**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to evaluate and address a resident's continued poor appetite for adequate nutrition and hydration, failed to follow the dietary's recommendation, and failed to consistently implement interventions, monitor the effectiveness of interventions and revising them as necessary for one (R1) out of four residents reviewed for nutritional services. These failures resulted in R1 being hospitalized due to hypovolemic shock, malnutrition, and dehydration.Findings Include:R1's clinical records revealed R1 was admitted in the facility on 6/23/25 and was discharged home on 7/9/25. R1's listed diagnoses include but not limited to cerebral infarction, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, dysphagia pharyngoesophageal phase, and major depressive disorder. R1's Minimum Data Set, dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 14, which indicates R1 was cognitively intact, and was total dependent on staff's assistance for her activities of daily living (including eating). R1's weight record shows 88.3 pounds on 6/23/25. No other weights recorded for the entire stay of R1 in the facility. R1's physician orders reads in part: General diet (ordered on 6/24/25) and House Supplement 1 carton three times a day (ordered on 6/25/25).R1's progress notes dated 6/26/25 to 7/9/25 revealed no documentation of any follow-up notification to V20 (R1's Physician) or V10 (Registered Dietitian/RD) about R1's consuming 25% or less of her meals. R1's vitals report revealed R1's amount eaten for breakfast, lunch, and dinner (25% or less):6/24/25: 1-25% for dinner6/26/25: 1-25% for dinner6/29/25: 1-25% for dinner7/2/25: None eaten for breakfast7/3/25: 1-25% for breakfast and lunch7/5/25: 1-25% for breakfast and lunch7/6/25: 1-25% for breakfast and lunch7/7/25: 1-25% for breakfast and lunch7/8/25: 1-25% for breakfast and lunchR1's progress notes dated 6/25/25 at 11:41 AM documented by V10 reads in part: RD new admission referral for this 78 y/o female. admitted [DATE]. DX/PMH [Diagnoses/Primary Medical History] including but not limited to cerebral infarction, COPD, T2DM, chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, MDD, dysphagia, glaucoma, anxiety DO, bilateral primary osteoarthritis of knee, hypertensive heart disease without HF, rheumatoid arthritis, spinal stenosis, radiculopathy, retention of urine, GERD, pain in left hip, central retinal vein occlusion, brachial plexus DO, Vitamin D deficiency. Reviewed orders. NKA per EMR. Diet: general. Per progress notes, no teeth observed, no dentures, noted decreased vision in both eyes. Per EMR, PO intake 6/23-6/25 was variable 26-100% of meals, with 1 meal 1-25%. Weight on 6/23 was 88.3 [pounds], Ht: 64 (per hospital records), BMI 15.2-underweight. Wt [Weight] stability/gain beneficial d/t [due to] underweight status. Skin intact per wound report. Per progress notes, two healed/closed pressures ulcers on the left and right ankle. No edema noted. No GI problems. No recent labs. Estimated needs using IBW (55kg): 1650-1925kcals/day (30-35kcals/kg), 55g protein/day (1.0g protein/kg), 1650-1925mL/day (1ml/kcal). Recommend SLP [Speech Language Pathologist] referral for appropriate diet consistency d/t no teeth and house supplement/med pass 1 carton TID [three times a day] to promote wt stability/gain, Refer to RD as needed.R1's progress notes dated 7/4/25 at 5:32 PM documented by V34 (Licensed Practical Nurse) reads in part: R1 had inadequate meal intake and consumed 750cc fluids. Total assist with ADL's provided by staff and all care provided in resident room.R1's hospital records (7/11/25 to 7/14/25) documented in part: [R1] recently completed 2 week stay at [Nursing Home Facility Name] for respite care, [V33 (R1's Daughter)] is primary caregiver. On return home patient [R1] was noted by daughter [V33] to be altered with slurred speech. admitted with AMS [Altered Mental Status], hypotension and elevated lactic acid thought initially to be due to urosepsis however urine culture grew mixed flora. Therefore, shock due entirely to hypovolemia. Stroke workup negative for acute stroke. [R1] (90 pounds) received 7L [liters] of IV [Intravenous] fluids for resuscitation guided by lactic acid levels and bedside IVC ultrasound without signs of volume overload. Hypovolemic shock is determined to be from lack of PO [by mouth] intake of food and water during stay at nursing home for respite care. [R1] report she did not receive food or water during her time at nursing home.On 7/23/25 at 10:56 AM, V11 (Licensed Practical Nurse) stated she was one of the regular nurses who took care of R1 in the facility. V11 stated R1 barely talked, total dependent, and was on general diet changed to mechanical soft because R1 was pocketing her food. V11 stated R1 ate at least 50% of her meals but there were days R1 ate less. V11 stated she did not inform V20 (R1's Physician) because R1 had poor appetite since the first day R1 was admitted in the facility. V11 stated that R1 was not on calorie count, R1 was on one-on-one feeding and not on any supplements. V11 stated she provides the residents water during medication pass. On 7/23/25 at 11:03 AM, V12 (Restorative Aide) stated, R1 came as total assist. R1 was on Geriatric chair. R1's arms and legs were already contracted when she came. V12 stated that R1 was a picky eater and sometimes R1 would refuse to eat. V12 stated that she told the nurse but can't remember who the nurse. When R1 refuses, V12 stated they would offer substitute soup or a sandwich and would eat a little bit of that. On 7/23/25 at 11:32 AM, V13 (Certified Nursing Assistant) stated, If residents don't eat, I don't offer them alternatives. Kitchen staff come around with what food options they can have the day before. They give them what they ordered. I took care of R1. She would eat her meals at least half. Sometimes she would have just a couple of bites. She was a picky eater. I tried to give her a little more of what she likes. She was not offered substitute because I think she can only eat certain foods. I didn't tell the nurse about R1 because she's been having poor appetite since she came here to us. On 7/24/25 at 1:05 PM, V4 (Certified Nursing Assistant/CNA) stated she was of the CNAs that regularly took care of R1. V4 stated some days R1 would eat 50% and other days R1 would eat very little. V4 stated, If [R1] would not eat I tell the nurse and they give her a supplement. She [R1] was not offered alternatives just milk shakes. I offer water in the beginning of my shift and in between meals and when they asked. [R1] was offered water, and she can talk and can tell you if she's hungry or thirsty.On 7/24/25 at 1:41 PM, V7 (Agency Registered Nurse) stated that R1 had poor appetite. V7 stated that sometimes R1 would not eat. Sometimes R1 would eat just a little bit. On 7/24/25 at 9:07 AM, a phone interview was conducted with V10 (Registered Dietitian). V10 stated that on 6/25/25, she recommended speech referral to evaluate R1 for difficulty chewing because R1 had no teeth and no dentures. R1 also had poor appetite and underweight. V10 stated having no teeth could contribute to R1's poor appetite. V10 stated she recommended house supplement three times a day. V10 stated she was not notified of R1's continued poor appetite and was eating less than 25% most of her meals. V10 stated she would have ordered additional supplements, calorie count, and weekly weights. V10 stated she recommended speech therapy to work on R1's appropriate diet texture and consistency. V10 stated that with the right diet, R1 would have better appetite that matches her needs, weight stability and no weight loss. V10 stated R1 was not provided speech therapy services because V10 can't find any reports from speech. V10 further stated that if residents do not like the food and refuse to eat, staff should offer alternatives and substitutes, and it should always be available with each meal. V10 stated that having dehydration and acute malnutrition with shock could not happen in just two days. It could happen after a week of not drinking and not eating enough. On 7/24/25 at 9:29 AM, V17 (Director of Rehab) stated that speech therapy [ST] sees residents with cognition issues and dysphagia, and for dietary referrals for diet texture and consistency. ST works on what is appropriate for the resident. They work on mastication, rate of chewing, if there is food left over in the mouth if they are pocketing. V17 stated that she did not receive any referral about R1. V17 stated that if she sees any referral or if she was notified, ST would evaluate the resident within 24-48 hours. V17 stated R1 was not screened or evaluated by speech therapy. V17 stated she has no documentation about speech services provided for R1. V17 stated R1 was only provided skilled occupational therapy during R1's stay at the facility.On 7/24/25 at 10:34 AM, V34 (Licensed Practical Nurse) stated that she took care of R1 on 7/4/25. Breakfast, lunch, and dinner R1 only ate about 50-60%. R1's good with her fluids. R1 did not want to eat. The CNAs are supposed to inform the nurses if the resident did not eat or did not want to eat. If it's a pattern nurses could contact the dietitian and the doctor. V34 stated she did not inform V20 of R1's poor appetite because R1 was already seen by V10.On 7/24/25 at 2:52 PM, a phone interview was conducted with V35 (R1's Hospital Physician). V35 stated, R1 was admitted in the hospital on 7/11/25 and was discharged on 7/14/25. [V33] brought her [R1] in after getting her [R1] back from the nursing home the day before. She [R1] was not as alert and not answering questions as typically did. She [R1] had severe electrolytes imbalance, had kidney injury with elevated lactic acid level which indicated she [R1] was in shock. Initially we thought it was UTI [Urinary Tract Infection], but nothing came back with infection. She [R1] did not have UTI. She [R1] was dehydrated based on her labs and required large amount of fluids compared to her body weight to correct her kidney injury and electrolytes. She [R1] was able to eat and back to her normal mental status after we gave her the fluids. She [R1] told us that she was not given foods and fluids at the nursing facility. She weighed 90 pounds when she came in the hospital. That was documented on the 11th before she [R1] received the fluids. She [R1] required 7 liters of fluids total during her hospitalization. That amount of fluid was indicative that she [R1] was not provided enough hydration and nutrition for a longer period of time. That can't happen it just two days. To be hypovolemic, severely dehydrated and with acute malnutrition with shock to happen it could take longer than 2 days. It's a matter of days but not 2 days. If she [R1] was seen by speech therapy at the nursing home that would help identify what's an appropriate diet and fluids for her. On 7/25/25 at 10:55 AM, a phone interview was conducted with V20 (R1's Physician). V20 stated that he expects nursing to contact and notify him if his residents are not eating or having poor appetite. V20 stated he was not made aware of R1's poor appetite or eating less than 25% some of her meals in the nursing home. V20 stated that the nursing staff at the facility are pretty good of notifying him about his residents' change in condition. V20 stated dehydration and malnutrition with shock do not happen in the span of 2 days and it could result from 3 or more days of not eating or drinking. The facility's Hydration policy dated 2005 documents in part: the physician will manage fluid and electrolyte imbalance, and associated risks, appropriately and in a timely manner. The physician will help monitor the development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals. Adjust treatments on specific information relevant to that individual.The facility's Passing Meal Trays policy (no date) documents in part: Nursing will offer alternates to residents who refuse their food or request a substitute. Nursing will advise dietary of such requests.The facility's DIETARY SERVICES policy (no date) documents in part: It is the policy of this facility to provide a quality dietetic service using high standards of sanitation that meet the daily nutritional needs of the residents. Each resident's nutrition and hydration status is assessed and monitored. Residents shall be observed to determine acceptance of the diet. Should residents refuse foods served, or eat less than 50% of the total meal, appropriate substitutes of similar nutritive value will be offered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one resident (R2) was free from abuse from two residents (R1 and R8) in a sample of 6 residents reviewed for abuse. These failures resulted in R1, an ambulatory resident, physically punching R2, a wheelchair resident, in the face causing a facial skin tear, periorbital contusion and nasal fracture, and R8, an ambulatory resident, physically hitting R2 in the back of the head. Findings include: On 2/24/25 at 12:52 pm, R2 was observed in R2's room in R2's wheelchair propelling self in room. When asked about an incident with another resident that occurred in the facility on 2/10/25, R2 stated, He (R1) came up to me (R2) and hit me. R2 stated that R2 was downstairs in the cafeteria (dining room) in the basement in R2's wheelchair, and I (R2) was just sitting. He (R1) hit me. R2 stated, It broke my nose. I felt it (pain) all the way to the back of my neck. When asked did R1 hit R2 in the face with an open hand or a closed hand (fisted hand), and R2 showed this surveyor a fisted hand. This surveyor observed faded bruise under R2's left eye as R2 is pointing to the area where R1 punched R2. When asked how many times did R1 hit you in the face with fisted hand, R2 stated, Twice. R2 stated, I couldn't move. I couldn't do anything. R2 couldn't remember if there was another resident in the dining room at the time. When asked did R2 see any facility staff before R1 hit you on 2/10/25 in the basement dining room, R2 stated, No, I didn't see anyone. When asked does R2 feel safe in the facility, R2 stated, I am okay. R2 stated that R2 moves R2's self freely in the wheelchair on the floor and down to the basement. R2's Face Sheet documents, in part, diagnoses of Parkinson's disease without dyskinesia, schizophrenia, adult failure to thrive, asthma, heart failure, hypertension, anemia, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, mild neurocognitive disorder due to known physiological condition without behavioral disturbance and major depressive disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2 has a Brief Interview for Mental Status (BIMS) score of 8 which indicates that R2 has moderate cognitive impairment; no behavioral symptoms or indicators of psychosis (hallucinations or delusions); and R2 mobility device is a wheelchair. R2's Emergency Hospital Records, dated 2/10/25, documents, in part, that R2 was seen in the hospital for: Victim of assault and battery, head injury and contusion of periorbital region. R2's hospital CT (Computerized Tomography) scan of the maxillofacial region (2/10/25 at 6:51 pm) results documents, in part, that R2's head injury with left orbit swelling has findings of: There is an acute minimally displaced left nasal bone fracture with adjacent soft tissue swelling. There is deviation of the nasal septum towards the left. R1's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, conduct disorder-aggressive behavior, unspecified psychosis, schizoaffective disorder (bipolar type), chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic mononeuropathy, anemia, epilepsy, hyperlipidemia, dysphagia, and hypertension. R1's MDS, dated [DATE], documents, in part, a Staff Assessment for Mental Status is documented, in part, of short-term memory problems, and R1's Cognitive Skills for Daily Decision Making as 2 which indicates moderately impaired - decisions poor; cues/supervision required. R1's Resident Census documents, in part, that R1 is on hospital leave as of 2/10/25 and was unable to be interviewed by this surveyor. On 2/26/25 at 10:46 am, R6 stated that that remembers the incident between R1 and R2 on 2/10/25 in the basement dining room. R6 stated, He (R1) hit her (R2). I (R6) was behind them. When asked who else was there in the basement dining room that day, R6 stated, Vending machine guy (V6, Vending Machine Driver/Stocker, Contract Vendor). R6 stated that R2 was sitting at the table in R2's wheelchair close to the vending machines, and that R1 was arguing with R2. R6 stated, He (R1) stands up and he (R1) hit her (R2). When asked if it was with a closed fists or open hand, R6 put up R6's closed hand in a fist to show this surveyor. R6 stated that no one else, facility staff or residents, were in the basement dining room on 2/10/25 when R1 hit R2. R6's Face Sheet documents, in part, diagnoses of hyperlipidemia, paranoid schizophrenia, asthma, and hypertension. R6's MDS, dated [DATE] and 11/13/24, document, in part, a BIMS score of 14 which indicates that R6 is cognitively intact. On 2/25/25 at 12:37 pm, V6 (Vending Machine Driver/Stocker, Contract Vendor) stated that V6 was restocking vending machine items in the facility on 2/10/25 in the basement dining room. When asked about the incident that occurred on 2/10/25 in basement dining room, V6 stated, A fight broke out. I (V6) don't pay much attention when I am stocking. I'm there to do my job. When asked if V6 heard or seen anything, V6 stated, A man (R1) was standing and throwing punches at a lady (R2). V6 stated, I (V6) heard and saw them arguing. When asked what argument was about, V6 stated, I saw they (R1 and R2) were pushing and trying to get into a box. When asked what box, V6 stated, I (V6) have a box (extra) that I put aside when I am restocking and use if for garbage. I will take it out when I am done. When asked did this extra box have food items in it, V6 stated, No, it was empty. V6 stated that his body was turned towards the vending machines (south wall) in the dining room, but the table that R2 was sitting at was right in front of the vending machines. V6 stated that V6 continued stocking and when V6 heard yelling, V6 turned around from stocking the vending machines and observed (R1) punching (R2). V6 stated that R1 was standing and that R2 was in the wheelchair. V6 stated, I knew that was trouble, so I ran out the door to call for help, and there was a lady (V5, Laundry Aide), by the elevator, who came in. When asked what did V6 tell V5, V6 stated, I told her (V5) what happened. The man (R1) was punching her (R2). On 2/24/25 at 3:04 pm, V5 (Laundry Aide) stated that on 2/10/25, V5 did not observed the incident with R1 and R2 in the basement dining room. V5 stated, I (V5) didn't see anything. I was at the elevator. In the basement to take stuff (clean laundry) upstairs. The vending machine man (V6) came out and asked for help. I ran in there (inside the basement dining room). I seen them. 2 residents (R1 and R2). They were separated already. (V6) said they (R1, R2) was fighting. I went to go get help. When asked what did V6 say to V5, V5 stated that V6 said, I need help. V5 stated that V6 saw V5 by the elevator in the basement hallway and that V6 ran into the last door (end of hallway) to dining room. When asked what did V5 see upon entering inside the basement dining room, V5 stated, There are residents. One man (R1) standing by the door (last door) and the lady (R2) in a wheelchair over by the table. I never saw a thing. I went to go get help. When asked was there anyone else in the basement dining room, V5 stated, It happened so fast. I (V5) just went back out to holler for help and he (V7, Maintenance Operations Director) came and got (R2). V5 stated that V7's office is in the basement and that V7 took over with the residents in the basement dining room. On 2/25/25 at 10:58 am, V7 (Maintenance Operations Director) stated that V7's office is in the basement on the east side of the building, and on 2/10/25, V5 alerted V7 that there was an altercation between a female and male resident in the basement dining room. V7 stated that V7 walked to the basement dining room and observed R2 wheeling out of the basement dining room with an injury to (R2's) face. When asked to elaborate, V7 stated that V7 saw a dark bruise under (R2's) eye and that R2 was not saying anything. V7 stated that V7 wheeled from the basement hallway into the elevator to bring R2 to V1's office on the main floor. V7 stated that V7 and V37 (Plant Operations Manager) then took elevator to R1 and R2's floor, where R1 was standing, and escorted R1 to R1's room. On 2/24/25 at 2:22 pm, V3 (Licensed Practical Nurse, LPN), stated that V3 has worked in the facility for about 6 years and is assigned to R1 and R2's floor. V3 stated that R1 and R2's floor has a combination of skilled care residents and residents with severe mental illness. When asked to tell this surveyor about R1, V3 stated, He's (R1) somebody that you cannot come close to, or he will knock you out. Doesn't matter who you are. He's not (V3 pauses) . how can I explain it. He's crazy. He don't have anything here (pointing to V3's head making a looping circle). He will knock anyone out. It doesn't matter who you are. He will fight you. He will throw food at you. V3 stated that V3 would come close to R1 when V3 would attempt to give R1 medications, and then R1 would swing at V3 where V3 would have to stand back and curse at V3. When asked where would R1 spend time, V3 stated that R1 walks around independently, is alert and oriented times 2 (person, place), and He (R1) would come from his room to the day room, then back to his room. Sometimes he would want to go to the other side, the other hallway. When asked why wouldn't V3 want R1 to walk down the other hallway, V3 stated, (R1) may smack at peers. They (other residents) may accidentally cross him or get to close to his face, and he will smack you. He will hit you. V3 stated that V3 has witnessed R1 pulls back with a closed fist and says, 'I will kick you're a**' to another staff member. V3 stated that R1 would eat in the dining room on R1's floor, but on 2/10/25, He (R1) went to basement. I (V3) didn't see him (leaving floor). You know (I am) busy with my head down. I would have stopped him. He would fight. You don't know who he would pick to hit. Don't get in his face. V3 stated that V3 couldn't remember the time on 2/10/25 when V3 was notified of R1 and R2's incident in the basement. V3 stated, They (staff) called me (V3) and said that he (R1) hit her (R2). I was like 'Oh now. When did he go down?' They (R1, R2) are in basement. He's not to go to the basement if someone isn't watching. (saff) should be going with him. V3 stated that V3 took the elevator downstairs to the basement and neither R1 or R2 are there. V3 stated that on the main floor, V3 observed R2 in R2's wheelchair receiving first aide care from V2 (Director of Nursing, DON) and V36 (Former Employee, Wound Care Nurse) under R2's left eye. V3 stated that upon V3's assessment of R2 back in R2's room on 2/10/25, V3 stated, She (R2) was upset from being hit. She didn't explain it to me. She just said he (R1) hit her. (R2) couldn't tell me what happened. I know that man (R1), and I asked her, 'Did you provoke him (R1)? You can't get in his face' And she (R2) said, 'He hit me.' That man (R1) is just like a time bomb. (R1's) very easy to provoke. When asked to tell me any further details about the 2/10/25 incident between R1 and R2, V3 stated, Since no one saw them (R1, R2), I (V3) don't know. I wasn't there. V3 stated that R2 is alert, oriented times two (person, place), propels R2's self in wheelchair and is a one person assist with bathing. V3 stated, She (R2) goes around every floor. The basement was like her house and can navigate by R2's self. When asked when R2 is frequently going down to the basement, who is monitoring R2, and V3 stated, Nobody. After that, they lock it (basement dining room). There is supposed to be someone there. When asked prior to this incident with R1/R2 on 2/10/25, was the dining room in basement open, and V3 stated, Yes it was always open. All day. But not now. Not since this second incident. She (R2) got beat up again by another man (R7). On 2/10/25 at 4:53 pm, V3 (LPN) documented, in part, in R2's Progress Notes, Received resident (R2) on first floor from administration. Informed of the altercation between (R2) and another resident (R1). Upon assessment, the resident was noted with a small skin tear under her left eye with minimal discoloration. First aid and pain medication administered. R2's Care Plan (Problem Start date of 4/15/2023) documents, in part, the problem of Category: Psychosocial Well-Being (Abuse/Neglect) Resident (R2) is at risk for abuse due to impaired cognition, communication, and verbal and physical aggression. (R2) was the target of aggression on 1/6/25, 2/10/25 with a goal of Resident will be free of abuse/neglect daily through next review. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of Category: Behavior Symptoms: (R1) has physically aggressive behavioral symptoms towards others (e.g. (for example), hitting, kicking, pushing, scratching, abusing others sexually). (R1) was sexually inappropriate with female staff 11/19/2024. (R1) on 2/5/25 exhibited verbally aggressive threatening behavior toward staff with a goal of (R1) will not harm others secondary to physically abusive behavior. R1's Approaches (Interventions) for this specific care plan for R1 includes: Offer one step verbal direction for tasks. Allow for extra time to process the information with approach start date of 11/20/24; When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors with approach start date of 11/20/24; and When resident becomes physically abusive, move to a quiet, calm environment with approach start date of 11/20/24. On 2/25/25 at 9:57 am, V1 (Administrator) stated that V1 is the abuse coordinator for the facility and is responsible for monitoring residents for abuse, facility staff training, and coordinating the facility's abuse prohibition program. V1 stated that V1 has been educating facility staff for a few months and explaining to them that we are worried about our high traffic areas especially near the elevators and any common areas. When asked V1 how are the facility staff to prevent resident to resident abuse, V1 stated, Monitoring any pre abuse type thing. Resident may say to another resident, 'Hey move.' And staff will say, 'Let me help you.' As example of that, if 25 people are trying to get in one elevator. Listening for signs of people (residents) agitated or frustrated. What's the purpose of monitoring residents in communal areas, V1 stated, Make sure resident was safe. When asked how was V1 informed on 2/10/25 about R1/R2 incident, V1 stated that V1 remembers being in V1's office and that V7 brought R2 up to V1's office. V1 stated, I asked maintenance (V7), where is he (R1)? Make sure someone is monitoring (R1). V1 stated that this was around noon on 2/10/25. V1 stated that V2 (DON) was informed to come to assess R2 in R2's wheelchair where V2 rendered R2's first aide. V1 stated that V1 observed R2's face with a break in the skin under the left eye, and R2 saying, He (R1) hit me (R2). V1 stated, That's the only thing I am getting from her. He hit me. V1 stated that V1 called the police department and arrived in the facility after R1 and R2 had been transferred to separate hospitals. When asked how is the facility staff monitoring residents in the basement dining room, V1 stated, Managers watching and directing them (residents). The dining room didn't have someone in there (2/10/25). Now there is more (staff). We lock it to make open certain times. Why do you want staff supervising in the basement dining room when residents are there, V1 stated, Frankly, in the location that it occurred and no one in there to possibly see if it is escalating into something. Does 'something' mean resident being physical volatile, I would say that. This surveyor had made several requests with V1 on 2/24/25 the video camera footage from the basement dining room from 2/10/25 for R1 and R2's incident, and V1 confirmed during this interview with this surveyor that V1 can only go 10 days back to review the video footage. When asked for the detailed description of V1's viewing of the video camera footage review from 2/10/25 incident in the basement dining room, V1 stated, I saw that (R2) and (R1) were in there. There was another person (R6). The guy (V6) was doing the vending machine. He (V6) had boxes. It was a low profile box. (R2) rolled up and picked up the box. (R1) got up and got the box and looked in it. Maybe thinking it was chips. (R2) moved the box close to (R2). R2 was in wheelchair at the table that was right next to the vending machine. V1 stated, (R1) walked up to the box. (R2) lifted the box up by her head. (R1) walked away. (R2) put the box on the table. V1 stated, A few minutes later, he (R1) got up and said something to her (R2) first. Then he was hitting her. V1 stated that R1 was originally sitting in a regular chair near the basement dining room door on the south side of the room: walked up to R2's table to look in the box; R1 yelling something at R2; R1 then walked back to the chair near the door and waited 1 and a half minutes before walking back to R2 hitting R2 in the face. When asked how many times did R1 strike R2, V1 stated, A couple. When asked the conclusion of V1's abuse investigation for the incident on 2/10/25 between R1 and R2, V1 stated, Conclusion is that he (R1) hit her (R2) and injured her. He hit her. It's abuse. He mistreated her. When asked about an incident that occurred between R2 and R7 in the basement dining room on 1/6/25, V1 stated that R7 is no longer a resident in the facility and that the incident was witnessed by facility staff (V38, Activities Aide). V1 stated that both R2 and R7 were wheeling in their respective wheelchairs out of the basement dining room door with V38 in the room picking up activity's items from the tables when R7 began hitting R2 with R2's backpack. V1 stated that the State Agency investigated this facility reported incident on a prior survey and that physical abuse towards R2 from R7 was substantiated. V1 stated, (R2) is victim of abuse. Both times (1/6/25 and 2/10/25), yes. 2) On 3/3/25 at 9:29 am, V1 stated, Something happened over the weekend. (R2) got hit again. V1 stated that R8 walked by R2 in the hallway on their floor and just hit her (R2). V1 stated that R8 was sent out to the hospital, and R2 has been moved to a different floor. On 3/3/25 at 10:13 am, this surveyor re-interviewed R2 on R2's new floor. When asked about the incident with R8 on 3/1/25 on the floor, R2 stated, She (R8) hit me (R2). When asked where did R8 hit R2, R2 stated, Back of my head. R2 stated that R2 came out of R2's room in wheelchair and in hallway is where R8 hit R2 on 3/1/25. R2 stated that R2 feels safe in the facility and likes R2's new room and floor. On 3/3/25 at 10:42 am, when asked about the incident between R2 and R8 on 3/1/25, V29 (Certified Nursing Assistant, CNA) stated, Yes, I (V29) witnessed it. I was sitting in dining room. (R8) walked past her (R2) and hit her (R2). I said, Don't that. Why would you hit this woman (R2). She (R2) didn't do anything? And she (R8) ignored me. (V30, Agency Registered Nurse, RN) asked her (R8) too. (R8) said, 'It was an accident.' I (V29) said, 'No, you (R8) purposely hit her (R2).' (V30) asked (R8), 'Would you want someone to hit you? Then why did you hit her (R2)?' She (R8) said, 'It was an accident'. On 3/3/25 at 10:17 am, V30 (Agency RN) stated that on 3/1/25 around 9:45 to 10:00 am, V30 was sitting at the nurse's station desk charting, and V29 (CNA) alerted V30 that R8 hit R2 in the back of the head. V30 stated that V30 did not observe it, but V29 did. V30 stated that V30 kept R2 and R8 separated, and R8 told V30, It was an accident. V30 assessed R2 with no injuries, and V30 transferred R8 out to the hospital for a psychiatric evaluation. V30 informed V1 and V37 (Plant Operations Manager) who was on duty. In R2's Progress Notes, dated 3/1/25 at 10:19 am, V30 (RN) documented, in part, While charting at Nurses station Writer (V30) was informed by Nurses aide (V29) that resident above (R2) was hit in back of head while sitting in wheelchair in the hallway. Both residents (R2, R8) separated. Writer and MOD (manager on duty, V37) asked Resident (R2) what happened? Resident (R2) unable to verbalize what happened. In R8's Progress Notes, dated 3/1/25 at 10:09 am, While charting at Nurses station Writer was informed by Nurses aide that resident above (R8) hit another resident (R2) in back of head while walking pass her in the hallway. Both residents separated. Writer and MOD (V37) asked Resident (R8) what happened? Resident (R8) stated It was a (an) accident. Writer and MOD spoke with Resident informing her that behavior is unacceptable, resident verbalized understanding. On 3/3/25 at 12:36 pm, V1 and this surveyor together viewed the video camera footage in V1's office from 3/1/25 of the camera view from R2 and R8's floor dining room on north side of building facing down the hallway towards south side of the building. On 3/1/25 at 9:46:19 am, V29 (CNA) is observed in the dining room sitting watching down the hallway, and R8 walks freely out of her room; walks down the hallway to the alcohol based hand sanitizer (ABHS) dispenser on the wall near the nurse's station; pumps it 22 times to get ABHS and then walks back into R8's room. On 3/1/25 at 9:47 am, R2 is observed wheeling out of her room in R2's wheelchair and is staying on the side of the hallway (east side) and wheels past R8's room. R8 next walks out of R8's room and with an open hand, R8 hits R2 on the back of R2's head while in the wheelchair with R2's head jerking forward. V29 points to R8 who continues walking towards the nurse's station. R8's Face Sheet documents, in part, diagnoses of fibromyalgia, personality disorder (unspecified), asthma, anxiety disorder, psychotic disorder with delusions due to known physiological condition, major depressive disorder, hypertension, venous insufficiency, constipation and obesity. R8's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R8 is cognitively intact. Facility policy (undated) titled Abuse Prevention Policy documents, in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents . This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents. Facility policy with a revision date of 10/2024 and titled Resident Rights Guideline documents, in part, . Guideline: Our residents have certain rights and protection under Federal law that help ensure appropriate care and services are provided . Our facility will treat each resident with respect and dignity and care for each resident in a manner an (and) in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . Freedom from Abuse, Neglect, Misappropriation of Property and Exploitation: The right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation, and misappropriation of your property by anyone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide facility staff supervision of a resident (R1) in the basement dining room in a sample of 6 residents reviewed for improper nursing care. This failure resulted in R2, a wheelchair resident, being punched in the face two times by R1, an ambulatory resident with verbal and physical aggressive behaviors, causing R2 to sustain a facial skin tear, periorbital contusion and nasal fracture. Findings include: On 2/24/25 at 12:52 pm, R2 was observed in R2's room in R2's wheelchair propelling self in room. When asked about an incident with another resident that occurred in the facility on 2/10/25, R2 stated, He (R1) came up to me (R2) and hit me. R2 stated that R2 was downstairs in the cafeteria (dining room) in the basement in R2's wheelchair, and I (R2) was just sitting. He (R1) hit me. R2 stated, It broke my nose. I felt it (pain) all the way to the back of my neck. When asked did R1 hit R2 in the face with an open hand or a closed hand (fisted hand), and R2 showed this surveyor a fisted hand. This surveyor observed faded bruise under R2's left eye as R2 is pointing to the area where R1 punched R2. When asked how many times did R1 hit you in the face with fisted hand, R2 stated, Twice. R2 stated, I couldn't move. I couldn't do anything. R2 couldn't remember if there was another resident in the dining room at the time. When asked did R2 see any facility staff before R1 hit you on 2/10/25 in the basement dining room, R2 stated, No, I didn't see anyone. When asked does R2 feel safe in the facility, R2 stated, I am okay. R2 stated that R2 moves R2's self freely in the wheelchair on the floor and down to the basement. R2's Face Sheet documents, in part, diagnoses of Parkinson's disease without dyskinesia, schizophrenia, adult failure to thrive, asthma, heart failure, hypertension, anemia, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, mild neurocognitive disorder due to known physiological condition without behavioral disturbance and major depressive disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2 has a Brief Interview for Mental Status (BIMS) score of 8 which indicates that R2 has moderate cognitive impairment; no behavioral symptoms or indicators of psychosis (hallucinations or delusions); and R2 mobility device is a wheelchair. R2's Emergency Hospital Records, dated 2/10/25, documents, in part, that R2 was see in the hospital for: Victim of assault and battery, head injury and contusion of periorbital region. R2's hospital CT (Computerized Tomography) scan of the maxillofacial region (2/10/25 at 6:51 pm) results documents, in part, that R2's head injury with left orbit swelling has findings of: There is an acute minimally displaced left nasal bone fracture with adjacent soft tissue swelling. There is deviation of the nasal septum towards the left. R1's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, conduct disorder-aggressive behavior, unspecified psychosis, schizoaffective disorder (bipolar type), chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic mononeuropathy, anemia, epilepsy, hyperlipidemia, dysphagia, and hypertension. R1's MDS, dated [DATE], documents, in part, a Staff Assessment for Mental Status is documented, in part, of short-term memory problems, and R1's Cognitive Skills for Daily Decision Making as 2 which indicates moderately impaired - decisions poor; cues/supervision required. R1's Resident Census documents, in part, that R1 is on hospital leave as of 2/10/25 and was unable to be interviewed by this surveyor. On 2/26/25 at 10:46 am, R6 stated that that remembers the incident between R1 and R2 on 2/10/25 in the basement dining room. R6 stated, He (R1) hit her (R2). I (R6) was behind them. When asked who else was there in the basement dining room that day, R6 stated, Vending machine guy (V6, Vending Machine Driver/Stocker, Contract Vendor). R6 stated that R2 was sitting at the table in R2's wheelchair close to the vending machines, and that R1 is arguing with R2. R6 stated, He (R1) stands up and he (R1) hit her (R2). When asked if it was with a closed fists or open hand, R6 put up R6's closed hand in a fist to show this surveyor. R6 stated that no one else, facility staff or residents, were in the basement dining room on 2/10/25 when R1 hit R2. R6's Face Sheet documents, in part, diagnoses of hyperlipidemia, paranoid schizophrenia, asthma, and hypertension. R6's MDS, dated [DATE] and 11/13/24, document, in part, a BIMS score of 14 which indicates that R6 is cognitively intact. On 2/25/25 at 12:37 pm, V6 (Vending Machine Driver/Stocker, Contract Vendor) stated that V6 was restocking vending machine items in the facility on 2/10/25 in the basement dining room. When asked about the incident that occurred on 2/10/25 in basement dining room, V6 stated, A fight broke out. I (V6) don't pay much attention when I am stocking. I'm there to do my job. When asked if V6 hear or see anything, V6 stated, A man (R1) was standing and throwing punches at a lady (R2). V6 stated, I (V6) heard and saw them arguing. When asked what argument was about, V6 stated, I saw they (R1 and R2) were pushing and trying to get into a box. When asked what box, V6 stated, I (V6) have a box (extra) that I put aside when I am restocking and use if for garbage. I will take it out when I am done. When asked did this extra box have food items in it, V6 stated, No, it was empty. V6 stated that his body was turned towards the vending machines (south wall) in the dining room, but the table that R2 was sitting at was right in front of the vending machines. V6 stated that V6 continued stocking and when V6 heard yelling, V6 turned around from stocking the vending machines and observed (R1) punching (R2). V6 stated that R1 was standing and that R2 was in the wheelchair. V6 stated, I knew that was trouble, so I ran out the door to call for help, and there was a lady (V5, Laundry Aide), by the elevator, who came in. When asked what did V6 tell V5, V6 stated, I told her (V5) what happened. The man (R1) was punching her (R2). On 2/24/25 at 3:04 pm, V5 (Laundry Aide) stated that on 2/10/25, V5 did not observed the incident with R1 and R2 in the basement dining room. V5 stated, I (V5) didn't see anything. I was at the elevator. In the basement to take stuff (clean laundry) upstairs. The vending machine man (V6) came out and asked for help. I ran in there (inside the basement dining room). I see them. 2 residents (R1 and R2). They were separate already. (V6) said they (R1, R2) was fighting. I went to go get help. When asked what did V6 say to V5, V5 stated that V6 said, I need help. V5 stated that V6 saw V5 by the elevator in the basement hallway and that V6 ran into the last door (end of hallway) to dining room. When asked what did V5 see upon entering inside the basement dining room, V5 stated, There are residents. One man (R1) standing by the door (last door) and the lady (R2) in a wheelchair over by the table. I never saw a thing. I went to go get help. When asked was there anyone else in the basement dining room, V5 stated, It happened so fast. I (V5) just went back out to holler for help and he (V7, Maintenance Operations Director) came and got (R2). V5 stated that V7's office is in the basement and that V7 took over with the residents in the basement dining room. On 2/25/25 at 10:58 am, V7 (Maintenance Operations Director) stated that V7's office is in the basement on the east side of the building, and on 2/10/25, V5 alerted V7 that there was an altercation between a female and male resident in the basement dining room. V7 stated that V7 walked to the basement dining room and observes R2 wheeling out of the basement dining room with an injury to (R2's) face. When asked to elaborate, V7 stated that V7 sees a dark bruise under (R2's) eye and that R2 was not saying anything. V7 stated that V7 wheeled from the basement hallway into the elevator to bring R2 to V1's office on the main floor. V7 stated that V7 and V37 (Plant Operations Manager) then took elevator to R1 and R2's floor, where R1 was standing, and escorted R1 to R1's room. On 2/24/25 at 2:22 pm, V3 (Licensed Practical Nurse, LPN), stated that V3 has worked in the facility for about 6 years and is assigned to R1 and R2's floor. V3 stated that R1 and R2's floor has a combination of skilled care residents and residents with severe mental illness. When asked to tell this surveyor about R1, V3 stated, He's (R1) somebody that you cannot come close to, or he will knock you out. Doesn't matter who you are. He's not (V3 pauses) . how can I explain it. He's crazy. He don't have anything here (pointing to V3's head making a looping circle). He will knock anyone out. It doesn't matter who you are. He will fight you. He will throw food at you. V3 stated that R1 would come close to R1 when V3 would attempt to give R1 medications, and then R1 would swing at V3 where V3 would have to stand back and curse at V3. When asked where would R1 spend time, V3 stated that R1 walks around independently, is alert and oriented times 2 (person, place), and He (R1) would come from his room to the day room. Then back to his room. Sometimes he would want to go to other side, the other hallway. When asked why wouldn't V3 want R1 to walk down the other hallway, V3 stated, (R1) may smack at peers. They (other residents) may accidentally cross him or get to close to his face, and he will smack you. He will hit you. V3 stated that V3 has witnessed R1 pulls back with a closed fist and says, 'I will kick you're a**' to another staff member. V3 stated that R1 would eat in the dining room on R1's floor, but on 2/10/25, He (R1) went to basement. I (V3) didn't see him (leaving floor). You know (I am) busy with my head down. I would have stopped him. He would fight. You don't know who he would pick to hit. Don't get in his face. V3 stated that V3 couldn't remember the time on 2/10/25 when V3 was notified of R1 and R2's incident in the basement. V3 stated, They (staff) called me (V3) and said that he (R1) hit her (R2). I was like 'Oh now. When did he go down?' They (R1, R2) are in basement. He's not to go to the basement if not someone watching. Someone (staff) should be going with him. V3 stated that V3 took the elevator downstairs to the basement and neither R1 or R2 are there. V3 stated that on the main floor, V3 observed R2 in R2's wheelchair receiving first aide care from V2 (Director of Nursing, DON) and V36 (Former Employee, Wound Care Nurse) under R2's left eye. V3 stated that upon V3's assessment of R2 back in R2's room on 2/10/25, V3 stated, She (R2) was upset from being hit. She didn't explain it to me. She just said he (R1) hit her. (R2) couldn't tell me what happened. I know that man (R1), and I asked her, 'Did you provoke him (R1)? You can't get in his face' And she (R2) said, 'He hit me.' That man (R1) is just like a time bomb. (R1's) very easy to provoke. When asked to tell me any further details about the 2/10/25 incident between R1 and R2, V3 stated, Since no one see them (R1, R2), I (V3) don't know. I wasn't there. V3 stated that R2 is alert, oriented times two (person, place), propels R2's self in wheelchair and is a one person assist with bathing. V3 stated, She (R2) go around every floor. The basement was like her house and can navigate by R2's self. When asked when R2 is frequently going down to the basement, who is monitoring R2, and V3 stated, Nobody. After that, they lock it (basement dining room). There is supposed to be someone there. When asked prior to this incident with R1/R2 on 2/10/25, was the dining room in basement open, and V3 stated, Yes it was always open. All day. But not now. On 2/10/25 at 4:53 pm, V3 (LPN) documented, in part, in R2's Progress Notes, Received resident (R2) on first floor from administration. Informed of the altercation between (R2) and another resident (R1). Upon assessment, the resident was noted with a small skin tear under her left eye with minimal discoloration. First aid and pain medication administered. On 2/25/25 at 9:57 am, V1 (Administrator) stated that V1 has been educating facility staff for a few months and explaining to them that we are worried about our high traffic areas especially near the elevators and any common areas. When asked V1 how are the facility staff to prevent resident to resident abuse, V1 stated, Monitoring any pre abuse type thing. Resident may say to another resident, 'Hey move.' And staff will say, 'Let me help you.' As example of that, if 25 people are trying to get in one elevator. Listening for signs of people (residents) agitated or frustrated. What's the purpose of monitoring residents in communal areas, V1 stated, Make sure resident was safe. When asked how was V1 informed on 2/10/25 about R1/R2 incident, V1 stated that V1 remembers being in V1's office and that V7 brought R2 up to V1's office. V1 stated, I asked maintenance (V7), where is he (R1)? Make sure someone is monitoring (R1). V1 stated that this was around noon on 2/10/25. V1 stated that V2 (DON) was informed to come to assess R2 in R2's wheelchair where V2 rendered R2's first aide. V1 stated that V1 observed R2's face with a break in the skin under the left eye, and R2 saying, He (R1) hit me (R2). V1 stated, That's the only thing I am getting from her. He hit me. V1 stated that V1 called the police department and arrived in the facility after R1 and R2 had been transferred to separate hospitals. When asked how is the facility staff monitoring residents in the basement dining room, V1 stated, Managers watching and directing them (residents). The dining room didn't have someone in there (2/10/25). Now there is more (staff). We lock it to make open certain times. Why do you want staff supervising in the basement dining room when residents are there, V1 stated, Frankly, in the location that it occurred and no one in there to possibly see if it is escalating into something. Does 'something' mean resident being physical volatile, I would say that. This surveyor had made several requests with V1 on 2/24/25 the video camera footage from the basement dining room from 2/10/25 for R1 and R2's incident, and V1 confirmed during this interview with this surveyor that V1 can only go 10 days back to review the video footage. When asked for the detailed description of V1's viewing of the video camera footage review from 2/10/25 incident in the basement dining room, V1 stated, I saw that (R2) and (R1) were in there. There was another person (R6). The guy (V6) was doing the vending machine. He (V6) had boxes. It was a low profile box. (R2) rolled up and picked up the box. (R1) got up and got the box and looked in it. Maybe thinking it was chips. (R2) moved the box close to (R2). R2 was in wheelchair at the table that was right next to the vending machine. V1 stated, (R1) walked up to the box. (R2) lifted the box up by her head. (R1) walked away. (R2) put the box on the table. V1 stated, A few minutes later, he (R1) got up and said something to her (R2) first. Then he was hitting her. V1 stated that R1 was originally sitting in a regular chair near the basement dining room door on the south side of the room: walked up to R2's table to look in the box; R1 yelling something at R2; R1 then walked back to the chair near the door and waited 1 and a half minutes before walking back to R2 hitting R2 in the face. When asked how many times did R1 strike R2, V1 stated, A couple. When asked the conclusion of V1's abuse investigation for the incident on 2/10/25 between R1 and R2, V1 stated, Conclusion is that he (R1) hit her (R2) and injured her. He hit her. It's abuse. He mistreated her. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of Category: Behavior Symptoms: (R1) has physically aggressive behavioral symptoms towards others (e.g. (for example), hitting, kicking, pushing, scratching, abusing others sexually). (R1) was sexually inappropriate with female staff 11/19/2024. (R1) on 2/5/25 exhibited verbally aggressive threatening behavior toward staff with a goal of (R1) will not harm others secondary to physically abusive behavior. R1's Approaches (Interventions) for this specific care plan for R1 includes: Offer one step verbal direction for tasks. Allow for extra time to process the information with approach start date of 11/20/24; When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors with approach start date of 11/20/24; and When resident becomes physically abusive, move to a quiet, calm environment with approach start date of 11/20/24. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of (R1) has verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) with a goal of (R1) will not threaten, scream at, or curse at other residents, visitors, and/or staff. R1's Approaches (Interventions) for this specific care plan for R1 includes: Maintain a calm environment and approach to the resident with approach start date of 11/20/24; Refocus conversation when resident becomes verbally abusive with approach start date of 11/20/24; and When resident becomes verbally abusive, STOP and try the task later. Do not force the resident to do the task with approach start date of 11/20/24. On 2/25/25 at 1:21 pm, V9 (Psychiatric Rehabilitation Services Assistant, PRSA) stated that V9 is familiar with R1 and has V9's office on R1's floor. V9 stated that V9 is responsible for documentation of resident behaviors, counseling residents and updating the resident care plans. V9 stated that R1 is oriented to self and people, but has confusion; is independent in walking; becomes verbally aggressive and needs frequent redirection. V9 stated that when R1 is going downstairs to activities in the basement, staff will be monitoring him. When asked why is facility staff to be monitoring R1 in the basement, V9 stated, Because of his (R1's) aggression. We don't want him to go somewhere where something can happen. When asked about how does V9 know about R1's recent behaviors, V9 stated that V9 will receive information about R1's behaviors from the IDT (interdisciplinary) meeting (morning meeting) and by observing R1's behaviors. V9 stated that V9 will update R1's care plan when a quarterly assessment is due or when there is a behavior. This surveyor then read R1's current social services care plan to V9, which included R1 being sexually inappropriate with staff. V9 stated, Huh, (R1)? I think that must have been an error or wrong resident. When reading R1's care plan about being physically aggressive, V9 stated, What? I saw him making verbal threats. I saw him agitated but not swing at anyone. V9 stated that on 2/5/25, R1 was agitated that day with verbal outbursts, not receptive to redirection, despite asking R1 to come sit down in the dining room on the floor. V9 stated that R1 was pacing, going in and out of resident rooms, and trying to take residents' personal belongings. V9 stated that V9 tries to redirect R1 to a common area to watch him better. V9 stated that V9 tries not to agitate R1 by being to close to R1 but has to watch him to make sure he (R1) does not leave the floor without staff present. On 2/25/25 at 2:55 pm, V4 (Social Services Director, SSD) stated that R1 has displayed repeated verbally and physically aggressive behavior in the facility. V4 stated that facility staff are to be monitoring R1 when R1 is off of the floor because of (R1's) impulse behavior and it consistently happened. On 2/26/25 at 10:58 am, V2 (DON) stated that R1 is alert, ambulatory, can be combative and hostile with staff, aggressive with staff, can go in and out uninvited to other resident rooms and is hard to redirect. V2 stated that R1 did physically strike a staff member (V25, LPN). V2 stated that R1 likes food and likes coffee which helps with R1's redirection. This surveyor read to V2 a time-line from R1's Progress Notes from 10/28/24 (facility initial admission) to 2/10/25 (emergency discharge to hospital) with R1's behaviors documented, in part, of repeated verbal and physical aggression to staff; verbal aggression towards other residents; spitting at other residents; trying to steal food from residents in dining room; pacing; balling up fists with R1 threatening the lives of staff; screaming at other residents where staff needed to evacuate the floor dining room for safety; R1 throwing food trays in dining room; and R1 throwing items from the nurse's station and medication cart at the staff. This surveyor observed V2's face with eyes wide open, and V2 stating, I (V2) hadn't heard that. I wasn't aware of that. V2 stated, I absolutely was aware of his (R1's) behaviors towards staff. When asked about facility staff supervision for R1 in a communal place, like in the basement dining room, V2 stated, It's situational. If we see a behavior coming. Facility policy with revision date of 1/30/2025 and titled Safety and Supervision Guideline documents, in part, Purpose: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addressed risks for groups of residents . Resident-Oriented Approach to Safety: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents . Systems Approach to Safety: 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. Facility policy (undated) titled Abuse Prevention Policy documents, in part, . Procedures: . IV. Establishing a Resident Sensitive Environment: . Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur.

Based on observation, interview and record review, the facility failed to provide the necessary care to prevent frequent multiple hospitalizations of a resident. This failure affected one resident (R1), reviewed for quality of care. The facility also failed to follow physician orders for the administration of resident's medications, failed to administer the gastrostomy tube (G-Tube) water flush as ordered, and failed to provide care of a G-Tube. This failure has the potential to affect three residents (R3, R4 and R5) reviewed for gastrostomy tube care. R1 was hospitalized eleven times in the past 8 months with diagnoses which included but were not limited to Hypernatremia, Dehydration, G-Tube malfunction, and Sepsis related to bleeding from G-tube site. Findings include: 1.) R1 has diagnoses which include but are not limited to: Dementia, Cerebral Infarction, Pressure Ulcers, Aphasia, Dysphagia, Protein calorie malnutrition, and gastrostomy tube. On 8/7/23 at 2pm, V2(Director of Nursing) presented the Census report that shows the hospital visit dates of R1 as follows, with the following admitting diagnoses: 1/1/23 - 1/7/23 - Unspecified Fever 1/9/23 - 1/19/23 - G-Tube Malfunction 2/8/23 - 2/14/23 - Hyperkalemia (Elevated Potassium level) 2/17/23 - 2/23/23 - Unwitnessed Fall 3/8/23 - 3/22/23 - Abdominal Pain, Sepsis, UTI, and Pneumonia. 3/28/23 - 4/5/23 - Sepsis related to Bleeding from G-tube site. 5/16/23 - 5/27/23 - Low Hemoglobin 6/4/23 - 6/6/23 - Low Hemoglobin 6/19/23 - 7/7/23 - Shortness of Breath, Labored Breathing 7/14/23 - 7/31/23 - Hypernatremia (Elevated Sodium Level) 8/6/23 - 8/9/23 - Gastrostomy Tube Complication/Failure to Thrive R1's hospital records as dated below documented the following: 1/7/23: Hospital Course - Hypernatremia - (R1) arrived at the hospital with Sodium level of 157, likely severely dehydrated. 2/17/23: Discharge Summary written by V12(Hospital Attending Physician)- Principal/Secondary Diagnosis includes Lactic Acidosis from volume depletion/infection; Chronic Aspiration from G-Tube feeding. 3/8/23: Discharge Summary written by V36(Hospital Physician) - Chief Complaint was Tachycardia. On arrival, tachycardia was in the 160s. Patient had problems with Hypernatremia (Sodium was 166), (normal range is 135-145); Chronic Aspiration, Pressure Wounds. Hospital Course and Therapy states in part: After review, it was determined that the most likely cause of her tachycardia was Dehydration and losses. Recurrent Aspiration Pneumonia with acute respiratory failure. 3/28/23: Principal/Secondary Diagnosis - Hypotension, Dehydration, Sepsis. History of Present Illness states in part: She was also treated with IV (intravenous) fluids and free water flushes with resolution of her lactic acidosis and hypernatremia. Hospital course was complicated by bleeding around G-Tube site for which GI (Gastro-Intestinal Doctor) was consulted. 6/19/23: R1's hospital Records dated 6/19/23 written by V12(Hospital Attending Physician) states in part: G-Tube noted to be kinked and unkempt, replaced in the ED (Emergency Department). (R1) has had 9 hospital admissions since January of 2023 and that there is a concern about Neglect in the nursing home. Hospital Discharge Summary notes states in part Likely hypovolemic in the setting of missed tube-feeds due to G-Tube dysfunction. Initial sodium 169, received Normal Saline 1150 ml in ED. This Hospital Discharge Summary also states that R1 has AKI (Acute Kidney Injury) on chronic kidney disease stage 3, and that Starvation Ketosis is now resolved. On 6/21/23 at 2:01pm, V34(Hospital Medical Social Worker) documented that on 6/19/23, the nursing home neglected to care for R1 and sent R1 to the emergency room for Hypernatremia (Elevated Sodium levels). V34 added that R1's G-Tube was clogged and kinked and was likely not flushed for approximately one week, contributing to malnourishment. On 7/17/23 at 12:22pm, V35(Hospital Care Coordinator) documented that the nursing home neglected to provide care for R1. R1's Nutrition Care Plan dated 7/13/23 states that R1 is dependent on tube feeding due to dysphagia and CVA (Cerebrovascular Accident) and R1 is at risk for malnutrition. Goal states that R1 will receive adequate nutrition and hydration as evidenced by stable weight and absence of signs and symptoms of dehydration. R1's progress notes dated 7/14/23 at 6:25pm written by V23 (Licensed Practical Nurse/LPN) states that R1's sodium level was 162 (normal range is 135-145). Progress notes dated 1/9/23 at 7:30pm written by V30(LPN) states that R1 was sent to the hospital for G-Tube Malfunction. Progress notes dated 3/28/23 at 8:07am written by V10(RN) states: Resident admitted to the (hospital), Admitting Diagnosis: Sepsis related to Bleeding from G-tube site. On 8/9/23 at 11:48am, V20(Nurse Practitioner) was interviewed regarding the possible cause of Dehydration for R1. V20 stated that if a resident who is dependent on G-Tube does not get enough water flush, it could cause dehydration. V20 added that the nurses should follow the facility's policy on how to administer water flushes into resident's G-Tube. On 8/9/23 at 1:18pm, V24(Registered Dietitian) was interviewed regarding R1's diagnosis of Hypernatremia and Dehydration. V24 stated It's hard for me to say why the resident is dehydrated without observing staff there every shift. The water flush was previously 150 ml every 8 hours. Now, I increased the water flush to 150 ml five times a day. The previous feeding recommendation and water flush recommended were supposed to meet her estimated nutrient needs. On 8/10/23 at 12:10pm, V22(LPN) was interviewed regarding R1's last hospital visit of 8/6/23. V22 stated I sent her(R1) to the hospital because the G-Tube got disconnected. On 8/16/23 at 8:58am, V34(Hospital Social Worker) was interviewed. V34 stated in part: I've had (R1) as a patient 3-4 times in the past few months. She's had up to 15 admissions in this hospital since January of this year. Several doctors have documented that the admissions were due to neglect at the nursing home because the reason for admission were issues like the G-Tube is kinked, G-Tube is coming out, Dehydration, Hypernatremia, and other issues that are due to neglect. In the last 2 admissions, there was Hypernatremia and dehydration. I don't know what's going on at the nursing home, but it doesn't sound good to me. 2.) R3 has diagnosis which include but are not limited to: Gastrostomy Status, Vascular Dementia, Cerebral Infarction, and Protein calorie malnutrition. On 8/7/23 at 12:12pm with V11(LPN), R3 was observed in bed with G-Tube Stoma site having dried crust around the stoma. V11 stated that she(V11) would ensure to clean the G-Tube stoma and apply a gauze to absorb any further secretion or leakage. R3's POS (Physician Order Sheets) dated 6/11/23 states in part: Check enteral feeding stoma every shift. R3's care plan dated 8/4/23 states that R3 is dependent on tube feeding for total nutrition and hydration support due to history of CVA (Cerebrovascular Accident). 3.) R4 has diagnoses which include but are not limited to: Gastrostomy, Diabetes, and Cerebral Infarction. On 8/7/23 at 12:20pm, R4 was observed in the room with V10(LPN). R4's G-Tube stoma was observed with some brownish sticky secretion. There was no Enteral Syringe at the bedside to flush the G-Tube. The surveyor inquired from V10 if R4's G tube has been flushed. V10 stated I didn't flush it this morning. I didn't see a piston syringe. I gave the medication by mouth. She can swallow her medication, but I will flush it now. V10 later brought a 60 ml (Milliliter) Enteral piston /syringe, filled the syringe half-way with water and pushed the water through the G-Tube. V10 did not flush the tube by gravity according to facility's policy. V10 also stated I will clean the secretion on stoma. R4's POS dated 11/22/22 states: Cleanse Enteral feeding site with Normal Saline, change dressing as needed. POS dated 7/19/23 states to flush with 200ml distilled water every shift. R4's POS shows that all medications were supposed to be given by G tube. R4's Nutritional Care Plan dated 4/23/23 states that R4 is dependent on tube feeding and oral diet for adequate nutrition and hydration due to poor oral intake, swallowing difficulty, related to CVA (Cerebrovascular Accident). Intervention states to follow swallowing strategies when feeding resident to ensure safe swallowing, cleanse G-tube site as needed. 4.) R5's diagnoses include but are not limited to the Dysphagia, Cerebral Ischemia, and Aphasia. On 8/7/23 at 12:27pm, R5 was observed in the room with V10(LPN). There was no enteral piston/syringe to flush R5's G-Tube. The surveyor inquired from V10 if V10 flushed R5's G-tube during medication pass in the morning. V10 explained that she(V10) did not flush R5's G-Tube in the morning because R5 received all medication by mouth because he can swallow his medications. V10 later brought a new piston/syringe, filled the syringe half-full of water and pushed the water through R5's G-Tube. V10 did not flush the tube by gravity according to facility's policy. R5's POS shows that some of the medications are to be given by G-Tube while others were ordered for oral administration. On 8/8/23 at 1:15pm, V2(Director of Nursing) was interviewed regarding R5's medications administration route. V2 stated Usually, if the resident has a G-Tube, the medications are given by G-Tube, especially if the resident has a diagnosis of Dysphagia, like (R5). Maybe the nurse that put in the order for oral administration did not know. If the Doctor's Order says the medications should be given by G tube, the nurse should not give the medications by mouth. The resident's diet order is for pleasure feeding and medications are ordered to be given by G-Tube. Inquired from V2 about the process for G-Tube water flush for residents; V2 stated that water flush should be by gravity, and the nurse should not push the water into the G-Tube. V2 explained that if the nurse pushes the water through the G-tube, that there will be too much gas going into the resident's G-tube which will cause abdominal discomfort. V2 stated I will in-service the nurses about G-Tube. Facility's Policy on Enteral Tube Medication Administration with effective date of 10/25/2014 states in part: #11: Remove plunger from the 60 ML catheter tipped syringe and connect syringe to clamped tubing. #12: Put 15-30 ml off water and syringe and flush tubing using gravity flow. #13: Pour dissolved dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity. #14: Flush with 5-10ml warm water between each medication. Pinch tubing below the syringe tip when each volume of liquid clears the syringe to avoid excessive air from entering the stomach. This can cause discomfort or emesis. #Hc: Do not force-flush the tube or use a rigid object in an attempt to clear the tube. If clog is persistent, contact the MD (Medical Doctor) if the above technique fails. Facility's policy on nutrition and hydration with latest revision date of August 2008, states in part: When apparently well-nourished individuals develop in adequate dietary intake of protein or calories, offer support with eating. Ensure that interventions to prevent malnutrition are compatible with the individuals wishes and advance directives. Ensure that the resident's intake of fluid is sufficient. Facility's policy titled Medication Administration states: Medications administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to do so. #4 under Five Rights of Medication Administration states: Right Resident, Right Drug, Right Dose, Right Route, and Right Time, applied for each medication being administered. Under Administration, #2 states: Medications are administered in accordance with written orders of the prescriber.

Based on interview and record review, the facility failed to provide adequate nutrition and hydration to a resident with gastrostomy tube (G-Tube) feeding. This failure affected one resident (R1), reviewed for weight loss and dehydration. As a result, R1 consistently had significant weight loss since initial admission to the facility and was hospitalized for dehydration and Hypernatremia. Findings include: On 8/7/23 at 11am, V2(Director of Nursing) presented the weight records of R1 in pounds as dated below: 1/9/23 - 115.8; 2/15/23 - 113.8; 2; 2/27/23 - 106.2; 3/4/23 - 106.2; 5/3/23 - 96.3; May and June records showed 96.6 pounds while 7/11/23 weight was 86.2 pounds. R1 weighed 115.8 pounds on 1/9/23 and weighed 86.2 pounds on 7/11/23, which means that R1 lost an average of 29.6 pounds between January to July of 2023. R1 has diagnoses which include but are not limited to: Dementia, Cerebral Infarction, Pressure Ulcers, Aphasia, Dysphagia, Protein calorie malnutrition, and gastrostomy tube. R1's MDS (Minimum Data Status dated 7/12/23, Section K (Weight Loss) shows the following: R1 is 62 inches tall and weighs 86 pounds and had lost 5 percent or more in the last month or 10 percent or more in the last 6 months, while not on physician-prescribed weight loss regimen. R1's progress notes dated 7/14/23 at 6:25pm written by V23(Licensed Practical Nurse/LPN) states that R1 had a critically elevated sodium level of 162(normal range is 131-145). R1's laboratory report dated 6/19/23 upon arrival at the hospital was critically high at 169. R1's hospital records dated 3/8/23: Discharge Summary written by V36(Hospital Physician) - Chief Complaint was Tachycardia. On arrival, tachycardia was in the 160s. Patient had problems with Hypernatremia (Sodium was 166), (normal range is 135-145); Chronic Aspiration, Pressure Wounds. Hospital Course and Therapy states in part: After review, it was determined that the most likely cause of her tachycardia was Dehydration and losses. Recurrent Aspiration Pneumonia with acute respiratory failure. R1's hospital Records dated 6/19/23 written by V12(Hospital Attending Physician) states in part: G-Tube noted to be kinked and unkempt, replaced in the ED (Emergency Department). This hospital records also documented that there has been concerns in the past about Neglect in the nursing home. V12 documented that R1's secondary diagnoses include Hypernatremia (elevated sodium levels) and that R1 is malnourished. Hospital Discharge Summary notes states in part Likely hypovolemic in the setting of missed tube-feeds due to G-Tube dysfunction. Initial sodium 169, received Normal Saline 1150 ml in ED. This Hospital Discharge Summary also states that R1 has AKI (Acute Kidney Injury) on chronic kidney disease stage 3, and that Starvation Ketosis is now resolved. R1's Nutrition Care Plan dated 7/13/23 states that R1 is dependent on tube feeding due to dysphagia and CVA (Cerebrovascular Accident) and R1 is at risk for malnutrition. Goal states that R1 will receive adequate nutrition and hydration as evidenced by stable weight and absence of signs and symptoms of dehydration. Progress notes dated 1/9/23 at 7:30pm written by V30(LPN) states that R1 was sent to the hospital for G-Tube Malfunction. Progress notes dated 3/28/23 at 8:07am written by V10(RN) states: Resident admitted to the (hospital), Admitting Diagnosis: Sepsis related to Bleeding from G-tube site. On 8/10/23 at 12:10pm, V22(LPN) was interviewed regarding R1's last hospital visit of 8/6/23. V22 stated I sent her(R1) to the hospital because the G-Tube got disconnected. On 8/9/23 at 11:48am, V20(Nurse Practitioner) was interviewed regarding the possible cause of Dehydration for R1. V20 stated that if a resident who is dependent on G-Tube does not get enough water flush, it could cause dehydration. On 8/9/23 at 1:18pm, V24(Registered Dietitian) was interviewed regarding R1's diagnosis of Hypernatremia. V24 stated It's hard for me to say why the resident is dehydrated without observing staff there every shift. The water flush was previously 150 ml every 8 hours. Now, I increased the water flush to 150 ml five times a day. The previous feeding recommendation and water flush recommended were supposed to meet her estimated nutrient needs. V24 also stated that R1 has been having significant weight loss. On 8/16/23 at 8:58am, V34(Hospital Social Worker) was interviewed. V34 stated in part I've had (R1) as a patient 3-4 times in the past few months. She's had up to about 15 admissions in this hospital since January of this year. Several doctors have documented that the admissions were due to neglect at the nursing home because the reason for admission were issues like the G-Tube is kinked, G-Tube is coming out, Dehydration, Hypernatremia, and other issues that are due to neglect. In the last 2 admissions, there was Hypernatremia and dehydration. I don't know what's going on at the nursing home, but it doesn't sound good to me. Facility's policy on nutrition and hydration with latest revision date of August 2008, states in part: When apparently well-nourished individuals develop inadequate dietary intake of protein or calories, offer support with eating. Ensure that interventions to prevent malnutrition are compatible with the individuals wishes and advance directives. Ensure that the resident's intake of fluid is sufficient.

Based upon observation, interview, and record review the facility failed to ensure that all nursing staff were aware of resident fall prevention interventions and failed to implement fall prevention interventions for one of four residents (R2) reviewed for falls. These failures resulted in R2's fall (5/8/23) resulting in forehead knot and bruising. Findings include: R2's diagnoses include Alzheimer's disease, hemiplegia and hemiparesis affecting left side. R2's (4/21/23) BIMS (Brief Interview Mental Status) determined a score of 13 (cognitively intact). R2's (4/21/23) functional assessment affirms (2 persons) physical assist is required for bed mobility, transfers, and toilet use. R2's (7/22/22) fall risk evaluation determined a score of 18 (high risk). R2's care plan includes (1/26/23) history of falling related to poor balance and gait as a result of Cerebrovascular Accident with left hemiparesis and Alzheimer's type dementia with poor safety awareness. (5/11/23) Resident had a fall and is at risk for future falls. Ensure resident is placed in the middle of the bed before, during and after ADL care. Keep call light within reach at all times. R2's (5/8/23) incident report states while am care was being rendered in bed by CNA (Certified Nursing Assistant), resident let go the side bed and fell to the floor. Bruising to left frontal forehead and small knot noted. If witnessed list by whom: V13 (CNA). Therefore only 1 staff was present (R2 requires 2 persons assist). On (5/8/23) V13 wrote the following statement I turned resident on his right side to continue patient care, he rolled out of the bed and fell on the floor. I pulled the call light and call for help, then 2 CNAs came. On 5/22/23 at 12:48pm, surveyor inquired about R2's (5/8/23) fall. V14 (Licensed Practical Nurse) stated, The CNA came to me and told me that during patient care the resident rolled out of bed onto the floor. I saw him on the floor on the side of his bed. I saw I think a raised area on his left forehead. We sent him out because of the raised area and the nurse didn't see the fall. Surveyor inquired about R2's fall prevention interventions. V14 responded, He has mats on the floor and bed to the lowest position. We don't have side rails. On 5/17/23 at 11:49am, R2 was observed lying in bed sideways. R2's right shoulder was near the edge of the bed and his left foot near the opposite edge of the bed. R2's call light was on the floor. Surveyor inquired if R2 was able to walk. R2 responded, I can barely stand up. I'm so weak. R2's left side appeared to be flaccid while attempting to move therefore unable to reposition himself. Surveyor inquired about R2's (5/8/23) fall. R2 stated, I was in the bed rolling over and I fell out the bed and affirmed one CNA was present. On 5/17/23 at 11:53am, V8 (Licensed Practical Nurse) affirmed she was currently assigned to R2. Surveyor inquired about R2's fall prevention interventions. V8 stated, We make sure we keep the bed low, and the call light is in place, and we always monitor him. Surveyor inquired how R2 is always monitored by staff while lying in bed and his room is farthest from the nurse's station. V8 responded, The CNA will go, and the Nurse will go monitor. V8 subsequently entered R2's room (as requested) surveyor inquired about the location of R2's call light. V8 replied, This call light was here before then placed it on R2's bed near R2's left shoulder [R2's left arm is flaccid]. Surveyor inquired where the call light was located prior to placement. V8 stated, On the floor. Surveyor inquired about R2's positioning in the bed. V8 responded, His position, he's not use and affirmed she was at a loss for the correct word. Surveyor inquired if R2 appears comfortable. V8 replied, No, he doesn't look comfortable. Surveyor inquired if floor mats were adjacent to R2's bed. V8 stated, There's no floor mat at this time. I'm going to get help so I can move him. Surveyor inquired if R2's bed has side rails. V8 responded, No side rail. On 5/17/23 at 12:20pm (27 minutes later), R2's call light was observed on the floor. V10 (Agency Certified Nursing Assistant) subsequently entered R2's room. Surveyor inquired why R2's call light was on the floor (again). V10 stated, It looked like it was a clip but uh, it's broken then placed it on R2's bed (near R2's left shoulder) therefore inaccessible. On 5/25/23 at 11:25am, surveyor inquired about potential harm to a resident that falls. V21 (Medical Director) stated, It depends on the fall. Generally speaking, one can have injury including a possible fracture, skin laceration or if they hit their head, they can get hematoma. The falls clinical protocol (revised August 2008) states as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on interview and record review, the facility failed to prevent a resident from being physically abused by facility staff. This failure resulted in one resident (R1) obtaining an injury to the head, requiring hospitalization. This failure affects one of three residents reviewed for physical abuse in total sample of three residents. Findings include: R1 's diagnoses are but not limited to stroke, left side body paralysis, seizures, high blood pressure, osteoarthritis, high cholesterol, depression, delusional disorders, and neuromuscular dysfunction of bladder. R1's BIMS (Brief Interview for Mental Status) dated 09/13/2022, notes R1 is alert. R1 requires assistance from two staff members. R1's care plan notes that R1 is at risk for abuse due to R1's impaired mobility. Progress notes dated 11/04/2022, notes R1 states that a CNA (Certified Nursing Assistant) that was assigned to R1 allegedly exhibited inappropriate behavior during ADL (Activities of Daily Living) care. A head-to-toe assessment noted right side of forehead raised. On 11/12/2022 at 12:45PM, V1 (Administrator) stated, There was an allegation from R1 when the shift was ending. I was told by R1 that V2 hit R1. I was talking to R1. R1 stated V2 was not doing what R1 wanted V2 to do. R1 was offended that V2 asked R1 if R1 could walk. R1 then started talking about R1's medical experience for years. I asked R1 if V2 hit R1 and R1 said V2 was doing this and that. I asked what R1 was doing. I tried to determine if V2 hit R1. R1 had an issue with how the V2 turned R1. R1 stated V2 had an attitude and R1 called V2 a b*****. R1 did not tell me that R1 was abused. Everything is in my report. On 11/12/2022 at 2:35PM, R2 stated, V2 had pulled the curtain and I could not see. But I could still hear it. V2 hit R1 in the head. V2 spit in R1's face. R1 and V2 were doing a lot of talking. V2 stated to R1 that the family should not have put R1 in a nursing home. On 11/12/2022 at 2:36PM, R1 stated, I have never seen V2 before. I was looking at V2. I am a survivor of a stroke. V2 had on a pink and yellow top. V2 came to my bed. I told V2 I have 14 years of school. V2 stated to R1, that is why your family put your bony a** here. Then V2 spit on me. V2 pulled the curtain and V2 punched me in my skill. I asked the facility to send me to the hospital because I felt V2's knuckle on my skull. It happened at 4:04AM. It was the 11:00PM to 7:00AM shift. The police officer stated that the officer forgot to take pictures and that is why the officer came back to the facility. The officer stated they picked V2 up and arrested V2. V2 is in jail. On 11/15/2022 at 3:55PM, V5 (Nurse Practitioner) stated, There was a swollen area on the right side of R1's head. R1 told me that a staff member hit R1. I just noticed bruising. On 11/15/2022 at 4:10PM, V2 stated, I don't know anything about that. I am still going to work, and I am going to report that facility to the state for neglect. They wrongfully fired me. Do not call my motherf****** phone again. On 11/16/2022 at 12:24PM, V4 (Licensed Practical Nurse) stated, I do not remember what side of R1's face was injured, but I left a note. That day I was not the nurse assigned to R1. I do not know if R1's nurse was on break. The lady that was drawing R1's blood came to the nurse's station and stated that R1 needed to see a nurse right away. I went in the room to see if R1 was alright. R1 stated R1 wanted to report V2 that worked overnight to me. R1 said that they were arguing. R1 threw a cup at V2 and V2 hit and spit in R1's face. Initially, R1's face was flat but then it was raised. To me it did not look like R1 was hit on the face. It was a little bit raised. I reported it to the administrator. V2 was removed out of the building. Ambulance report dated 11/04/2022, notes crew dispatched to nursing home for R1. R1 victim of assault and battery. R1 stated eight hours ago, V2 punched R1 in the head. R1 has a very small contusion on forehead. Medical records dated 11/04/2022, notes R1 presents to the hospital with assault. R1 was reportedly assaulted by agency aide this morning and was repeatedly punched in the head. R1 had small area of swelling with TTP (Thrombotic Thrombocytopenia Purpura-rare disorder of blood coagulation) without overlying skin changes to the right forehead. R1 is a victim of assault. Police Victim Information Notice dated 11/04/2022, notes aggravated battery towards R1. Final facility investigation dated, 11/08/2022, notes R1 reported that a staff member was rough with R1 during care. R1 stated V2 spoke to R1 in a discourteous manner, which escalated the care experience. This resulted in V2 hitting R1, according to R1. R1 was assessed from head to toe. Staff observed a small, raised area to the forehead. Abuse policy, undated, notes abuse means any physical, mental, or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. The term willful in the definition of abuse means the individual must have acted deliberately. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Deficiency Text Not Available

Based on observation, interview and record review the facility failed to address significant, unplanned weight loss, and failed follow Registered Dietitian's recommendation to start oral nutritional supplements. The facility also failed notify the physician of a significant, unplanned weight loss. This resulted in a continued weight loss including a significant weight loss (>5% change over a span of 1 month and >7.5% change over a span of 3-month period) for 1 (R63) of 7 residents reviewed for nutrition for a total of 25 residents in the final sample. Findings include: On 11/01/22 at 11:19 AM, surveyor observed R63 sitting in chair at bedside with lunch tray on the table in front of him. R63 had consumed approximately 1-2 bites of rice, 100% strawberry dessert, and 100% of juice. R63 stated, I don't like it. It looks like cat food. The food is not all bad, sometimes I eat it. It depends on what they are serving. R63 refused surveyor's offer to obtain menu alternative. Surveyor did not observe any supplement on tray or observed at supplement at bedside. On 11/01/22 at 3:18 PM, V8 (Food Service Director) stated that the kitchen does not give out any oral nutritional supplements and R63 is not receiving any extra food or snacks between meals from the kitchen. V8 stated if a resident has a physician order for a supplement, then the nurses would give it out on the unit. On 11/01/22 at 3:25 PM, V7 (Licensed Practical Nurse) stated the nurses would give out a nutrition supplement if there is a physician order for a supplement. V7 stated that if a resident had an order for a supplement, it would be listed on the paper Medication Administration Record (MAR). Surveyor asked V7 to review the paper MAR for R63 to see if R63 has been receiving an oral nutritional supplement. After reading through all R63's paper MARs V7 stated, no. On 11/02/22 at 9:27 AM, V6 (Certified Nursing Assistant) stated that R63 only consumed one hardboiled egg, juice, and coffee this morning and that R63 is not a big breakfast eater. V6 stated that R63 will eat less on days he (R63) is served scrambled eggs because he (R63) thinks they are powdered eggs. On 11/02/22 at 10:03 AM, surveyor requested for staff to obtain R63's current weight. V33 (Restorative Aide) and V34 (Restorative Aide) weighed R63 using the mechanical lift scale in R63's room. V33 and V34 stated that this is the way R63 is usually weighed. V33 and V34 read the weight of R63 when he (R63) was fully up in the air, not touching the mattress and not rocking back and forth. When the surveyor asked how much R63 weighed V33 looked at the mechanical lift's digital scale and stated, 119.2 pounds. Surveyor viewed the mechanical lift's digital scale and confirmed the reading of 119.2 pounds. R63 stated, I used to weigh 127 pounds a couple of months ago and closer to 150 pounds when I first came into this place. Now my legs look like they are getting skinnier. On 11/02/22 at 10:33 AM, V17 (Licensed Practical Nurse) reviewed paper MARs and stated that R63 is not getting any type of supplement because there is not any order for it in the MARs. On 11/02/22 at 11:50 AM, V6 showed surveyor R63's lunch tray once R63 was finished eating. R63 consumed 100% spaghetti with meat sauce, 0% spinach, 0% bread, 0% dessert. On 11/02/22 at 1:30 PM, V17 stated that if V16 (Registered Dietitian) has a recommendation for a resident to be started on a supplement then V16 gives nursing a recommendation form and V17 would then call the physician to get the order approved. V17 stated that the physicians are very responsive and always approve V16's recommendations. V17 stated that once the supplement is approved by the physician the nurse would enter the order into the electronic medical record (EMR) and manually add the information to the paper MARs, so the nurses know to give out the supplement. V17 stated that the facility uses a (name brand) commercial oral supplement and that this supplement is in stock. Surveyor observed a carton of (name brand) commercial oral supplement on the 1st floor medication cart. On 11/02/22 at 1:55 PM, surveyor spoke with V16 (Registered Dietitian) over the phone. V16 stated that she (V16) is a consultant Registered Dietitian and one of her responsibilities is to complete high risk nutrition assessments include any weight loss changes 5% or more over 1-month period, 7.5% change or more over 3-month period, 10% change or more over 6-month period. V16 stated that she (V16) checks residents weights every visit for significant changes and addresses any weight triggers or concerns within the month they are identified. V16 stated that the EMR generates a weight report which flags residents who have had a significant weight loss and that she (V16) also manually checks the weight data to make sure it is accurate. V16 stated that all of her (V16) nutrition assessment/documentation is included in the progress note section of the EMR. V16 stated that she (V16) generates a consultant report at the end of every visit she (V16) makes to the facility which includes a list of residents seen, concerns and recommendations which are listed on separate recommendation forms. V16 stated that she (V16) emails this report and nutrition recommendation forms to V1, V2, and V8. V16 stated that the information on the nutrition recommendation form includes the resident's name, what her (V16) recommendation is and the rationale for the recommendation. V16 stated she (V16) also participates in a NARS (Nutrition At Risk & Skin) meeting monthly which is when residents who have lost weight would be discussed with the interdisciplinary team and to discuss nutrition recommendations submitted to make sure they were followed through on and that the physician was notified. On 11/02/22 at 2:30 PM, surveyor continued interview over the phone and asked V16 to review R63's weight data in the EMR and why the 22.8-pound weight loss which occurred from 08/2022 to 09/2022 was not addressed. V16 stated that typically when she (V16) sees a weight jump like that she (V16) would request for the resident to be reweighed to check the accuracy of the weight and that this request would be included on her (V16)'s consultant reports. V16 stated that it does not look like a reweight was obtained during the month of September. Surveyor asked V16 to view her(V16) September consultant reports and recommendation forms to see if she (V16) requested a reweight for R63. After reviewing her (V16) September 2022 reports V16 stated, I don't see it on the three reports I submitted in the month of September. V16 stated that she (V16) assessed R63 on 10/13/22 for unplanned weight loss and noted BMI (Body Mass Index) at that time was 19.2 which is below the desired BMI range for older adults which is between (23-27). V16 stated that she (V16) attributed R63's weight loss to poor appetite and that he (R63) was barely eating and consistently consuming <50% of meals. V16 stated that functional decline could also have contributed to some of the weight loss. V16 stated that she (V16) had recommended to start oral supplements on 10/13/22 to supplement R63's poor intake and help prevent further weight loss. V16 stated that she (V16) submitted this recommendation to V1 and V2 on 10/13/22. V16 provided a copy of this recommendation to surveyor. V16 stated there was no NARS meeting in the month of October and therefore her (V16) recommendations were not followed up with or discussed as a team. V16 stated that without the use of oral nutrition supplements R63 is at high risk for continued weight loss. Surveyor shared with V16 R63's current weight obtained 11/02/22 of 119.2 pounds and V16 stated that this amount of weight loss was very concerning and indicates another significant weight change. V16 stated R63 meets criteria for malnutrition based on the amount of weight loss, evidence of continued weight loss, low BMI and poor intake. V16 stated that the CNAs are documenting that R63 is consuming between 25-50% of meals. Surveyor asked V16 if she (V16) has ever conducted meal rounds observations with R63 or seen him (R63) eat a meal since R63 has been at the facility and V16 replied, no, I haven't done a meal round observation since he's been there and now that he's lost weight it would be appropriate to consider. Surveyor asked V16 if she (V16) has every met with R63 to review his (R63)'s food preferences and V16 stated, no because that is V8's responsibility. V16 stated that if R63 had received the nutrition supplement she (V16) had recommended it would have helped to prevent some of the weight loss which has occurred. Surveyor discussed R63's physician order for daily weight monitoring for CHF/Abnormal Weight Loss with V16 and V16 stated that if the weights were done the results would be entered into EMR system and that she (V16) does not see that the daily weights were being completed. V16 stated there is no separate weight binder. On 11/02/22 at 3:11 PM, V2 (Director of Nursing) stated that V16 sends her (V16)'s nutrition recommendations via email and then V2 prints them off and gives them to the nurses to follow through on by calling the physician. V2 stated that the order is carried out right away and that the physicians follow V16's recommendations because V16 is the nutrition expert. V2 stated that once the physician approves the recommendation nursing enters it into the EMR and the paper MAR. V2 stated that all weights are completed by the restorative department including initials, reweights, readmissions, weekly and daily if ordered. On 11/02/22 at 3:30 PM, V10 (Restorative Director) stated that all weights are entered into EMR system and that the weight sheet forms used by the restorative aides to enter the weights on are shredded as soon as they are entered into the EMR system and because of this V10 stated there are no weight data sheets available to review. V10 stated none of the residents are on daily weights right now and that if any of the residents had orders for daily weights, they would be entered into the EMR system, and that there is no separate weight binder(s). On 11/03/22 at 10:21 AM, V2 stated that she (V2) was aware of R63's weight loss based on 119.2-pound weight obtained on 11/02/22. V2 stated that restorative reported this to nursing who will then contact V8 and V16 for recommendations. V2 stated it is the nurse's duty to call the doctor and that the nurse will then write a progress note in the EMR indicating that the doctor was notified about the weight loss. On 11/03/22 at 1:46 PM, surveyor spoke with V35 (Attending Physician) over the phone. V35 stated that he was not aware that R63 had lost weight and that he (V35) has not received a recent phone call and does not recall being notified of any weight loss from 08/2022-09/2022. V35 stated, maybe he is not eating well. V35 stated that R63 is probably losing weight due to a combination of dementia, acute cholecystitis requiring a drainage tube and poor intake. V35 stated R63 does not have a diagnosis of cancer. V35 stated R63 had a diagnosis of abnormal weight loss upon admission to the facility. Surveyor told V35 R63's current weight of 119.2 pounds compared to initial weight of 148 pounds upon initial admission in July 2022. V35 stated due to the weight loss identified a nutritional replacement with use of oral supplement would be recommended, calorie counts to see what R63 is actually eating and that R63 may need a tube feeding placement due to having lost so much weight. V35 stated that he (V35) was not aware that the Registered Dietitian had made a recommendation to start oral supplements last month. V35 stated that since there is no order for an oral supplement in the EMR system then either the facility did not call him (V35) or the call was not relayed however V35 stated that the nurse typically would enter a progress note into the EMR to indicate that the physician was called, and message was left with a call back requested. V35 stated that he (V35) does not see a nursing progress note indicating he (V35) was called and stated, there is your answer. V35 stated resident does have a diagnosis of heart failure but has not been on diuretics since admission to the facility. V35 stated that there is an order for R63 to have daily weights due to heart failure upon admission and this recommendation likely came from the hospital. V35 stated that if the daily weights were being done at the facility R63's weight loss would have been identified earlier. On 11/03/22 at 2:05 PM, R63 stated that he (R63) does not know why he (R63) he is losing weight. R63 stated, I can feel it, look at my arms they are skinny. R63 stated that he (R63) has not been offered a supplement since he's been at the facility, but he stated, I'd take it if they gave it to me. On 11/04/22 at 8:22 AM, via email correspondence surveyor requested percentage meal intake documentation for all meals for R63 from 8/1/22 - present. V1 (Administrator) responded via email at 10:56 AM that, Unfortunately, there was no in-take recorded for (R63). R63 has diagnosis not limited to Dementia, Heart Failure, Cholecystitis, Cerebrovascular Disease, Dysphagia, Abnormal Weight Loss, Unspecified Toxic Encephalopathy. R63 MDS (Minimum Data Set) dated 08/01/22 BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognition. R63's Active Orders printed on 11/01/22 documents in part, daily weights (CHF/Abnormal Weight Loss) once a day at 9:00 AM ordered 07/27/22, diet: NAS, low cholesterol/low fat, regular with thin liquids three time a day ordered 10/03/22. R63's care plan dated 08/02/22 documents in part, R63 is at high (risk) for malnutrition related to diagnosis and conditions that affect nutritional status, and at risk for excess fluid volume related to left sided CHF and weigh daily, report to physician if greater than 2 pound weight gain per week. R63's Dietary progress note dated 08/08/22 at 01:12 PM completed by V16 (Registered Dietitian) documents in part, PO intake are between 25-50% for most meals, requires extensive assistance from staff during meals, open area to sacrum, BMI 22.7 is below normal weight range for advanced age, weight gain/stability is desirable for resident, will monitor weight trends. Weight used to complete this assessment was 149.6 pounds. R63's Dietary progress note dated 10/13/22 at 05:02 PM completed by V16 documents in part, weight (10/8) 127.8 pounds, BMI 19.4 is below normal weight range for advanced age, weight is stable from last month follows a period of unplanned/significant weight loss possibly related to functional declines, weight gain is desired for resident related to high risk for malnutrition and recommend adding liquid oral supplement 4 ounces twice a day to support weight gain, will monitor weight trends. Facility document titled, Weight Variance Report 05/03/22-11/03/22 for R63 documents weight as follows: (07/27/22 at 10:24 AM weight 148.4, BMI 22.56), (08/03/22 at 12:28 PM weight 149, BMI 22.65), (08/08/22 at 2:49 AM weight 149.6, BMI 22.74), (08/17/22 at 12:29 PM weight 148.2, BMI 22.53), (09/02/22 at 10:43 AM weight 126.2, BMI 19.19, -22 weight loss, -14.8% weight change in 16 days), (10/03/22 at 9:45 AM weight 127.8, BMI 19.43), (10/08/22 at 10:34 AM weight 127.9, BMI 19.43), (11/2/22 at 10:44 AM weight 119.2, BMI 18.12, -8 pound loss, -6.7% change in 25 days). V16 provided document titled, Dietary Recommendations for Physician Approval dated 10/13/22 documents in part, recommend adding (commercial liquid oral supplement) 4 ounces twice a day to support weight gain for R63. The form is not signed by R63's physician (V35). Facility document titled, Medications Flowsheet from 10/1/22-10/31/22 for R63 documents daily weight (CHF/Abnormal Weight Loss) once a day dated 07/27/22 with no entry weights documented for the month of October 2022. Facility job description titled, Consultant Dietitian Job Description undated, documents in part, providing clinical nutrition expertise on a consultation basis including nutrition assessment, maintain compliance with state and federal regulations, provide nutrition assessment not limited to significant changes, weight changes, and submit a written report to facility after each visit: directly to the administrator and the Dietary Manager and Director of Nursing for specific actions to be taken. Facility job description titled, Licensed Practical Nurse and Registered Nurse dated 10/11/2019 documents in part, receive and transcribe telephone order from physicians and record on the Physician's Order Form. Facility policy titled, Weight Assessment and Intervention dated August 2008 documents in part, the nursing staff and the Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss, weights will be recorded in the clinical record of the resident, any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation, if weight is verified and triggers a significant weight change the physician will be notified, negative trends will be assessed and addressed by the Dietitian, significant weight changes are defined as: more or less than 5% within 30 days, 7.5% or less within 90 days, and more or less than 10% within 6 months, liquid nutritional supplements may be considered if resident calorie intake remains inadequate to stabilize or increase weight, the resident's physician and resident's family/responsible party should be notified of any significant weight loss. Facility policy titled, Weight Maintenance undated documents in part, the facility to monitor the nutritional status of all residents including all significant weight change, an Evaluation of Significant and Insidious Weight Change Observation will be completed anytime there is a noted significant weight fluctuation, in the case of a significant weight change notify the physician and responsible party, the Dietitian will make recommendations and the director of nursing will refer all recommendations to the appropriate department for action and ensure physicians are informed of significant weight fluctuations or concerns regarding a change in the resident's nutritional status.