implement effective interventions to address R #2's physically aggressive behaviors after R #2 physically assaulted R #1 on 03/15/20 and then again on 03/27/20. R #1 was punched on the shoulder and/or face on two separate occasions by R #2, sustaining pain to her left shoulder, which required an x-ray. R #1 sustained pain to her shoulder and facial bruising to the left side of her face. R #1 stated and displayed signs of being fearful of R #2. 2. The facility failed to develop and implement effective interventions to address R #1's behaviors, such as provocation, physical aggression, and resistance to care. 3. The facility failed to identify R #2's two separate acts of physical aggression towards R #1 as acts of abuse, instead, the facility identified the acts as behaviors. 4. The Administrator, who was the Abuse Coordinator did not identify R #2 punching R #1 on 03/15/20 and then again on 03/27/20 as abuse therefore, the incidents were not reported as acts of abuse. The Abuse Coordinator did not thoroughly investigate the first incident and missed the identification of R #1's fear of and anger for R #2, and a second incident of physical abuse towards R #1 occurred. 5. The facility failed to protect R #1, allowing R #2 ongoing access to R #1. R #1 expressed changes in behavior of increased agitation, aggression, and provocation whenever R #2 was in sight. 6. The facility failed to assess R #1's psychosocial effects after she was the recipient of two separate incidents of physical abuse and allowed the perpetrator, R #2, to remain in the near vicinity of R #1. An Immediate Jeopardy (IJ) situation was identified 04/07/20. While the IJ was removed on 04/09/20 at 4:42 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices of the facility's failure to implement their policy and procedures to intervene after abusive incidents could result in further abuse and injury. The findings included: Record review of the facility's Abuse Prevention Program: Policy Statement dated September 2018 documented: Our residents have the right to be free from abuse, neglect, misappropriation of residents' property, corporal punishment and involuntary seclusion. 1. Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to: employees, other residents, consultants, volunteers, agents or power of attorney, and or staff from other agencies providing services to our residents, family members, legal guardians, surrogates, resident responsible parties, friends, visitors, or any other individual. The Administrator is overall responsible for all the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Our facility will protect residents from harm during investigations of alleged abuse. 1. During investigations of alleged abuse, residents will be protected from harm by the following measures: .c. If alleged abuse involves another resident, the accused resident's representative and attending physician will be informed of the alleged abuse incident and that there may be restrictions on the accused ability to visit other resident's rooms unattended. If necessary, the accused resident's family members may be required to help meet this requirement. 2. Appropriate authorities will be notified of the investigation. Please refer to the policy Reporting Abuse to State Agencies and Other Entities. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Mental abuse is defined as, but is not limited to humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . 9. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and or Director of Nursing Services must be called at home or must be paged and informed of such incident. 10. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred . 11. Upon receiving reports of physical abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. The person performing the examination must document the findings in the medical record and obtain a written, signed, and dated statement from the person reporting the incident. 12. A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. 13. Upon receiving information concerning a report of abuse, the Director of Nursing Services will request that a representative of the Social Services Department monitor the resident's reactions to and statements regarding the incident and his/her involvement in the investigation. Reporting Abuse to State Agencies and Other Entities: All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. 1. Should a suspected violation or substantiated incident of neglect, injuries of an unknown source, or abuse (including resident to resident abuse), misappropriation of resident property be reported the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally or written) of such incident: a. The State Licensing/Certification Agency responsible for surveying/licensing the facility b. The local/state ombudsman c. The resident representative of record d. Law enforcement officials when a crime is suspected to have occurred e. The resident's attending physician f. The facility medical director g. Other agencies as needed . 3. Should a suspected crime resulting in serious bodily injury, the employee shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. 4. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident . Abuse Investigations: All reports of alleged resident abuse, neglect, misappropriation of resident property and injuries of unknown source shall be promptly and thoroughly investigated by facility management . 2. The individual conducting the investigation will, as a minimum: a. Review the resident's medical record to determine events leading up to the alleged incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; d. Interview the resident (as medically appropriate); e. Interview the resident's attending physician as needed to determine the resident's current level of cognition function and medical condition; f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members, and visitors; h. Interview other residents with whom the individual provides care or services and/or interacts; and i. Review all events leading up to the alleged incident . Record review of R #1's Face Sheet dated 04/06/20 documented a [AGE] year-old female admitted [DATE] with the [DIAGNOSES REDACTED]. Record review of R #1's Comprehensive Care Plan dated 01/20/20 documented: -(R #1) is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) cognitive deficits . -(R #1) is an elopement risk/wanderer r/t history of attempts to leave facility unattended, Impaired safety awareness, resident wanders aimlessly -(R #1) resides in the secure unit due to wandering, she is new to facility and has been packing and unpacking belongings . -(R #1) has impaired cognitive function/dementia or impaired thought processes r/t dementia -(R #1) uses antidepressant medication r/t poor adjustment to admission [MEDICATION NAME] and [MEDICATION NAME] PATCH . The resident uses anti-anxiety medications ([MEDICATION NAME]) r/t anxiety disorder . The resident uses antipsychotic medications [MEDICATION NAME] . Monitor/record occurrence of/for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. Record review of R #1's Quarterly Minimum (MDS) data set [DATE] documented she: -had adequate hearing and clear speech -understood others and made self-understood -had a brief interview of mental status score of 4-severely impaired -required supervision for bed mobility, transfers, dressing, and limited assistance for personal care -had physical behavioral symptoms towards others and other behavioral symptoms not towards others that occurred 1-3 days. Record review of R #1's Nursing Progress Notes and Change in Condition Communication Form dated 03/15/20 documented 10:16 PM- SN (Skilled Nurse) notified by CNA (Certified Nurse Aide) that resident received physical aggression and was physical towards another resident (R #2). Upon entering the secured unit SN was informed that resident was in her room. Upon entering resident's room, she was observed sitting on her bed. SN asked resident what happened, and she stated (she) and another resident (R #2) were arguing when he hit her on her shoulder and she then bit his hand. SN asked resident if she had any pain and resident denied. SN assessed both of resident's shoulders and no redness or discoloration was observed. Vitals were . SN notified DON (Director of Nurses), RP (Responsible Party), and MD (Medical Doctor). No new orders received from MD. RP aware and no concerns at this time. SN placed resident on 72-hour (hr) critical behavior monitoring every hour. Resident remains in her room. Safety has been maintained, will continue to monitor. Record review of R #1's Incident/Accident Report dated 03/15/20 documented 10:30 PM- SN notified by CNA that resident received physical aggression and was physical towards another resident. Upon entering the secured unit SN was informed that resident was in her room. Upon entering resident's room, she was observed sitting on her bed. SN asked resident what happened, and she stated she and another resident (R #2) were arguing when he hit her on her shoulder, she then bit his hand. SN asked resident if she had any pain and resident denied. SN assessed both of resident's shoulders and no redness or discoloration was observed . SN notified DON, RP, and MD. No new orders received from MD. RP aware and no concerns at this time. SN placed resident on 72-hour critical behavior monitoring every hour. Resident remains in her room. Safety has been maintained. Will continue to monitor. Residents separated. Resident assessed, all appropriate parties notified. Upon investigation this resident was observed in her room sitting on her bed. Resident noted to be upset saying a man hit her on her shoulder and she bit him back. Noted bilateral shoulders with redness, bruising at present. Shoulders will be monitored. Resident denies being fearful of other resident at present. CNA will help separate and continue to monitor for further behaviors. Resident offered pain medicine. RP and MD notified of incident. Behavior monitoring for residents hourly X 72 hours. In an interview with CNA A on 04/06/20 at 4:05 PM, she stated the day following the incident (03/16/20), R #1 told her she was afraid of R #2, she (R #1) said she did not want him around. CNA A said R #1 put a chair and wheelchair to block the doorway to her room to keep him from coming in the room. CNA A said she (R #1) stayed distant, she stayed in her room for a couple of days behind the privacy curtain. CNA A stated, She did not want to be next to him (R #2) at all. Then a couple of days later she would constantly follow (R #2) with her eyes and purposely walk in front of (R #2), staring him down. Record review of R #1's Acute Care Plan dated 03/15/20 documented Behavior - Problem: Physical aggression/combativeness related to unknown .Approach: Reorient and redirect to self; Notify MD/RP of any changes in behavior; one-hour behavior monitoring for 72 hours. The care plan did not include any interventions in attempt to prevent incidents of physical aggression from re-occurring or what actions to implement should the aggression occur again. Record review of R #1's Nursing Progress Notes dated 03/18/20 documented 1:24 PM - 72-hour behavior (monitoring). Resident, this 6-2pm shift not having aggressive behaviors. SN placed call to daughter regarding approx. 1in. x 1in. discoloration to left shoulder . Resident at this time is able to perform full range of motion in all extremities with no non-verbal signs of pain nor is pain verbalized. Resident able to make needs known. Behavioral monitoring continued. Record review of R #1's left shoulder x-ray result, for a [DIAGNOSES REDACTED].#1 did not have a fracture. Record review of R #1's Nursing Progress Notes dated 03/20/20 documented 5:00 PM - SN observed resident being verbally aggressive towards male resident (R #2) in secure unit. Upon assessing resident, resident stated she knows male resident from years before and she doesn't like him. SN provided redirection and monitoring. SN notified MD for hyper fixating on male resident. New orders received for Trazadone 25mg tid (three times a day). SN notified RP, will continue to monitor. Record review of R #1's Nursing Progress Notes dated 03/23/20 documented 3:51 PM - Par meeting held IDT (interdisciplinary team)-Res had combative behaviors throughout the day with staff care at intervals. New onset of resisting care. Res was not easily redirected . Record review of R #1's Social Services Progress Note dated 03/24/20 documented 2:50 PM - Resident with recent changes in behavior including increased agitation. Current precautions in place in this facility are restricting visitors and resulting in some disruption to (R #1's) daily routine. Will continue to monitor and offer support as needed. This note documented changes in behavior with increased agitation but did not address R #1's psychosocial needs, her fear or her feelings towards her aggressor (R #2). Record review revealed there was no Social Services note regarding the 03/15/2020 altercation with another resident. In an interview with the Social Worker (SW) on 04/07/20 at 10:05 AM she said the IDT did not further explore or investigate R #1's increased agitation and resisting of care. The SW said R #1's behaviors could have been a result of R #2 being within her line of sight, possibly being fearful and angry at R #2 for punching her. Record review of R #1's Nursing Progress Notes dated 03/26/20 documented 1:37 PM - resident continues with agitation and verbal aggression towards other residents in the unit. Resident believes another male resident is after her, unable to redirect due to impaired cognition. Resident continues with delusions, resident closely monitored, SN notified md of current behavior. Pending response at this time, RP notified, will continue to monitor. Record review of R #1's Nursing Progress Notes dated 03/26/20 documented 2:04 PM - new orders from (physician) received to decrease PRN [MEDICATION NAME] to 0.5mg prn every 6 hours and to increase Trazadone to 50 mg tid. SN notified RP. Will continue to monitor. Record review of R #1's Nursing Progress Notes and Change in Condition Communication Form dated 03/27/20 documented 9:42 PM - SN notified by CNA that resident had received physical aggression from another resident. Upon assessment resident was observed sitting in chair in her bedroom. SN assessed resident and observed a hematoma to the top of her left eyebrow. Resident noted with bruising/discoloration from fall that previously happened. Resident verbalized pain to area and PRN Tylenol was administered. SN asked resident what happened, and she stated she was hit in the face. CNA stated that she witnessed another resident (R #2) hit (R #1) twice on her temple and side of the eye and she immediately separated the two and called for assistance of other CNA and notified SN. Upon assessment, no other injuries were apparent. Vitals at the time of incident were . SN notified (physician) and no new orders. DON was notified. RP notified, no concerns or issues at this time. SN initiated 72-hour critical behavior monitoring hourly, and neuro checks x72 hours. Resident remained in room, safety maintained, will continue to monitor. Record review of R #1's Incident/Accident Report dated 03/27/20 documented 9:30 PM - .SN asked resident what happened, and she stated she was hit in the face. Upon investigation this resident was observed by CNA being hit on the left eye by another resident. Residents were both separated immediately. This resident (R #1) resides on the dementia unit and is able to state what occurred, oriented X1. Ice pack applied, and neuro checks were monitored. Prior to this incident resident had sustained a fall and noted with bruising discoloration to left side of eye (fall occurred on 03/20/20) RP and MD notified of incident. PRN adjustment for physical aggression, on 03/26/20 with new order for [MEDICATION NAME] 0.5 mg PRN (as needed) every 6 hours. Will continue to monitor. Resident denies being fearful of other resident at this time. After resident's family gave consent, resident was trialed outside the unit as an intervention. She did well for 4 hours then resident was observed ambulating down the hallway asking for way out of the facility. Resident required redirection but asked a second time how to get out of the building. Was then assisted back to the unit for safety. Due to recent restrictions related to COVID-19 resident is not a candidate to be out of the unit or for transfer to another facility and family cannot care for her at home at this time. Record review of R #1's Accident Investigation Report - Witness Interview documented by CNA B dated 03/27/20 documented A physical altercation between (R #1) and (R #2). I was assisting a resident in her room when I heard yelling. I ran out and saw (R #2) punching (R #1) twice, once near her temple and again her eye. I stepped between them and (R #2) grabbed my hand. He would not respond to his name and was intently staring at (R #1). I yelled his name loudly and he asked me who I was. I told him my name and that he was hurting me. He immediately let go of my hand and said he was sorry. Record review of R #1's Nursing Progress Notes dated 03/28/20 documented 10:24 AM - 24 hour follow up physical aggression received, resident stable, no s/s of distress, resident continues with contusion to left upper brow and temple. Resident medicated with prn pain medication for complaints of general pain. Resident alert, watching tv in common room, will continue to monitor . The 03/27/20 incident was the second incident of abuse, there was no documentation of any other interventions to protect R #1 from R #2, other than will continue to monitor. Record review of R #1's Nursing Progress Notes dated 03/30/20 documented 10:41 AM - 72-hour behavior monitoring. Patient is alert with discoloration to the left eye. Patient voiced that she has pain to the site. Ice pack and PRN medication administered. No signs of aggressive behaviors or fearful behavior noted. Record review of R #1's Physician order [REDACTED]. Observation of R #1 on 04/06/20 at 10:19 AM revealed she had purple discoloration beneath her left eye, on her left temple, down to her left cheek. R #1 was sitting in a chair in the common area of the secured unit watching television. At 10:21 AM, CNA D asked R #1 if she would like to go to the bathroom, R #1 said yes, and she ambulated to her room using a rolling walker. R #1 walked out of the bathroom and ambulated to her bed and sat on the edge of her bed. The privacy curtain was pulled around R #1's bed. R #1 frequently looked around the privacy curtain towards the hallway. When asked what R #1 was looking for, R #1 said Ese viejo (that man). Record review of R #1's Nursing Progress Notes dated 04/03/20 documented 11:44 AM - notified RP for resident (R #1) aggressive behavior towards male resident (R #2). Resident was observed attempting to hit resident (R #2) with walker. Male resident was not engaged in any behavior prior to resident's aggression. SN separated residents, will continue to monitor. There was no evidence the facility took any further action other than resident separation. Interview with R #1 on 04/06/20 at 10:26 AM revealed she was alert to self, able to correctly state her name, stating she was not in her home but was unable to state her current location and time. R #1 was sitting on the edge of her bed with the privacy curtain pulled all the way around her bed. R #1 stated she was hit by a male resident, whom the only description she gave was a white man with no teeth. R #1 stated the male resident entered her room when it was still somewhat dark outside since she could see outside her window. R #1 said she was lying down on her right side, in bed, when the male resident entered her room and began pulling down her bed sheets. R #1 stated she yelled at him to leave her room and he kept telling her Shhh and called her Mammacita. R #1 said she held on to her sheets tightly as he tried to pull them off. R #1 said as she began to sit up, the male resident hit her in the face twice using his closed right fist. R #1 said she fell back on the bed when she got hit. R #1 said she pushed him with her walker and kicked him in his groin. R #1 said after that, she stood up and began to walk forward when he cornered her to the wall and hit her again on her left shoulder, using his closed fist. R #1 said she bit R #2's hand just before someone came into the room and escorted R #2 out. R #1 said her left eye, left temple, and right temple hurt. Further inspection of R #1's face revealed she had a slight raised area to her right temporal region. R #1 also complained of pain to her left shoulder. R #1 said she felt drunk from lack of sleep because she did not sleep well at night. When asked why she did not sleep well, R #1 said she was afraid the man was going to come back and hurt her again. R #1 said she hated that man for hitting her and was afraid of him. R #1 said the man continued to live in the facility because she was told the man had a right to live there. R #1 could not recall who or when she was told that. R #1 said she wanted her curtain pulled all the way around her bed so He don't see me when he is walking back and forth. Record review of R #1's Comprehensive Care Plan revised 04/06/20 documented The resident is/has potential to be physically aggressive related to dementia and depression. Due to resident's past history from family, resident has some issues with men. Can become aggressive with staff and at times other residents Interventions: Analyze times of day, places, circumstances, triggers, de-escalating behavior and document; Anticipate resident needs; Provide physical and verbal cues to alleviate anxiety. This care plan revision was done after the surveyor began the investigation, when the survey was in progress. In an interview with the DON on 04/07/20 at 10:40 AM, she said R #1 did not have any other revisions to her care plan that specifically addressed effective interventions to prevent further behaviors. Observation of R #1 on 04/07/20 at 10:20 AM revealed she sat on the couch in the secured unit's common area, behind R #2. Both R #1 and R #2 kept to themselves and watched television. At 10:24 AM, R #2 stood up and ambulated down the hallway towards his room. R #1 continuously stared at R #2 until R #2 was no longer in sight. R #2: Record review of R #2's Face Sheet dated 04/06/20 documented an [AGE] year-old male admitted [DATE] with the [DIAGNOSES REDACTED]. Record review of R #2's Admission Minimum (MDS) data set [DATE] documented he: - had minimal difficulty hearing and clear speech -had a brief interview of mental status score of 4- severely impaired -had inattentive fluctuating behavior -required limited assistance for bed mobility; extensive assistance with one-person physical assist for transfers, dressing, toilet use, and personal hygiene. Record review of R #2's Comprehensive Care Plan dated 03/03/20 documented: -The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits - The resident has an ADL self-care performance deficit r/t dementia . - The resident has a behavior problem (R #2) will urinate where ever he can. Corners trash cans closets and other residents' rooms. (R #2) is to be monitored when up and ambulating . - The resident is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities . - The resident has impaired cognitive function/dementia or impaired thought processes r/t altered cognitive status . Record review of R #2's Nursing Progress Notes and Change of Condition Communication Form dated 03/15/20 documented 10:53 PM - SN notified by CNA resident was physical towards another resident (R #1) and then received physical aggression. Upon entering the secured unit resident was observed standing in the living/common area. SN approached resident and asked resident to see his right hand. upon further assessment resident was observed with discoloration/bruising. SN asked resident what happened and resident unable to verbalize. SN asked resident if he was in any pain and resident stated no. SN then assisted resident back to his room, assisted with toileting needs, and assisted resident to bed . resident remains in bed at this time. Safety maintained. DON notified, RP notified, no concerns at this time. On call for (physician) was notified new order for UA (urine) C&S (culture & sensitivity) and (lab). Oncoming 10-6 nurse aware of new orders. Orders have been transcribed, lab slip placed in binder. SN placed resident on 72- hour critical behavior monitoring, will continue to monitor. There was no documentation of any interventions put in place to prevent incident re-occurrence or protection. Record review of R #2's Acute Care Plan dated 03/15/20 documented Behavior - Problem: Physical aggression/combativeness related to unknown .Approach: Reorient and redirect to self; Notify MD/RP of any changes in behavior; 72-hour behavior monitoring. The care plan did not include any interventions in attempt to prevent incidents of physical aggression from re-occurring or what actions to implement should the aggression occur again. Record review of R #2's Nursing Progress Notes dated 03/16/20 documented 5:24 PM - resident 24-hour follow up behavior. Resident observed walking throughout hallway no s/s of pain. No s/s of anxiety or distress. Safety has been maintained. Resident remains on 72-hour critical behavior monitoring, will continue to monitor. Record review of R #2's Nursing Progress Notes and Change in Condition Communication Form dated 03/27/20 documented 8:50 PM - SN notified by CNA at approx. 4:30 PM that resident was physically aggressive towards another resident (R #1). Upon entering 500 hall, resident was observed sitting at desk at the end of the hall eating his dinner. Resident observed with no s/s of anxiety/distress or pain/discomfort. SN assessed resident and no injuries were present .CNA stated that she saw resident walking down hall towards dining area while assisting another resident in her room and when she entered dining area resident was physically hitting another resident (R #1), CNA stated that she witnessed him hit (R #1) twice on her temple and side of the eye and she immediately separated the two and called for assistance of other CNA and notified SN. SN initiated 72-hr. critical behavior monitoring hourly. Nurse Practitioner (NP) was notified and new order for [MEDICATION NAME] 0.5 mg every 12hrs. PRN x2weeks was received. SN transcribed order and faxed it over to pharmacy. New order also received to have (psychological) services evaluate and treat . DON notified of incident and all new orders. RP was also notified, no concerns at this time. Safety has been maintained. Will continue to monitor. Record review of R #2's clinical record including physician's orders [REDACTED]. Record review of R #2's Accident Investigation Report - Witness Interview documented by CNA B dated 03/27/20 documented A physical altercation between (R #1) and (R #2). I was assisting a resident in her room when I heard (R #1) yelling. I ran out and saw (R #2) punching (R #1) twice near her temple and eye. I stepped between them and (R #2) grabbed my hand as I stopped (R #2) from hitting (R #1). R #2 was staring at (R #1) intently. I had to yell to get his attention. He let go of my hand and I walked him away from (R #1) who was calling (R #2) names. Record review of R #2's Nursing Progress Notes dated 03/28/20 documented 10:14 AM - 24-hour follow up physical aggression initiated. Resident continues with agitation at beginning of shift, SN administered prn medication for anxiety. Resident redirected, resident with SN at nurses' station reading magazines and drinking coffee. Resident calm, no anxiety observed . Observation of R #2 on 04/06/20 beginning at 10:21 AM, revealed he independently ambulated back and forth in the hallway, the same hallway R #1's room was located. In an interview with R #2 on 04/06/20 at 11:45 AM, he correctly stated his name. R #2 was not able to correctly state the day/time or place. R #2 said he was well taken care of and did not have issues or feared anyone in the facility. R #2 denied getting into any verbal or physical confrontations with anyone in the facility. In an interview with CNA A on 04/06/20 at 4:05 PM, she stated On 03/15/20 after dinner, (R #1) said she was going to her room to get ready to go to bed. CNA A said (R #2) had already been agitated that afternoon. CNA A explained she was documenting on the tracker when she heard thumps. CNA A said the tracker was located approximately a couple of feet adjacent to R #1's room. CNA A stated she went to find where the thump came from and heard some voices coming from R #1's room. CNA A said she walked into R #1's room and saw R #2 had R #1 pinned between the wall and the closet and he was hitting her with his right hand, closed fist on her right shoulder. CNA A said R #1 was trying to block R #2's hits. CNA A stated she immediately intervened and blocked some of the punches. CNA A explained CN(TRUNCATED)

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one Resident (R#1), of three residents reviewed for abuse, in that: The facility did not thoroughly investigate the first incident of physical abuse contributing to a second incident and the missed identification of R #1's fear and anger of R #2. R#1 was witnessed by staff to be punched in the face and torso by R #2, on two separate occasions. An Immediate Jeopardy (IJ) situation was identified 04/07/20. While the IJ was removed on 04/09/20 at 4:42 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems These deficient practices could affect residents residing in the secured unit and place them at risk of further abuse and delays in having their incidents investigated timely by the facility and for preventative interventions being put into place. The findings included: Record review of R #1's Face Sheet dated 04/06/20 documented a [AGE] year-old female admitted [DATE] with the [DIAGNOSES REDACTED]. Record review of R #1's Comprehensive Care Plan dated 01/20/20 documented: -(R #1) is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) cognitive deficits . -(R #1) is an elopement risk/wanderer r/t history of attempts to leave facility unattended, Impaired safety awareness, resident wanders aimlessly -(R #1) resides in the secure unit due to wandering, she is new to facility and has been packing and unpacking belongings . -(R #1) has impaired cognitive function/dementia or impaired thought processes r/t dementia -(R #1) uses antidepressant medication r/t poor adjustment to admission [MEDICATION NAME] and [MEDICATION NAME] PATCH . The resident uses anti-anxiety medications ([MEDICATION NAME]) r/t anxiety disorder . The resident uses antipsychotic medications [MEDICATION NAME] . Monitor/record occurrence of/for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. Record review of R #1's Quarterly Minimum (MDS) data set [DATE] documented she: -had adequate hearing and clear speech -understood others and made self-understood -had a brief interview of mental status score of 4-severely impaired -required supervision for bed mobility, transfers, dressing, and limited assistance for personal care -had physical behavioral symptoms towards others and other behavioral symptoms not towards others that occurred 1-3 days. Record review of R #1's Nursing Progress Notes and Change in Condition Communication Form dated 03/15/20 documented 10:16 PM- SN (Skilled Nurse) notified by CNA (Certified Nurse Aide) that resident received physical aggression and was physical towards another resident (R #2). Upon entering the secured unit SN was informed that resident was in her room. Upon entering resident's room, she was observed sitting on her bed. SN asked resident what happened, and she stated (she) and another resident were arguing when he hit her on her shoulder and she then bit him his hand. SN asked resident if she had any pain and resident denied. Sn assessed both of resident's shoulders and no redness or discoloration was observed. Vitals were . SN notified DON (Director of Nurses), RP (Responsible Party), and MD (Medical Doctor). No new orders received from MD. RP aware and no concerns at this time. SN placed resident on 72-hour (hr) critical behavior monitoring every hour. Resident remains in her room. Safety has been maintained, will continue to monitor. Record review of R #1's Incident/Accident Report dated 03/15/20 documented 10:30 PM- SN notified by CNA that resident received physical aggression and was physical towards another resident. Upon entering the secured unit SN was informed that resident was in her room. Upon entering resident's room, she was observed sitting on her bed. SN asked resident what happened, and she stated she and another resident (R #2) were arguing when he hit her on her shoulder, she then bit his hand. SN asked resident if she had any pain and resident denied. SN assessed both of resident's shoulders and no redness or discoloration was observed . SN notified DON, RP, and MD. No new orders received from MD. RP aware and no concerns at this time. SN placed resident on 72-hour critical behavior monitoring every hour. Resident remains in her room. Safety has been maintained. Will continue to monitor. Residents separated. Resident assessed, all appropriate parties notified. Upon investigation this resident was observed in her room sitting on her bed. Resident noted to be upset saying a man hit her on her shoulder and she bit him back. Noted bilateral shoulders with redness, bruising at present. Shoulders will be monitored. Resident denies being fearful of other resident at present. CNA will help separate and continue to monitor for further behaviors. Resident offered pain medicine. RP and MD notified of incident. Behavior monitoring for residents hourly X 72 hours. In an interview with CNA A on 04/06/20 at 4:05 PM, she stated the day following the incident (03/16/20), R #1 told her she was afraid of R #2, she (R #1) said she did not want him around. CNA A said R #1 put a chair and wheelchair to block the doorway to her room to keep him from coming in the room. CNA A said she (R #1) stayed distant, she stayed in her room for a couple of days behind the privacy curtain. She did not want to be next to him (R #2) at all. Then a couple of days later she would constantly follow (R #2) with her eyes and purposely walk in front of (R #2), staring him down. Record review of R #1's Acute Care Plan dated 03/15/20 documented Behavior - Problem: Physical aggression/combativeness related to unknown .Approach: Reorient and redirect to self; Notify MD/RP of any changes in behavior; one-hour behavior monitoring for 72 hours. The care plan did not include any interventions in attempt to prevent incidents of physical aggression from re-occurring or what actions to implement should the aggression occur again. Record review of R #1's Nursing Progress Notes dated 03/18/20 documented 1:24 PM - 72-hour behavior (monitoring). Resident, this 6-2pm shift not having aggressive behaviors. SN placed call to daughter regarding approx. 1in. x 1in. discoloration to left shoulder . Resident at this time is able to perform full range of motion in all extremities with no non-verbal signs of pain nor is pain verbalized. Resident able to make needs known. Behavioral monitoring continued. Record review of R #1's left shoulder x-ray result dated 03/18/20 revealed R #1 did not have a fracture. Record review of R #1's Nursing Progress Notes dated 03/23/20 documented 3:51 PM - Par meeting held IDT (interdisciplinary team)-Res had combative behaviors throughout the day with staff care at intervals. New onset of resisting care. Res was not easily redirected . Record review of R #1's Social Services Progress Note dated 03/24/20 documented 2:50 PM - Resident with recent changes in behavior including increased agitation. Current precautions in place in this facility are restricting visitors and resulting in some disruption to (R #1's) daily routine. Will continue to monitor and offer support as needed. This note documented changes in behavior with increased agitation but did not address R #1's psychosocial needs, her fear or her feelings towards her aggressor (R #2). Record review revealed there was no Social Services note regarding the 03/15/2020 altercation with another resident. Interview with Social Worker (SW) on 04/07/20 at 10:05 AM revealed she confirmed the IDT did not further explore or investigate R #1's increased agitation and resisting of care. The SW said R #1's behaviors could have been a result of R #2 being within her line of sight, possibly being fearful and angry at R #2 for punching her. Record review of R #1's Nursing Progress Notes dated 03/26/20 documented 1:37 PM - resident continues with agitation and verbal aggression towards other residents in the unit. Resident believes another male resident is after her, unable to redirect due to impaired cognition. Resident continues with delusions, resident closely monitored, SN notified MD of current behavior. Pending response at this time, RP notified, will continue to monitor. Record review of R #1's Nursing Progress Notes dated 03/26/20 documented 2:04 PM - new orders from (physician) received to decrease PRN [MEDICATION NAME] to 0.5mg prn every 6 hours and to increase Trazadone to 50 mg tid. SN notified RP. Will continue to monitor. Record review of R #1's Nursing Progress Notes and Change in Condition Communication Form dated 03/27/20 documented 9:42 PM - SN notified by CNA that resident had received physical aggression from another resident. Upon assessment resident was observed sitting in chair in her bedroom. SN assessed resident and observed a hematoma to the top of her left eyebrow. Resident noted with bruising/discoloration from fall that previously happened. Resident verbalized pain to area and PRN Tylenol was administered. SN asked resident what happened, and she stated she was hit in the face. CNA stated that she witnessed another resident (R #2) hit (R #1) twice on her temple and side of the eye and she immediately separated the two and called for assistance of other CNA and notified SN. Upon assessment, no other injuries were apparent. Vitals at the time of incident were . SN notified (physician) and no new orders. DON was notified. RP notified, no concerns or issues at this time. SN initiated 72-hour critical behavior monitoring hourly, and neuro checks x72 hours. Resident remained in room, safety maintained, will continue to monitor. Record review of R #1's Incident/Accident Report dated 03/27/20 documented 9:30 PM - .SN asked resident what happened, and she stated she was hit in the face. Upon investigation this resident was observed by CNA being hit on the left eye by another resident. Resident were both separated immediately. This resident resides on the dementia unit and is able to state what occurred, oriented X1. Ice pack applied, and neuro checks were monitored. Prior to this incident resident had sustained a fall and noted with bruising discoloration to left side of eye (fall occurred on 03/20/20) RP and MD notified of incident. PRN adjustment for physical aggression, on 03/26/20 with new order for [MEDICATION NAME] 0.5 mg PRN (as needed) every 6 hours. Will continue to monitor. Resident denies being fearful of other resident at this time. After resident's family gave consent, resident was trialed outside the unit as an intervention. She did well for 4 hours then resident was observed ambulating down the hallway asking for way out of the facility. Resident required redirection but asked a second time how to get out of the building. Was then assisted back to the unit for safety. Due to recent restrictions related to COVID-19 resident is not a candidate to be out of the unit or for transfer to another facility and family cannot care for her at home at this time. Record review of R #1's Accident Investigation Report - Witness Interview documented by CNA B dated 03/27/20 documented A physical altercation between (R #1) and (R #2). I was assisting a resident in her room when I heard yelling. I ran out and saw (R #2) punching (R #1) twice, once near her temple and again her eye. I stepped between them and (R #2) grabbed my hand. He would not respond to his name and was intently staring at (R #1). I yelled his name loudly and he asked me who I was. I told him my name and that he was hurting me. He immediately let go of my hand and said he was sorry. Record review of R #1's Nursing Progress Notes dated 03/28/20 documented 10:24 AM - 24-hour follow up physical aggression received, resident stable, no s/s of distress, resident continues with contusion to left upper brow and temple. Resident medicated with PRN pain medication for complaints of general pain. Resident alert, watching tv in common room, will continue to monitor . The 03/27/20 incident was the second incident of abuse, there was no documentation of any other interventions to protect R #1 from R #2, other than will continue to monitor. Record review of R #1's Nursing Progress Notes dated 03/30/20 documented 10:41 AM - 72-hour behavior monitoring. Patient is alert with discoloration to the left eye. Patient voiced that she has pain to the site. Ice pack and PRN medication administered. No signs of aggressive behaviors or fearful behavior noted. Record review of R #1's Physician order [REDACTED]. Observation of R #1 on 04/06/20 at 10:19 AM revealed she had purple discoloration beneath her left eye, on her left temple, down to her left cheek. R #1 was sitting in a chair in the common area of the secured unit watching television. At 10:21 AM, CNA D asked R #1 if she would like to go to the bathroom, R #1 said yes, and she ambulated to her room using a rolling walker. R #1 walked out of the bathroom and ambulated to her bed and sat on the edge of her bed. The privacy curtain was pulled around R #1's bed. R #1 frequently looked around the privacy curtain towards the hallway. When asked waht R #1 was loking for, R #1 said Ese viejo (that man). Record review of R #1's Nursing Progress Notes dated 04/03/20 documented 11:44 AM - notified RP for resident (R #1) aggressive behavior towards male resident (R #2). Resident was observed attempting to hit resident (R #2) with walker. Male resident was not engaged in any behavior prior to resident's aggression. SN separated residents, will continue to monitor. There was no evidence the facility took any further action other than resident separation. Interview with R #1 on 04/06/20 at 10:26 AM revealed she was alert to self, able to correctly state her name, stating she was not in her home but was unable to state her current location and time. R #1 was sitting on the edge of her bed with the privacy curtain pulled all the way around her bed. R #1 stated she was hit by a male resident, whom the only description she gave was a white man with no teeth. R #1 stated the male resident entered her room when it was still somewhat dark outside since she could see outside her window. R #1 said she was lying down on her right side, in bed, when the male resident entered her room and began pulling down her bed sheets. R #1 stated she yelled at him to leave her room and he kept telling her Shhh and called her Mammacita. R #1 said she held on to her sheets tightly as he tried to pull them off. R #1 said as she began to sit up, the male resident hit her in the face twice using his closed right fist. R #1 said she fell back on the bed when she got hit. R #1 said she pushed him with her walker and kicked him in his groin. R #1 said after that, she stood up and began to walk forward when he cornered her to the wall and hit her again on her left shoulder, using his closed fist. R #1 said she bit R #2's hand just before someone came into the room and escorted R #2 out. R #1 said her left eye, left temple, and right temple hurt. Further inspection of R #1's face revealed she had a slight raised area to her right temporal region. R #1 also complained of pain to her left shoulder. R #1 said she felt drunk from lack of sleep because she did not sleep well at night. When asked why she did not sleep well, R #1 said she was afraid the man was going to come back and hurt her again. R #1 said she hated that man for hitting her and was afraid of him. R #1 said the man continued to live in the facility because she was told the man had a right to live there. R #1 could not recall who or when she was told that. R #1 said she wanted her curtain pulled all the way around her bed so He don't see me when he is walking back and forth. Record review of R #1's Comprehensive Care Plan revised 04/06/20 documented The resident is/has potential to be physically aggressive related to dementia and depression. Due to resident's past history from family, resident has some issues with men. Can become aggressive with staff and at times other residents Interventions: Analyze times of day, places, circumstances, triggers, de-escalating behavior and document; Anticipate resident needs; Provide physical and verbal cues to alleviate anxiety. R #1's care plan was revised after surveyor started the investigation, when the survey was in progress. In an interview with the DON on 04/07/20 at 10:40 AM, she said R #1 did not have any other revisions to her care plan that specifically addressed effective interventions to prevent further behaviors, prior to the 4/6/20 revision. Observation of R #1 on 04/07/20 at 10:20 AM revealed she sat on the couch in the secured unit's common area, behind R #2. Both R #1 and R #2 kept to themselves and watched television. At 10:24 AM, R #2 stood up and ambulated down the hallway towards his room. R #1 continuously stared at R #2 until R #2 was no longer in sight. R #2: Record review of R #2's Face Sheet dated 04/06/20 documented an [AGE] year-old male admitted [DATE] with the [DIAGNOSES REDACTED]. Record review of R #2's Admission Minimum (MDS) data set [DATE] documented he: - had minimal difficulty hearing and clear speech -had a brief interview of mental status score of 4- severely impaired -had inattentive fluctuating behavior -required limited assistance for bed mobility; extensive assistance with one-person physical assist for transfers, dressing, toilet use, and personal hygiene. Record review of R #2's Comprehensive Care Plan dated 03/03/20 documented: -The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits - The resident has an ADL self-care performance deficit r/t dementia . - The resident has a behavior problem (R #2) will urinate where ever he can. Corners trash cans closets and other residents' rooms. (R #2) is to be monitored when up and ambulating . - The resident is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities . - The resident has impaired cognitive function/dementia or impaired thought processes r/t altered cognitive status . Record review of R #2's Nursing Progress Notes and Change of Condition Communication Form dated 03/15/20 documented 10:53 PM - SN notified by CNA resident was physical towards another resident (R #1) and then received physical aggression. Upon entering the secured unit resident was observed standing in the living/common area. SN approached resident and asked resident to see his right hand. upon further assessment resident was observed with discoloration/bruising. SN asked resident what happened and resident unable to verbalize. SN asked resident if he was in any pain and resident stated no. SN then assisted resident back to his room, assisted with toileting needs, and assisted resident to bed . resident remains in bed at this time. Safety maintained. DON notified, RP notified, no concerns at this time. On call for (physician) was notified new order for UA (urine) C&S (culture & sensitivity) and (lab). Oncoming 10-6 nurse aware of new orders. Orders have been transcribed, lab slip placed in binder. SN placed resident on 72- hour critical behavior monitoring, will continue to monitor. There was no documentation of any interventions put in place to prevent incident re-occurrence or protection. Record review of R #2's Acute Care Plan dated 03/15/20 documented Behavior - Problem: Physical aggression/combativeness related to unknown .Approach: Reorient and redirect to self; Notify MD/RP of any changes in behavior; 72-hour behavior monitoring. The care plan did not include any interventions in attempt to prevent incidents of physical aggression from re-occurring or what actions to implement should the aggression occur again. Record review of R #2's Nursing Progress Notes dated 03/16/20 documented 5:24 PM - resident 24-hour follow up behavior. Resident observed walking throughout hallway no s/s of pain. No s/s of anxiety or distress. Safety has been maintained. Resident remains on 72-hour critical behavior monitoring, will continue to monitor. Record review of R #2's Nursing Progress Notes and Change in Condition Communication Form dated 03/27/20 documented 8:50 PM - SN notified by CNA at approx. 4:30 PM that resident was physically aggressive towards another resident (R #1). Upon entering 500 hall, resident was observed sitting at desk at the end of the hall eating his dinner. Resident observed with no s/s of anxiety/distress or pain/discomfort. SN assessed resident and no injuries were present .CNA stated that she saw resident walking down hall towards dining area while assisting another resident in her room and when she entered dining area resident was physically hitting another resident (R #1), CNA stated that she witnessed him hit (R #1) twice on her temple and side of the eye and she immediately separated the two and called for assistance of other CNA and notified SN. SN initiated 72-hr. critical behavior monitoring hourly. Nurse Practitioner (NP) was notified and new order for [MEDICATION NAME] 0.5 mg every 12hrs. PRN x2weeks was received. SN transcribed order and faxed it over to pharmacy. new order also received to have (psychological) services evaluate and treat . DON notified of incident and all new orders. RP was also notified, no concerns at this time. Safety has been maintained. Will continue to monitor. Record review of R #2's clinical record including physician's orders [REDACTED]. Record review of R #2's Accident Investigation Report - Witness Interview documented by CNA B dated 03/27/20 documented A physical altercation between (R #1) and (R #2). I was assisting a resident in her room when I heard (R #1) yelling. I ran out and saw (R #2) punching (R #1) twice near her temple and eye. I stepped between them and (R #2) grabbed my hand as I stopped (R #2) from hitting (R #1). R #2 was staring at (R #1) intently. I had to yell to get his attention. He let go of my hand and I walked him away from (R #1) who was calling (R #2) names. Record review of R #2's Nursing Progress Notes dated 03/28/20 documented 10:14 AM - 24-hour follow up physical aggression initiated. Resident continues with agitation at beginning of shift, SN administered prn medication for anxiety. Resident redirected, resident with SN at nurses' station reading magazines and drinking coffee. Resident calm, no anxiety observed . Observation of R #2 on 04/06/20 beginning at 10:21 AM, revealed he independently ambulated back and forth in the hallway, the same hallway R #1's room was located. In an interview with R #2 on 04/06/20 at 11:45 AM, he correctly stated his name. R #2 was not able to correctly state the day/time or place. R #2 said he was well taken care of and did not have issues or feared anyone in the facility. R #2 denied getting into any verbal or physical confrontations with anyone in the facility. In an interview with CNA A on 04/06/20 at 4:05 PM, she stated On 03/15/20 after dinner, (R #1) said she was going to her room to get ready to go to bed. CNA A said (R #2) had already been agitated that afternoon. CNA A explained she was documenting on the tracker when she heard thumps. CNA A said the tracker was located approximately a couple of feet adjacent to R #1's room. CNA A stated she went to find where the thump came from and heard some voices coming from R #1's room. CNA A said she walked into R #1's room and saw R #2 had R #1 pinned between the wall and the closet and he was hitting her with his right hand, closed fist on her right shoulder. CNA A said R #1 was trying to block R #2's hits. CNA A stated she immediately intervened and blocked some of the punches. CNA A explained CNA B was in the shower room and Licensed Vocational Nurse (LVN) C was working the other hall when the incident happened. CNA A said R #2 made a comment a couple of hours earlier before the incident happened, saying That son of a b**** needs to be hit, referring to R #1. CNA A said the next day on 03/16/20, R #1 had bruising on her left shoulder and stated R #2 punched R #1 on her left shoulder and that he choked her. CNA A said she never saw R #2 choking R #1 but the following day she had bruise marks on her neck. I felt bad for her. (There was no documentation of bruising to R #1's neck in R #1's clinical record). CNA A said she did not inform a nurse of R #1's neck bruising because she thought the nurse already saw it when she assessed R #1. CNA A stated they were told to ensure both residents avoided contact with each other, which was difficult because it was a small area. CNA A also said they were told to monitor their (R #1 and R #2's) behaviors. CNA A said R #1 had a bruise to her left eye from a fall she had prior to the assault from R #2 however, R #1's left eye bruising worsened and grew in size. CNA A said on 03/27/20, prior to 9:00 AM, she was in the bathroom and when she arrived at the scene, she saw R #1 upset, sitting on the couch. CNA A said CNA B told her she witnessed R #2 punch R #1 on the face a couple of times. When asked if she was aware if R #2 had hit or hurt any other resident, CNA A said on 03/15/20, prior to R #2 hitting R #1 in her bedroom, she witnessed R #2 hit R #3 on her back while CNA A was escorting R #3 to the common area. CNA A said she redirected R #2 which was successful. CNA A said R #3 denied any discomfort. CNA A said she told LVN C of the incident but did not report the incident to the Abuse Coordinator. Record review of R #3's nursing progress notes and incident/accident reports dated 03/2020 revealed no documented incident of R #2 hitting R #3. In an interview with CNA B on 04/06/20 at 5:07 PM, she said on 03/15/20, she worked in the secured unit but did not witness the incident involving R #1 and R #2 because she was in the shower room. CNA B said CNA A told her that R #2 went to R #1's room and punched her on the shoulders. CNA B said R #1 stated that she bit R #2's hand. CNA B said before R #1 and R #2 got into the altercation, they kept staring at each other throughout the day and she recalled R #2 made a comment saying, That son of a b**** needed to be hit. CNA B said R #2 was staring at R #1 when he made the comment. CNA B said on 03/27/20, she was in a room helping another resident while CNA A went on break. CNA B said she was the only staff in the secured unit when she saw R #2 push a television tray and was pushing it down the hallway. CNA B said she suddenly heard R #1 yelling at R #2 and found both residents in the back area and witnessed R #2 hit R #1 twice on the left side of her face with his closed hand. CNA B said R #1 was also trying to hit R #2 but was unsuccessful because CNA B's arm was in the way and the television tray was between the two residents keeping R #1 from being within R #2's reach. CNA B said she grabbed R #2's hands and R #2 held on to her wrists. CNA B said she could not re-direct R #2 until she yelled his name loudly. CNA B said she told R #2 he was hurting her and he replied he was sorry for hurting her hand. CNA B stated R #2 seemed to think everyone in the unit was a man and sometimes referred to the unit as the barracks. CNA B said R #2 frequently confused R #1 as a man. CNA B said sometimes R #1 would instigate things such as stand in front of R #2 or she would say a comment towards him. CNA B said R #1 seemed to have anger towards R #2 because she remembers him hitting her. When asked what interventions she had been trained to implement when R #1 or R #2 display their behaviors, CNA B said We just re-direct. Interview with SW on 04/07/20 at 10:05 AM revealed she was informed of R #1 and R #2's physical altercations during the morning meetings. The SW said she spoke to the nurse and reviewed the nursing notes about the incidents. The SW said she had a basic conversation with both residents after the second incident. When asked to explain what a basic conversation meant, the SW said she asked each one if they were okay, if everything was okay and they both seemed fine. I just asked how they were feeling and if anything was wrong, the conversation did not go very far with either one of them. When asked if she spoke to R #1 and R #2 about the incidents and their feelings regarding the incident and each other, the SW said There was no conversation about the actual altercations. I asked if they were doing okay this morning and feeling alright, I did not ask them if they were comfortable or if they were fearful because I did not want to put that into their head. We felt (R #2) was a trigger for (R #1) which agitated (R #1) and showed aggression. I've seen her since the incident and she did not seem fearful or reserved. No, I did not specifically ask her how she felt about R #2 or if she feared anyone. At 10:20 AM, the SW and the surveyor visited R #1 in her room. The SW stated she did not understand Spanish and R #1 was primarily Spanish speaking. The SW asked CNA E to translate for her. When asked how she received her facial bruising, R #1 said A man (pointing to the hallway) that is over there hit me with his hand. His hand was closed (Resident demonstrated a closed fist). I feel very angry that he did that because no man should hit a woman. I feel angry and with disconfianza (distrust) and (am) scared. R #1 said the staff removed the male resident away from her and got mad at him for hitting her but he's still here. Observation of R #2 on 04/07/20 at 10:25 AM while the surveyor exited R #1's room revealed R #2 wandered throughout the secured unit hallway walking back and forth, past R#1's room each time. In an interview with the SW on 04/07/20 at 10:26 AM, she said she was not aware of R #1's feelings of anger, distrust and fear. In an interview with LVN C on 04/07/20 at 12:18 PM, she said she did not recall being told of R #2 hitting any another resident other than R #1. In an interview with the DON on 04/07/20 at 10:40 AM, when asked if R #1 and R #2's altercations were reported to the State agency, the DON said It was not reported to the state because they are both confused, it didn't fall under the guidelines to report. If they were not confused, then we would have definitely reported it. The DON stated the incidents were not reported to the local police either. When asked if being punched in the face or anywhere on the body, causing bruising, by another person met the definition of physical abuse, the DON did not reply to the surveyor's question. The DON explained R #2 did not have a history of physical aggression, however, R #1's family said that she had been hit in the past by her spouse. That may be part of her aggression towards a man. The DON said she was informed by staff that R #2 believed R #1 was a man because of her short hair So maybe that's why he would think it was okay to hit her. The DON said she interviewed staff regarding the incident. At this time the surveyor requested documentation of the investigations and interviews conducted. The DON said R #1 already had bruising to her left eye brow from the fall she sustained on 03/20/20, and the hit she received on 03/27/20 by R #2, unfortunately, in the same area made the bruising worse. The bruising traveled down from her eye to her cheek. When asked if she had any other statements or any other documents of investigation of the incidents, other than an incident/accident report (TRUNCATED)