**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy to ensure resident to resident physical abuse did not occur for one resident (R1) reviewed for abuse in a sample of five. Findings include:Facility's Initial and Final Reports to (State Department of Public Health) document: On 6/2/25 (R1) was noted on the patio when his wheelchair tipped back. Initial reports stated (R1) did a wheelie and fell. Further investigation, (R1) stated four residents (R2-R5) hit him multiple times and pulled his wheelchair back. R1 stated he did not fall out of his chair. R1 stated that R4 pulled his/R1's wheelchair backward. Residents (R2-R5) involved were questioned and admitted they hit him/R1. Police were called. R1's Minimum Data Set/MDS dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) of 14 on a scale of 00 - 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) (Documentation shows that R2, R3 and R4 have BIMS of 15; R5 has a BIMS of 13.) R1's current Care Plan documents: (R1) has a history of provoking peers. He requires assist of staff due to weakness/paralysis to left arm and leg related to history of stroke and traumatic brain injury. (R1) has history of behavior of purposely sliding himself down in his wheelchair even immediately after staff has repositioned him. (R1) has diagnosis of epilepsy with no recent episodes noted. (R1) is at risk for falls due to impaired balance and mobility. On 7/16/25 at 12:25pm, R1 stated that during the 6/2/25 altercation with R2-R5, They beat me up; one guy flipped my chair, tilted me back and I couldn't move. They just don't like me. On 7/17/25 at 9:15am, R1 stated that R4 Grabbed my wheelchair and flipped it over. On 7/17/25 at 9:35am, R2 stated regarding the 6/2/25 incident with R1, Everything happened so fast. Minding my own business; (R1) had called my mother a bitch and also called R5 a bitch; I laughed at (R1) about the whole thing and that's what he gets. On 7/16/25 at 12:50pm, R3 stated that on 6/2/25, that he was on the patio for smoking break. R3 stated that he had just gone to court in person today for the incident with R1; and got six months court supervision. R3 stated, I plead guilty to battery. R3 stated R3 was charged with mob action, aggravated battery. R3 stated that R1 got smart and cursed at R3. R3 stated, I have Post Traumatic Stress Disorder/PTSD and I popped (R1) in the mouth. He likes to be in everyone's way out on the patio. Asked him to move and he said to me Fxxx you fat ass, and I punched him in the mouth. There are four defendants including R2, R4 and R5, and we all got charged. On 7/16/25 at 12:50pm, R3 stated that during the incident, R1 was screaming and they/staff heard him. R1 got exactly what the hell he deserves; he bullies and curses everyone, even staff. On 7/16/25 at 1:00pm, R4 stated that he did not know who hit R1 first but did admit to hitting R1 as well. On 7/16/25 at 12:45pm, R5 stated, I hit him (R1) because he kept calling me a bitch, and my mother used to call me that and that triggered me. R5 stated that she did apologize to R1. On 7/17/25 at 12:45pm, V1 Administrator stated that she was surprised she did not hear about the 6/2/25 incident initially as a physical altercation. V1 stated V1 was surprised that R1 nor any of the other residents did not report the altercation. V1 stated, The residents do talk. I did not see R1 trying or attempting to do wheelies on the video (facility camera video of 6/2/25 incident); R1 was moved to the South Hall on 6/3/25 after review of the video; he did not go to the hospital; no injuries. On 7/17/25 at 10:17am, V4 Rehab Social Worker stated that the 6/2/25 altercation with R1 and R2-R5 was on a Monday around 11am; stated that she was outside the facility on her cigarette break and heard R1 yelling ‘Staff'; stated that R1 yells staff all the time, like just to have TV on, to get him a soda. V4 stated that R1 kept yelling and she wondered why. V4 stated that she V4 went inside the building and went to the patio; did not see him at first, that R1 was flipped backwards in his wheelchair. At this same time, V4 stated that when she went to tend to R1 for his yelling, that R2-R5 were laughing--saying that R1 was trying to do a wheelie. V4 stated that she V4 asked the residents why not get help and they said, Because it's (R1). On 7/17/25 at 10:17am, V4 stated that on 6/3/24 when they ran the camera video back, saw that R2 hit R1 first in the face; R5 hit him on his leg and arm, then R3 hit R1 in his face on the right side a couple of times; stated that R4 then hit R1 in the face, got up from R4's own wheelchair, laid the back of R1's wheelchair back and flipped R1 backwards. V4 stated that after the video was viewed, that R2-R5 admitted to hitting R1. V4 stated, R5 was the first one who said she was sorry; and she apologized to R1 before he was moved to the South Side from the North side. R3 was making threats and said he should have done more to R1.The Facility's Abuse Prevention Program Policy Dated 6/3/24, documents: This facility affirms the right of our residents to be from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians., friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.

Based on interview and record review, the facility failed to monitor, supervise, and follow its policy to ensure safe smoking environment for two residents (R1, R4) of five residents reviewed for smoking in a sample of five.Findings include:Documentation and interviews indicated that R1 and R4 were smokers. The facility's Incident Investigation Report Dated 6/2/25 documents both R1 and R4 were on the facility's patio for a smoke break when an altercation occurred involving R1 and R4. 1.R1's current Care Plan documents: (R1) is a level III supervised smoker. Interventions: Staff will remind (R1) about smoking policy and procedures as needed. Staff will supervise and assist (R1) with smoking safely. 2. R4's current Care Plan documents: (R4) is a smoker and requires supervision while smoking to maintain safety. Interventions: Staff will remind resident about smoking policy and procedures as needed. Staff will supervise and assist resident with smoking safely.On 7/16/25 at 12:50pm, R3 stated that there were no staff on the smoking patio prior to (6/2/25 altercation involving R1). R3 stated, After the incident, (R1) was screaming and they heard him; (V4 Rehab Social Worker) heard (R1) and came to the patio.On 7/17/25 at 9:35am, R2 stated that there were no staff on the patio on 6/2/25. R2 stated, They (Staff) came out there right after the mess (altercation involving R1).On 7/17/25 at 9:18am, R5 stated that no staff were out on the patio on 6/2/25 and staff had not been out there for their smoke breaks even prior to the 6/2/25 incident. R5 stated, Now they (Staff) have to be there since the incident.On 7/17/25 at 9:45am, V3 Activity Director stated that Staff were probably not out there on the patio to supervise on the 6/2/25 incident date. V3 stated that independent smokers could have been out on the patio without supervision. V3 stated, (R1) should not have been out there with staff monitoring; he is not independent; (R4) was supervised like (R1).On 7/16/25 at 2:30pm, V1 Administrator stated: There were no staff on the patio to supervise; a staff should have been out there supervising. The Activity Aide (V5) should have been on the patio supervising. He was supposed to be but stepped away to do a one on one when another staff had to step away. Facility's Smoking Safety Policy and Procedure, updated 6/5/25, documents: Supervised Smoking Program: Patients in the supervised smoking program need assistance and monitoring to maintain safety while smoking.The facility's Smoke Pass Times documents: Scheduled resident n times include 7am by designated staff: Security; 9am, 11am, 1pm, 3pm, and 5pm by designated staff: Activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse for one of four residents (R5) reviewed for abuse in a sample of seven. Findings include: R2's current Face Sheet documents R2 admitted to the facility on [DATE] with the following diagnoses, but not limited to: Unspecified Dementia (without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety), Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. R2's MDS (Minimum Data Set) Assessment, dated 5/6/25, documents R2 is cognitively intact and ambulates without assistance. R2's current Care Plan documents, (R2) has a history of inappropriate sexual behaviors. R5's MDS Assessment, dated 4/8/25, documents R5 is cognitively intact. On 5/19/25 at 12:55 PM R5 was sitting in the south dining room at a table in a chair. R5 was visibly upset and stated, (R2) constantly sexually assaults me and I don't like it at all. (R2) intentionally comes over by me and does sexual gestures with his fingers (makes his pointer finger and middle finger into a V shape, puts them up by his mouth, and sticks his tongue in and out). (R2) is trying to say he wants to do something sexual to me. (R2) is always saying directly to me I want to have sex with you just me and you me and you forever and let's go have sex. I have told him multiple times I don't like it, and he won't quit. I have PTSD (Post Traumatic Stress Disorder) because I was raped as a child. I have reported what (R2) has said and done to me to (V1/Administrator) a few months ago and multiple times before that including different staff members, but (V1/Administrator) says there is nothing they (the facility) can do besides re-direct (R2). R5 stated R2 just did the same sexual gestures to her last week and said again let's have sex to her in the dining room. On 5/19/25 at 1:02 PM V10/Restorative Aide stated, (R2) talks inappropriate to (R5) a lot. I think he does it to (R5) because he knows she does not like it. I have witnessed (R2) make sexual gestures to (R5) with his fingers and say things to her like let's have sex. (V1/Administrator) is aware of (R2) talking inappropriately to (R5) and just tells us too re-direct (R2). I don't know if I reported it myself to (V1), but I know she is aware of it. On 5/20/25 at 2:43 PM V15/Social Services stated, It was reported to me by (V17/Housekeeper) that he saw (R2) standing at (R5)'s table in the dining room and overheard (R2) telling (R5) and her boyfriend (R8) that if (R8) would have slept in a little longer, he would have had (R5) down to his room having sex with her. On 5/21/25 at 10:06 AM V17/Housekeeper stated While (R5) and (R8) were sitting at a table in the dining room (a month or two ago) I saw (R2) go over to their table and tell them both that if (R8) wouldn't have gotten up so early and down to the dining room with (R5), that he would have taken (R5) back to his room to have sex with her. (R5) was upset with him saying that. I reported it to (V15/Social Services) right after it happened. On 5/21/25 at 12:33 PM V1/Administrator verified (R5) did report to her around two months ago that (R2) was making sexual gestures with his hands directly to her constantly and that she didn't like it. V1 also verified R5 has reported to her in the past (could not remember exactly how long) that R2 kept telling R5 that he wanted to have sex and R2 asked him to stop, and he wouldn't stop asking her. V1 stated, I did not document when (R5) and I had these conversations and should have. The facility's Abuse Prevention Program Policy, dated 6/3/24, documents Abuse means any physical or mental injury or sexual abuse inflicted upon a resident other than by accidental means. Abuse is the willful infliction if injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report potential resident to resident sexual abuse allegations to the Administrator and state agency for one of four residents (R5) reviewed for abuse in a sample of seven. Findings include: R2's current Face Sheet documents R2 admitted to the facility on [DATE] with the following diagnoses, but not limited to: Unspecified Dementia (without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety), Bipolar Disorder, Major Depressive Disorder, and anxiety disorder. R2's MDS (Minimum Data Set) Assessment, dated 5/6/25, documents R2 is cognitively intact and ambulates without assistance. This same MDS also documents R2 is cognitively intact and ambulates without assistance. R2's current Care Plan documents, (R2) has a history of inappropriate sexual behaviors. R5's MDS Assessment, dated 4/8/25, documents R5 is cognitively intact. As of 5/19/25, the facility's reports in the last four months to the local State Agency did not contain documentation of R2 potentially sexually abusing R5 as being reported. On 5/19/25 at 12:55 PM R5 was sitting in the south dining room at a table in a chair. R5 was visibly upset and stated, (R2) constantly sexually assaults me and I don't like it at all. (R2) intentionally comes over by me and does sexual gestures with his fingers (makes his pointer finger and middle finger into a V shape, puts them up by his mouth, and sticks his tongue in and out). (R2) is trying to say he wants to do something sexual to me. (R2) is always saying directly to me I want to have sex with you just me and you me and you forever and let's go have sex. I have told him multiple times I don't like it and he won't quit. I have PTSD because I was raped as a child. I have reported what (R2) has said and done to me to (V1/Administrator) a few months ago and multiple times before that including different staff members, but (V1/Administrator) says there is nothing they (the facility) can do besides re-direct (R2). R5 stated R2 just did the same sexual gestures to her last week and said again let's have sex to her in the dining room. On 5/19/25 at 1:02 PM V10/Restorative Aide stated, (R2) talks inappropriate to (R5) a lot. I think he does it to (R5) because he knows she does not like it. I have witnessed (R2) make sexual gestures to (R5) with his fingers and say things to her like let's have sex. (V1/Administrator) is aware of (R2) talking inappropriately to (R5) and just tells us too re-direct (R2). I don't know if I reported it myself to (V1), but I know she is aware of it. I should have reported it to (V1). On 5/20/25 at 2:43 PM V15/Social Services stated, It was reported to me by (V17/Housekeeper) that he saw (R2) standing at (R5)'s table in the dining room and overheard (R2) telling (R5) and her boyfriend (R8) that if (R8) would have slept in a little longer, he would have had (R5) down to his room having sex with her. I did not report this to (V1). I am still new, so I didn't even think about reporting it. On 5/21/25 at 10:06 AM V17/Housekeeper stated While (R5) and (R8) were sitting at a table in the dining room (a month or two ago) I saw (R2) go over to their table and tell them both that if (R8) wouldn't have gotten up so early and down to the dining room with (R5), that he would have taken (R5) back to his room to have sex with her. (R5) was upset with him saying that. I reported it to (V15/Social Services) right after it happened. I did not report it to (V1/Administrator) or anyone else and should have. On 5/21/25 at 12:33 PM V1/Administrator verified (R5) did report to her around two months ago that (R2) was making sexual gestures with his hands directly to her constantly and that she didn't like it. V1 also verified R5 has reported to her in the past (could not remember exactly how long) that R2 kept telling R5 that he wanted to have sex and R2 asked him to stop, and he wouldn't stop asking her. V1 stated, I did not document when (R5) and I had these conversations and should have. I did not report to the state agency what (R5) reported to me what (R2) was doing to her. If anyone is aware or witnesses any type of abuse, including sexual abuse they should immediately report it to me. The facility's Abuse Prevention Program Policy, dated 6/3/24, documents Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. VIII. External Reporting: A. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public health's regional office shall be informed by telephone of fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigation. This report shall be made immediately, but not later than two hours after the allegation is made, if the event that cause the allegation involve abuse or resulted in serious bodily injury.

Based on record review and interview, the facility failed to ensure an investigation was completed after potential resident to resident sexual abuse allegation was reported for one of four residents (R5) reviewed for abuse in a sample of seven. Findings include: As of 5/19/25, the facility's investigations for allegations of abuse did not contain documentation of R5 being sexually abused by R2. On 5/19/25 at 12:55 PM R5 was sitting in the south dining room at a table in a chair. R5 was visibly upset and stated, (R2) constantly sexually assaults me and I don't like it at all. (R2) intentionally comes over by me and does sexual gestures with his fingers (makes his pointer finger and middle finger into a V shape, puts them up by his mouth, and sticks his tongue in and out). (R2) is trying to say he wants to do something sexual to me. (R2) is always saying directly to me I want to have sex with you just me and you me and you forever and let's go have sex. I have told him multiple times I don't like it and he won't quit. I have PTSD because I was raped as a child. I have reported what (R2) has said and done to me to (V1/Administrator) a few months ago and multiple times before that including different staff members, but (V1/Administrator) says there is nothing they (the facility) can do besides re-direct (R2). R5 stated R2 just did the same sexual gestures to her last week and said again let's have sex to her in the dining room. On 5/21/25 at 12:33 PM V1/Administrator verified (R5) did report to her around two months ago that (R2) was making sexual gestures with his hands directly to her constantly and that she didn't like it. V1 also verified R5 has reported to her in the past (could not remember exactly how long) that R2 kept telling R5 that he wanted to have sex and R2 asked him to stop, and he wouldn't stop asking her. V1 stated she did not document when her and R5 had those conversations, nor did an investigation regarding the alleged allegations. The facility's Abuse Prevention Program Policy, dated 6/3/24, documents Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. A. All incidents will be documented whether abuse, neglect, exploitation, mistreatment, or misappropriation of resident property occurred, was alleged or suspected. B. Any incident or allegation, involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. D. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewed. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents.

Based on interview, observation and record review, the facility failed to protect residents from episodes of physical abuse occurring from 10/29/24 - 02/25/25 for seven (R1, R2, R4, R6, R7, R12 and R14) reviewed for abuse in the sample of 16. Findings include: The facility's 'Abuse Prevention Program Facility Policy' (updated 06/03/24) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This same policy documents, The facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This policy also documents, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction on injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 1. The facility's Incident Investigation Report (dated 10/29/24) documents the following: On 10/29/24 at 09:10 AM on H Hall, (R4) and (R1) were physically aggressive toward one another, hitting each other with closed fists. Residents were separated and counseled. No injuries were noted, (R4) was sent to the hospital for a psychiatric evaluation, and he was asking to go stating he wasn't feeling well. (R4) thought (R1) was going to hurt him so he hit (R1) first. Police involved in transport. This same investigation documents the following Action Plan: Care Plans updated and staff reminded to use hands-on assistance to redirect (R1) from peers rooms. (R4) reassured and reminded of alternate ways to handle situations. On 03/20/25 at 08:20 AM, V7 (Housekeeping) stated she witnessed the 10/29/24 altercation between R1 and R4. V7 stated, (R1) was following me around in the hall while I was cleaning. He always walks with me. I had pushed my (housekeeping) cart down the hall and had stopped it near (R4's) room. (R1) was standing in the hall in front of the doorway to (R4's) room. (R1) must have been in (R4's) view because I turned around for a second to grab something from my cart, and when I turned back around, (R4) was punching (R1). I called for help and (R1 and R4) were separated. R1's Minimum Data Set Assessment (dated 12/23/24), Section C, documents a Brief Interview of Mental Status assessment was not able to be conducted on R1 due to R1's impaired cognition (rarely/never understood). This same section also documents R1 has a short- and long-term memory problem. On 03/19/25 at 01:20 PM, R1 was wandering throughout the H hallway carrying an empty disposable plastic cup. R1 was dressed and groomed and was wearing nonskid socks. R1 appeared to be pleasantly confused and was cooperative at this time. R4's current medical record documents R4's diagnoses to include Anxiety Disorder, Delusional Disorder, and Disorientation. On 03/20/25 at 10:10 AM, R4 was lying in bed watching television. R4 was dressed and groomed, and a wheeled walker was nearby his bed within his reach. R4 denied ever having any altercations with anyone at the facility at this time and stated, I get along with everyone. On 03/20/25 at 08:40 AM, V1 (Administrator) stated that R1 and R4 did have a physical altercation on 10/29/24. V1 stated, (R1) was walking in the hallway and stepped in view of (R4's) doorway, and that's when (R4) approached him and started hitting him. V1 then stated R1 has a diagnosis of Dementia and frequently wanders throughout the facility. 2. The facility's Incident Investigation Report (dated 11/02/24) documents the following: On 11/02/24 at 12:50 AM on G Hall, (R1) and (R9) ran into one another causing both to fall to the floor. (R9) then hit (R1) in the forehead twice with a closed fist. Residents were separated and staff assessed for injuries- none noted. When nurse expressed to (R9) that the collision was an accident, (R9) apologized to (R1). This same investigation documents the following Action Plan: Staff reminded to redirect (R1) from other halls and intervene proactively. (R9's) care plan updated, and staff re-educated to intervene early if agitated- remind him to walk slowly toward corners of halls. R1's Progress Note (dated 11/02/24) documents the following: This resident was struck by another resident twice in the forehead after apparently tripping over him and taking both to the floor in the hallway of G-Hall. Full body assessment reveals no signs or symptoms of injury at this time. Resident placed on head protocol. (V6, Medical Director) and (V1, Administrator) notified and family notification pending. On 03/26/25 at 11:40 AM, V2 (Director of Nursing) stated she obtained a statement from V14 (Registered Nurse), who was the individual that responded to the 11/02/24 altercation between R1 and R9. V14's statement, which was documented by V2 and included in the facility's incident investigation, documents the following: (V2) Spoke with (V14)- he stated that (R1) was walking up the hall on G Hall, when he tripped and fell into (R9). (R9) then struck (R1) before (V14) could get to them. (R1) was struck in the head two times. On 03/26/25 at 09:00 AM, V1 (Administrator) confirmed R9 physically abused R1 on 11/02/24. V1 stated R9 is no longer residing at the facility because he refused to return to the facility after he was sent to a local hospital for evaluation following an incident that occurred on 11/18/24. 3. The facility's Incident Investigation Report (dated 11/10/24) documents the following: On 11/10/24 at 02:10 PM, in the main dining room, (R1) was pushing (R3's) wheelchair which upset him (R3). (R1) didn't understand (R3) wanted his chair back. (R3) hit (R1) in the face with a closed fist. Staff immediately separated and counseled the residents. This same investigation documents the following Action Plan: To prevent further abuse, (R3) was reminded to resolve conflict and that physical aggression can hurt himself and others. Staff reminded to redirect (R1) when noticing he has something of a peers. R1's Progress Note (dated 11/10/24 and timed 02:23 PM) documents, Resident was noted pushing a wheelchair around facility. Resident peer noticed that it was his wheelchair and wanted it back. An argument ensued and then this resident was hit several times in the face with a closed hand. R1's Progress Note (dated 11/10/24 and timed 09:45 PM) documents, Resident continues to wander and needs frequent redirection from entering peers' rooms. He becomes agitated with staff during redirection and starts pushing staff and attempts to strike staff. He refuses to go to bed at night and when he does go to bed, he only stays in the bed a short time and gets back up wandering again. He remains on H.P. (head protocol) with no s/s (signs and symptoms) neurological deficits. On 03/18/25 at 02:40 PM, V4 (Certified Nursing Assistant) stated the following in regards to the 11/10/24 incident involving R1 and R3: I remember (R1) was pushing a wheelchair and we had taken it away from him. He wandered and found another wheelchair. We had seen him pushing it and wondered whose wheelchair it was. Then I heard some commotion and (R3) was hitting (R1). I ran to break it up. (R3) had punched (R1) in the face at least three times before I had got to them. On 03/19/25 at 01:45 PM, R3 was seated on his wheeled walker against the back wall in the dining room. R3 was dressed, groomed, and was drinking a can of soda, and stated he purchased the soda from the vending machine. R3 stated he has had, Some disputes with a few (residents), in the past, but that ain't no big deal now. On 03/18/25 at 02:05 PM, V1 (Administrator) confirmed that (R3) physically abused (R1) on 11/10/24. 4. The facility's Incident Investigation Report (dated 11/12/24) documents the following: On 11/12/24 at 09:15 AM in the main dining room, (R5) went behind (R6's) wheelchair, grabbed the handlebars and tipped (R6's) chair backwards causing (R6) to fall. (R6) did not hit her head and she got up on her own. No injuries noted. Both residents were 'talking nonsense' per witnesses. Staff separated and monitored the two women. This same investigation documents the following Action Plan: To prevent further abuse, staff were educated to monitor (R5) and (R6) in common areas and redirect them from one another/other peers who may trigger them. R5's Progress Note (dated 11/12/24) documents the following: Per witness resident (R16), (R5) was yelling/arguing with staff and female peer (R6). This resident (R5) noted to ambulate over to (R6), grabbed handles of wheelchair causing foot to base of wheelchair tilting wheelchair causing peer (R6) to fall from wheelchair. Both residents continue to argue as staff separated. Resident (R5) refuses to have vital signs done and full assessment. No apparent injuries noted. No complaints voiced. (V6, Medical Director), administrative staff notified. On 03/20/25 at 01:20 PM, R16 was sitting in his wheelchair near the window in the dining room. R16 was moving chess pieces around on a chess board, and recalls witnessing the 11/12/24 altercation that occurred between R5 and R6. R16 stated, They sit at different tables in the dining room, but they began arguing. (R5) got up and walked over to (R6). R16 then motioned his hands mimicking gripping an object, pulled his hands back toward his chest and explained as he mimicked R5 grabbing R6's wheelchair and tipping R6 wheelchair over backwards while R6 was sitting in it. R5's current medical record documents R5's diagnoses to include Major Depressive Disorder, Frontotemporal Neurocognitive Disorder, and Schizoaffective Disorder. On 03/20/25 at 02:25 PM, R5 was lying in bed with the hood of her shirt covering her head. R5 was mumbling incomprehensible phrases when greeted by this surveyor, and eventually stated, Get out. You need to get the hell out of here. R5 was not interviewed due to refusal. R6's current medical record documents R6's diagnoses to include Schizoaffective Disorder Bipolar Type, and Post Traumatic Stress Disorder. On 03/20/25 at 01:05 PM, R6 was propelling her wheelchair toward the vending machines in the dining room. When this surveyor approached and attempted to speak to R6, R6 began waving her left hand in the air above her, refused to speak with this surveyor and yelled the following nonsensical phrase: Nope! One went to heaven, and one went to hell, and I don't really care about any of it. On 03/20/25 at 12:40 PM, V1 (Administrator) confirmed R5 physically abused R6 on 11/12/24 when R5 deliberately tipped R6's wheelchair causing R6 to fall. 5. The facility's Incident Investigation Report (dated 11/13/24) documents the following: On 11/13/24 at 12:10 PM in the main dining room, (R8) was rolling up to a dining room table when (R7) started backing into her wheelchair. (R8) grabbed (R7's) arm and bit her. Redness was noted and ice was applied. Residents were separated to different tables and (R8) was counseled. (R8) has a diagnosis of Dementia and was confused as to what (R7) was doing. This same investigation documents the following Action Plan: Care Plan updated. To prevent further abuse, staff to intervene and assist (R8) proactively to address her needs (i.e. assist her to dining table). R7's Progress Note (dated 11/13/24) documents the following: (R7) noted arguing with peer (R8) over seating in dining room. Peer (R8) was pulling on (R7's) right arm and proceeded to pull her hair and bite her right forearm. Residents were separated and placed at different tables. Ice applied to (R7's) forearm. POA (Power of Attorney) contacted with no answer, left voicemail. Notified (V6, Medical Director) of incident. V11's written statement (dated 11/13/24) documents, Observed residents in dining room having an altercation. (R8) was pulling on the right forearm of (R7) and proceeded to bite her right forearm. (R7) was observed trying to pull arm back from (R8). This RN (Registered Nurse) did a head-to-toe assessment on both residents, separated them at dining tables. RN (Registered Nurse) placed ice on (R7) and received order for PRN (as needed) ice pack to site. V11 was not able to be interviewed due to currently being out of state on vacation. On 03/24/25 at 09:25 AM, R7 was sitting in her wheelchair at a table in the dining room with her eyes closed. R7 was dressed and several food particles and crumbs were covering her lap. R7 was confused and could not recall the 11/13/24 incident when she was bitten by (R8). On 03/24/25 at 08:55 AM, V2 (Director of Nursing) stated R8 is currently not in the facility. V2 stated R8 was admitted to the local hospital, and was discharged from the facility because, She was sent to (sister facility) for physical therapy. She has since been sent back to the hospital due to pulling out her PICC (peripherally inserted central catheter) line. I believe she pulled it out on Friday. On 03/24/25 at 08:45 AM, V1 (Administrator) stated, If I recall, (R8) didn't like (R7) at her table. The two began arguing, and (R8) pulled (R7's) hair and bit her. 6. The facility's Incident Investigation Report (dated 11/18/24) documents the following: On 11/18/24 at 11:45 AM in the Main Dining Room, (R9) was walking through and hit (R1) in the face with a closed fist which caused him to fall to the ground. No initial injuries were noted. Incident was unprovoked. Non-emergency police were called and consulted with psychiatrist. (R1) went to the hospital for evaluation; (R9) went to (local hospital) for psychiatric evaluation. This same investigation documents the following Action Plan: (R1) returned with no injuries and was placed on 1:1 monitoring for 72 hours. (R9) refused to return to the facility from the hospital and was discharged . R1's Progress Note (dated 11/18/24) documents the following: (R1) was walking past (R9), (R9) turned and punched (R1) in face, staff immediately separated residents, full body assessment implemented, assisted into a chair, vitals obtained, (R1) complains of jaw pain, (V6, Medical Director) notified. (R1) sent to (local hospital) for evaluation and treatment, bed hold policy sent with resident, Power of Attorney notified, and writer received no answer, message left on voicemail. On 03/24/25 at 11:15 AM, V9 (Front Desk) stated he vaguely recalls the incident that occurred between R1 and R9 over four months ago on 11/18/24. V9 verified his witness statement included in R1 and R9's 11/18/24 Incident Investigation and stated the following, A lot of time has passed since then. I believe (R9) was sitting at a table, and when (R1) walked by, (R9) suddenly got and punched him in the face pretty hard. I started heading toward them when I saw (R9) stand up, and got there to catch (R1) and assist him to the floor. On 03/24/25 at 11:35 AM, V1 (Administrator) confirmed R9 physically abused R1 on 11/18/24. V1 stated, We sent (R1) to the hospital to get checked out because he was hit very hard in the face. The (local police) came and spoke with (R9) and gave him the option to go to the hospital, or they would be taking him to jail. (R9) agreed to go to the hospital and when he was ready to be discharged , he refused to return to the facility. (R9) was his own POA (Power of Attorney). We notified (V6, Medical Director) who gave the okay for (R9) not to return. 7. The facility's Incident Investigation Report (dated 12/01/24) documents the following: On 12/01/24 at 02:02 PM in the main dining room, (R2) and (R1) were by the vending machines. (R2) was passing by (R1) and they began yelling at each other. (R1) hit the top of (R2's) head with a cup he was carrying. (R2) had a small laceration to his head. (V6, Medical Director), (V1, Administrator), responsible parties notified. (R2) was sent to the emergency room for evaluation. Returned with triple antibiotic ointment and a band-aid. On 03/18/25 at 02:20 PM, R15 stated he witnessed the incident between R1 and R2 on 12/01/24. R15 stated he recalls observing (R1) strike (R2) with a cup, but cannot recall much more, That was a long time ago. (R1) wanders around and does go into people's rooms. (R2) yells a lot. Due to R1's impaired cognition, he was unable to be interviewed about the 12/01/24 incident that occurred with R2. R2's Progress Note (dated 12/01/24 and timed 02:05 PM) documents the following: (R2) hit on the head with a cup by (R1) at the vending machine, (R2) sustained a little cut on the head that measures 0.5 centimeters by 0.2 centimeters with minimal bleeding. Area cleaned. Power of Attorney notified. (R2) placed on Head Protocol monitoring. Vitals as follows T (temperature) 97.6, (pulse) 78, R (respirations) 18, B/P (blood pressure) 140/81, SPO2 (pulse oximetry) 98. (V6, Medical Director) notified; order received to send (R2) to (local emergency department). (Emergency transport) here and resident taken to (local hospital). R2's Progress Note (dated 12/01/24 and timed 06:58 PM) documents the following: Resident returned from (local emergency department) with Triple Antibiotic Ointment and band-aid on the wound (abrasion), no new orders. Power of Attorney notified of his arrival. Will continue to monitor. On 03/19/25 at 01:35 PM, the door to R2's room was open approximately 6 inches. R2 was lying in a low bed with a fall mat in place and a bedside table positioned near the side of his bed. R2 was partially covered with a sheet, and was wearing a gown and an incontinence brief. An indwelling urinary catheter drainage bag was positioned inside of a dignity bag secured to the lower aspect of R2's bed. R2's call light was clipped on his bedding and within his reach. This surveyor knocked on R2's door and introduced herself. R2 became visibly upset and yelled, What are you doing? What do you want from me? R2 was not able to be interviewed regarding the 12/01/24 incident due to R2 becoming visibly upset upon greeting. On 03/18/25 at 02:30 PM, V1 (Administrator) confirmed that R1 physically abused R2 on 12/01/24 and stated, It happened. V1 then stated that staff were re-educated to remove objects from (R1) if he is carrying things in the facility, He has a tendency to take things of others that do not belong to him, and if staff see him carrying an item such as a cup, they should be intervening. 8. The facility's Incident Investigation Report (dated 12/05/24) documents the following: On 12/05/24 at 08:31 AM, (R2) was noted with bruising to his left eye. Upon investigation, (R10) admitted to hitting (R2) overnight. (R10) was receptive to counseling and requested a room move. (V6, Medical Director), (V1, Administrator) and responsible parties notified. Head protocol was initiated for (R2). This same investigation documents the following Action Plan: Care Plan updated for (R10) to seek out staff for help when bothered by peers/upset. Staff reminded to monitor (R2) if yelling at night to ensure safety and prevent abuse. On 03/19/25 at 03:35 PM, V5 (Certified Nursing Assistant) stated the following regarding the 12/05/24 incident involving R2 and R10: I had worked second shift on 12/04/24, and had put (R2) to bed. I worked day shift the following morning of 12/05/25, and when I went into (R2's) room to get him up for the day, I noticed (R2) had a black eye that he did not have when I put him to bed the night before. I reported it to (V1, Administrator). (R2) didn't say what happened when I asked him about his black eye. I talked to (R10), who had a shared bathroom with (R2) at that time. At first, (R10) tried to tell me he didn't know what happened to (R2), but then (R10) told me he went through the bathroom into (R2's) room during the night and punched (R2) because (R2) wouldn't stop hollering. R2's Progress Note (dated 12/05/24) documents the following: Resident (R2) noted with bruising to left eye (purplish). (R2) unable to fully recall how bruising occurred. Vital signs: blood pressure 134/78, temperature 98.2, 78 pulse, 20 respirations. Perl (Pupils equal and reactive to light) and no signs or symptoms of neurological deficits and no complaints voiced. No other apparent injures noted. Head protocol initiated. All appropriate parties notified. R10's Minimum data Set Assessment (dated 01/28/25) documents a Brief Interview of Mental Status score of 14, indicating R10 is cognitively intact. On 03/24/25, R10 declined to be interviewed. On 03/24/25 at 03:30 PM, V1 (Administrator) stated R10 physically abused R2 sometime between the night of 12/04/24 and morning of 12/05/25 when R10 entered R2's room through the shared bathroom. V1 then stated R10 admitted to punching R2 because R2 was yelling for an extended period of time. 9. The facility's Incident Investigation Report (dated 12/20/24) documents, On 12/20/24 in the South Main Dining Room, (R11) hit (R12) with a closed fist to the mouth, causing her lip to bleed. (R12) was (repeatedly) running her wheelchair into the table at dinner which bothered (R11). Staff intervened and separated the residents. (R11) calmed with counseling. This same investigation documents the following Action Plan: Care Plans updated for staff to assist (R12) into a regular chair during meal service. Staff re-educated and (R11) received counseling about aggressive behaviors. R11's Progress Note (dated 12/20/24) documents the following: (R11) was reported by staff that he hit (R12). When asked, he answered, I hit her with my right fist. (R12) kept coming back to (R11's) table while he was still eating his meal. Plan of care to place (R12) on a chair while other residents are still eating. (R11) and other residents will be away from being bothered by (R12) while eating. On 03/25/25 at 10:30 AM, V1 stated V10 (Registered Nurse), who witnessed the 12/20/24 incident between R11 and R12, is currently out of the country on vacation and will not be able to be reached for interview. V10's written witness statement (dated 12/20/24), which was included in the 12/20/24 Incident Investigation, documents the following: This nurse was alerted that (R12) was hit by (R11). When asked, (R11) stated, 'Yes I hit her.' (R12) was removed from (R11's) table. Prior to that this nurse was getting the medication of other residents to pass. (R12) was done with her dinner and she kept doing it (banging into R12's dining table with her wheelchair) where staff were redirecting her. She was hit on her lower lip that caused it to bleed. (R12) was removed away from (R11) and applied ice pack on her lower lip. (V2, Director of Nursing), (V1, Administrator), and (V6, Medical Director) notified. (R12) was seated on the chair. Power of Attorney notified. R11's Minimum Data Set Assessment (dated 02/11/25) documents a Brief Interview of Mental Status score of 15, indicating R11 is cognitively intact. On 03/25/25 at 12:40 PM, R11 was lying in bed covered with a blanket. R11's glasses and his call light were within his reach on a nearby bedside table. An indwelling urinary catheter drainage bag was secured to the lower aspect of R11's bed. R11 stated he recalls the 12/20/24 incident that occurred with R12. R11 stated, (R12) was banging on the tables (with her wheelchair) and was trying to run into people. She almost knocked two people over. I finally had enough and told her to knock her sh#t off. R11 lifted his right hand and made a fist, and then explained he did strike R12 in the face on 12/20/24 and stated, I'd had enough so I popped her in the mouth. I haven't had any issues since then, but she still bumps the tables. She knows exactly what she's doing. The staff come and take care of it when she is doing it. R12's Minimum Data Set Assessment (dated 03/04/25) documents a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. On 03/25/25 at 01:00 PM, R12 was sitting in her wheelchair alone at a table in the dining room. The arms of R12's wheelchair were padded, and R12 had bilateral forearm sleeves in place. R12 had her head placed down on the table. R12 raised her head upon greeting. R12 was able to answer a few simple yes/no questions, but then began verbalizing nonsensical words. R12 then began repeatedly moving her wheelchair back and forth striking the dining table she was seated at. R12's Progress Note (dated 12/20/24) documents, At 06:25 PM while in the dining area, (R12) was hit by (R11) on her lower lip that caused it to bleed. She kept hitting (R11's) table while he was eating. She was redirected many times and kept away from resident's table. When asked, (R11) he answered, 'I hit her with my right fist.' They were separated right away by staff. Head to toe assessment done. (V6, Medical Director), (V2, Director of Nursing), (V1, Administrator) notified. R12's Power of Attorney was notified too. V6 advised ice pack PRN (as needed), Tylenol PRN and neuro (neurological) checks. Care plan was updated to place (R12) on a chair during mealtime. Placed her on a one on one after she was back in her wheelchair when all residents are done with their meals. On 03/25/25 at 10:25 AM, V1 (Administrator) verified R11 struck R12 in the face on 12/20/24. V1 stated, (R12) has a history of repeatedly running her wheelchair into things. On 12/20/24, she was repeatedly running her wheelchair into the dining table where they (R11 and R12) were sitting. This upset (R11), and he hit (R12). We now transfer (R12) into a regular chair for meals. 10. The facility's Incident Investigation Report (dated 02/13/25) documents the following: On 02/13/25 at 11:00 AM in the North Dining Room, (R14) was yelling for a staff member as the staff member was exiting the bathroom. Before the staff member could get to (R14), (R13) approached (R14) and hit him in the face two times with a closed fist. Staff immediately intervened and separated the pair. Counseling provided. No injuries noted. This same investigation documents the following Action Plan: (R13) received counseling and care plan updated for (R13) to have patience with others' behaviors and allow staff to intervene without becoming aggressive. (R14) was reminded that yelling can bother peers and cause conflict. On 03/25/25 at 03:00 PM, V12 (Certified Nursing Assistant) stated she witnessed the 02/13/25 incident between R13 and R14. V12 verified her written statement included with the facility's Incident Investigation, and then stated the following: I ran to use the bathroom real quick. (R14) was yelling my name, which he frequently does when he sees me. One of his behaviors is yelling out. When I exited the bathroom, I could still hear (R14) yelling my name. As I was approaching, I saw (R13) propelling his wheelchair toward (R14), and before I had reached them, (R13) punched (R14) twice in the face pretty hard with a closed fist. (R13 and R14) were immediately separated. R13's Progress Notes (dated 02/13/25) documents the following: CNA (Certified Nursing Assistant) came to this nurse stating that (R13) and another resident (R14) got into a physical altercation. CNA stated that (R13) rolled up in his wheelchair on peer resident (R14) and proceeded to hit peer resident in his jaw two times with a closed fist. (R13) stated he hit (R14) in the face because he was yelling. Residents were moved to different parts of the dining room. Residents were reeducated on knowing how to avoid conflict with peer residents that share the same living environment. On 03/26/25 at 09:55 AM, R13 was sitting in a high-back wheelchair on the smoking patio smoking a cigarette. R13 was wearing a coat and stocking hat, and a full mechanical lift sling was in place underneath of him. R13 stated he has lived at the facility for 13 years, and gets along with 'most' residents. R13 stated he punched R14 in the face on 02/13/25 and added, (R14) is one I don't like. He's a pedophile, and I came unglued that day. R14's Minimum Data Set Assessment (dated 03/10/25) documents a Brief Interview of Mental Status score of 15, indicating R14 is cognitively intact. R14's Progress Note (dated 02/13/25) documents the following: CNA (Certified Nursing Assistant) came to this nurse stating that (R14) and another resident (R13) got into a physical altercation. CNA stated that peer resident (R13) rolled up in his wheelchair on (R14) and proceeded to hit (R14) in his jaw two times with a closed fist. Peer resident (R13) stated he hit (R14) in the face because (R14) was yelling. Residents were moved to different parts of the dining room. Residents were reeducated on knowing how to avoid conflict with peer residents that share the same living environment. On 03/26/25 at 09:40 AM, R14 was lying in bed watching television. R14's call light was within his reach, and R14 was sparsely covered with a blanket. R14 stated he recalls the 02/13/25 incident that occurred with R13 and stated, (R13) hit me in the jaw. Sometimes he be acting crazy. I was ok, and we haven't had problems since. On 03/25/25 at 03:15 PM, V1 (Administrator) confirmed R13 struck R14 in the face with a closed fist on 02/13/25. V1 stated, (R14) is one that yells out, and it can upset his peers. 11. The facility's Incident Investigation Report (dated 02/25/25) documents the following: On 02/25/25 at 06:55 PM in the dining room after dinner, (R5) grabbed the wheelchair handle bars behind (R6) and pulled her to the floor. Staff immediately intervened and separated the women. (R5) said that (R6) said something to her. Residents were redirected without further incident. (R6) sustained no injuries. This same report documents the following Action Plan: Residents were redirected to separate areas of the building and CNAs (Certified Nursing Assistants) on halls were instructed to monitor/keep them separate. No further issues occurred. R5's Progress Note (dated 02/25/25) documents the following: This resident (R5) was talked to negatively and confronted by a peer resident (R6) which caused her (R5) to tilt peer's wheelchair backwards, leaving it propped on the handles. Resident (R5) assisted to room for de-escalation. (V6, Medical Director) notified, guardian notified. No further action required. R6's Progress Note (dated 02/25/25) documents the following: Resident (R6) was talking negatively and being confrontational to another resident peer (R5). Resident (R5) then proceeded to tilt (R6's) wheelchair backwards, causing her chair to land on the handles propping the resident (in her wheelchair) upwards. (R6) never hit the floor no apparent injuries noted, full body assessment done. (V6, Medical Director) notified, guardian notified, no other concerns at this time. On 02/25/25 at 03:30 PM, V13 (Certified Nursing Assistant) stated she witnessed the 02/25/25 altercation that occurred between (R5) and (R6). V13 stated, (R5) got up from the table quickly, approached (R6), grabbed the handlebars to (R6's) wheelchair and pulled it backwards un[TRUNCATED]

Based on interview, observation and record review, the facility failed to implement behavioral interventions to prevent episodes of physical abuse for seven residents (R1, R4, R5, R6, R9, R11 and R12) reviewed for abuse in the sample of 16. Findings include: The facility's Abuse Prevention Program Facility Procedures policy (updated 06/03/24) documents the following: As part of the resident social history evaluation and Minimum Data Set assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. The facility's Behavior Monitoring policy (updated 06/05/24) documents the following: At any time the IDT (Interdisciplinary Team) may initiate resident checks for increased monitoring, either on an hourly, 15 minute or one-to one staff basis. This same policy documents, 'IDT will review residents on an increased monitoring and may discontinue checks at any time if they determine the monitoring is no longer necessary. This policy also documents, If a resident displays an increase in behavioral disturbances, his/her treatment plan will be reviewed and modified by the interdisciplinary team as needed. Any identified resident may be referred to the Psychiatrist for a medication efficacy review and adjustment as indicated. 1. R4's medical record documents R4's diagnoses to include: Anxiety Disorder, Delusional Disorder, and Disorientation. R4's Progress Note (dated 10/28/24) documents the following: (R4) noted in dining room. Approached female peer grabbed/placed hands to jawline of female peer in attempt to kiss peer then bit her on the left cheek. Both residents immediately separated. No injuries noted. Resident counseled regarding behavior. Family, administration and (V6, Medical Director) notified. R4's Progress Note (dated 10/28/24) documents the following: (R4) noted with increased mood swings with behavioral deficits. Attempted to hit a male peer with no provocation. (R4) counseled and begin to further become irate, expressing delusional comments related to events that are happening now. (R4) counseled by male staff member (R4) then expressed feeling of needing more medication. (Local mental health provider) here for weekly rounds and recommended to evaluate medication therapy for increased behaviors. R4's Progress Note (dated 10/28/24) documents the following: Assessed by (local mental health provider) today. New orders received to increase Seroquel (antipsychotic) to 100 milligrams by mouth every bedtime and start Seroquel 75 milligrams by mouth every morning, Depakote level in AM (morning). R4's Progress Note (dated 10/28/24) documents the following: (R4) was very agitated and was in a verbal altercation with a peer during breakfast approximately 08:45 AM this morning. (R4) was asked to calm down, (R4) abruptly left the dining room for approximately 10 minutes and returned still angry with the peer. R4's Progress Note (dated 10/29/24) documents the following: Summoned to hall per staff. (R4) noted in doorway of room having a physical altercation with another male resident (R1). Both parties immediately separated. (R4) refused vital signs and full body assessment. Per observation no physical injuries noted. No complaints voiced. (R4) counseled per psychiatric social department. Family, administrative staff and (V6, Medical Director) notified. The facility's Incident Investigation Report (dated 10/29/24) documents the following: On 10/29/24 at 09:10 AM on H Hall, (R4) and (R1) were physically aggressive toward one another, hitting each other with closed fists. Residents were separated and counseled. No injuries were noted, (R4) was sent to the hospital for a psychiatric evaluation, and he was asking to go stating he wasn't feeling well. (R4) thought (R1) was going to hurt him so he hit (R1) first. Police involved in transport. This same investigation documents the following Action Plan: Care Plans updated and staff reminded to use hands-on assistance to redirect (R1) from peer's rooms. (R4) reassured and reminded of alternate ways to handle situations. R4's current Care Plan documents the following focus: (R4) has a criminal background with charges of Aggravated Battery in 1994, Carry and Possess Firearm & Battery and Assault in 1985. (R4) may become physically aggressive with peers at times. This same care plan documents the following interventions were in place at the time of R4's altercation with R1 on 10/29/24: Encourage (R4) to participate in activities to increase positive peer interaction; Explain to (R4) the legal consequences of any new incidents of his previous offense; If staff notice (R4) in close proximity to a peer, staff to redirect and reassure his actions will not turn to physical aggression; Refer (R4) for Psychiatric consult as needed for increased agitation or aggression; Staff to intervene proactively when (R4) is becoming agitated with staff or peers to assist, reassure and redirect. R1's Current Care Plan documents the following focus: (R1) wanders throughout the facility, up and down halls and in common areas. (R1) may enter one of his peers' rooms without knowing due to Alzheimer's Disease. (R1) may pick up/mess with peers' belongings. This same care plan documents the following intervention was in place at the time of R1 and R4's 10/29/24 altercation: Staff will assist (R1) in maintaining appropriate boundaries between himself and peers/redirect from peers' rooms. On 03/20/25 at 08:40 AM, V1 (Administrator) stated that R1 and R4 had a physical altercation on 10/29/24. V1 confirmed R4 was never placed on 15-minute checks and stated, We can implement 15-minute checks or 1:1 monitoring with an increase in behaviors, and (R4) was having an increase in behaviors at that time. Looking back, we probably should have put him on 15-minute checks before the altercation with (R1) occurred, and staff should have redirected (R1) away from the doorway of (R4's) room. 2. R5's current medical record documents R5's diagnoses to include: Major Depressive Disorder, Frontotemporal Neurocognitive Disorder, and Schizoaffective Disorder. The facility's Incident Investigation Report (dated 11/12/24) documents the following: On 11/12/24 at 09:15 AM in the main dining room, (R5) went behind (R6's) wheelchair, grabbed the handlebars and tipped (R6's) chair backwards causing (R6) to fall. (R6) did not hit her head and she got up on her own. No injuries noted. Both residents were 'talking nonsense' per witnesses. Staff separated and monitored the two women. This same investigation documents the following Action Plan: To prevent further abuse, staff were educated to monitor (R5) and (R6) in common areas and redirect them from one another/other peers who may trigger them. R5's current care plan documents the following focus: (R5) has daily behaviors of yelling out in her room and common areas due to hallucinations related to Schizoaffective Disorder. (R5) may be physically aggressive at times. She can be resistive to redirection and refuses any medical intervention. This same care plan documents the following intervention was implemented on 11/12/24: Staff to monitor (R5) in common areas and redirect her from other residents whose behaviors may trigger her. R6's current Care Plan documents the following: (R6) experiences auditory hallucinations and has delusions that she is dead. (R6's) delusional comments may negatively impact others at times. This same care plan documents the following intervention was implemented on 11/12/24: Staff to monitor (R6) in common areas and redirect her from other residents whose behaviors may be triggered. The facility's Incident Investigation Report (dated 02/25/25) documents the following: On 02/25/25 at 06:55 PM in the Dining Room after dinner, (R5) grabbed the wheelchair handlebars behind (R6) and pulled her to the floor. Staff immediately intervened and separated the women. (R5) said that (R6) said something to her. Residents were redirected without further incident. (R6) sustained no injuries. This same report documents the following Action Plan: Residents were redirected to separate areas of the building and CNAs (Certified Nursing Assistants) on halls were instructed to monitor/keep them separate. No further issues occurred. On 03/27/25 at 09:15 AM, V1 (Administrator) stated that on 02/25/25, R5 became upset and proceeded to tip R6's wheelchair backwards causing R6 to fall after R6 had verbalized something that upset R5. V1 stated this is the second occurrence in which R5 has grabbed and tipped R6's wheelchair over in the dining room, and staff should be monitoring R5 and R6 closely when they are within close proximity of each other. 3. The facility's Incident Investigation Report (dated 11/02/24) documents the following: On 11/02/24 at 12:50 AM on G Hall, (R1) and (R9) ran into one another causing both to fall to the floor. (R9) then hit (R1) in the forehead twice with a closed fist. Residents were separated and staff assessed for injuries- none noted. When nurse expressed to (R9) that the collision was an accident, (R9) apologized to (R1). This same investigation documents the following Action Plan: Staff reminded to redirect (R1) from other halls and intervene proactively. (R9's) care plan updated and staff re-educated to intervene early if agitated- remind him to walk slowly toward corners of halls. R1's Current Care Plan documents the following focus: (R1) wanders throughout the facility, up and down halls and in common areas. (R1) may enter one of his peers' rooms without knowing due to Alzheimer's Disease. (R1) may pick up/mess with peers' belongings. This same care plan documents the following intervention is currently in place: Staff to redirect (R1) from other halls and escort him to his room as needed. R9's most recent Care Plan documents the following focus initiated on 06/21/23: (R9) has a diagnosis of Paranoid Schizophrenia and Major Depressive Disorder. (R9) has been observed to make delusional statements and respond to auditory hallucinations. He may be physically aggressive related to his paranoia. This same care plan documents the following interventions were in place at the time of R9's altercation with R1 on 11/02/24: (R9) has specific peers who trigger his delusional thought process. Staff to proactively intervene to prevent altercations; Encourage (R9) to vent his feelings when he feels uncertain or upset for any reason at any given moment; Observe (R9) to find what may trigger hallucinations/delusions to eliminate behaviors; Remind (R9) of potential legal consequences of physical aggression toward peers; Remind (R9) to get staff if peers are in his space/bothering him; Staff to intervene proactively if noticing (R9) is agitated by peers that may trigger aggression; Staff to provide 1:1 counseling to reassure paranoid thoughts. On 03/26/25 at 09:00 AM, V1 (Administrator) confirmed R9 physically stuck R1 in the face on 11/02/24. V1 stated at the time the 11/02/24 incident occurred, R1 was ambulating in a hall in which he did not reside, and staff should have redirected R1 out of the hall he was wandering in at that time. 4. The facility's Incident Investigation Report (dated 12/20/24) documents, On 12/20/24 in the South main Dining Room, (R11) hit (R12) with a closed fist to the mouth, causing her lip to bleed. (R12) was (repeatedly) running her wheelchair into the table at dinner which bothered (R11). Staff intervened and separated the residents. (R11) calmed with counseling. This same investigation documents the following Action Plan: Care Plans updated for staff to assist (R12) into a regular chair during meal service. Staff re-educated and (R11) received counseling about aggressive behaviors. R11's current Care Plan documents the following focus: (R11) has potential to be physically aggressive and may be easily agitated by peers. This same care plan documents the following intervention was in place at the time of the 12/20/24 incident that occurred between R11 and R12: When the resident becomes agitated: Intervene before agitation escalates, Guide away from source of distress, Engage calmly in conversation, If response is aggressive staff to walk calmly away and approach later. On 03/25/25 at 12:40 PM, R11 was lying in bed covered with a blanket. R11's glasses and his call light were within his reach on a nearby bedside table. An indwelling urinary catheter drainage bag was secured to the lower aspect of R11's bed. R11 stated he recalls the 12/20/24 incident that occurred with R12. R11 stated, (R12) was banging on the tables and was trying to run into people. She almost knocked two people over. I finally had enough and told her to knock her sh#t off. R11 lifted his right hand and made a fist, and then explained he did strike R12 in the face on 12/20/24 and stated, I'd had enough so I popped her in the mouth. I haven't had any issues since then, but she still bumps the tables. She knows exactly what she's doing. The staff come and take care of it when she is doing it. R12's current Care Plan documents the following focus: (R12) displays attention seeking behavior by running her wheelchair into staff, peers, and objects. This same care plan documents the following intervention in place (initiated 06/25/23): Staff will redirect (R12) when she is displaying behaviors of running her wheelchair into doors, walls, staff and her peers. On 03/25/25 at 01:00 PM, R12 was sitting alone in her wheelchair at a table in the dining room. The arms of R12's wheelchair were padded, and R12 had bilateral forearm sleeves in place. R12 had her head placed down on the table. R12 raised her head upon greeting. R12 was able to answer a few simple yes/no questions, but then began verbalizing nonsensical words and began repeatedly moving her wheelchair back and forth striking the dining table she was seated at. On 03/25/25 at 10:25 AM, V1 (Administrator) verified R11 struck R12 in the face on 12/20/24. V1 stated, (R12) has a history of repeatedly running her wheelchair into things. On 12/20/24, she was repeatedly running her wheelchair into the dining table where they (R11 and R12) were sitting. This upset (R11), and he hit (R12). We now transfer (R12) into a regular chair for meals. Staff was re-educated to intervene when (R11) becomes agitated with a peer, and to redirect (R12) when she is displaying behaviors of running her wheelchair into objects that disrupt her peers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update a care plan to include targeted behaviors and non-pharmacological interventions for two (R7 & R51) of 23 residents reviewed for care plan revision in a sample of 30. Findings include: Facility policy Care Plan Policy, updated 6/5/24, documents Patients receive care and treatment based on an assessment of their needs. The data is used to determine and prioritize the patient's plan of care. 1. R7's medical record documented R7 was alert and oriented, admitted to the facility on [DATE], and had Schizophrenia. R7's current physician orders for October 2024 documents R7 takes the following: Lorazepam 1 MG (milligram) by mouth two times a day for anxiety started 2/17/24; Zoloft 200 mg by mouth at bedtime started 2/27/24; Risperidone (antipsychotic) 5 mg by mouth two times a day started 2/28/24; Olanzapine (antipsychotic) 20 mg by mouth at bedtime started 5/28/24; and Trazodone (antidepressant) 50 mg by mouth at bedtime started 2/16/24. On 10/15/24 and 10/16/24 between the hours of 9 AM and 2 PM multiple observations were made of R7 in her room and in the dining room with no behaviors noted. On 10/17/24 at 11:10 AM, R7 was coming out of her room, no behavior noted, and stated she has hallucinations a lot that tell her to harm herself, and her hallucinations are from the past and present. R7's current care plan has no behaviors identified or documented with interventions, and no non-pharmacological interventions listed. On 10/17/24 at 11:20 AM, V3 RN/Registered Nurse Care Plan Coordinator verified R7's care plan does not have targeted behaviors with interventions, or non-pharmacological interventions listed and should. 2. R51's medical record documents R51 had Schizoaffective Disorder and Altered Mental Status, and did not take any Psychological medications. On 10/15/24 at 9:41 AM, R51 was yelling out in her room, surveyor went in the room to introduce herself, resident told surveyor to Get the hell out of my room, I don't want to talk to you and then slammed her door shut and continued yelling in her room. On 10/17/24 between 11:44 AM and 11:50 AM, R51 was yelling out in her room while lying on her bed. No staff members were present or went into R51's room. On 10/17/24 at 11:50 AM, V12 CNA/Certified Nurse Aid stated She (R51) always yells out, sometimes it is in the dining room and we have to take her to her room, that is her behavior. R51's current care plan had no behaviors identified or documented with interventions, and no non-pharmacological interventions listed. On 10/17/24 at 11:20 AM, V3 RN/Registered Nurse Care Plan Coordinator verified R51's care plan did not have targeted behaviors with interventions, or non-pharmacological interventions listed and should.

Based on Observation, Interview and Record Review the facility failed to ensure a range of motion program was in place for residents with functional limitations in range of motion for three of five residents (R8, R47, R90) reviewed for range of motion in the sample of 30. Findings include: The facility's Restorative Program Policy, dated 6/6/24, documents It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the individual's comprehensive assessment, to achieve and maintain the highest practicable outcome. Our goal is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible, and to achieve and preserve their highest level of mental, physical and psychosocial functioning. Restorative nursing is available seven days a week and is provided for the residents with assessed needs according to program criteria. Purpose: The restorative nursing program is designed to Preserve function, Promote optimal improvement, Increase independence, self esteem and dignity, Promote safety, Minimize deterioration within the limits of normal aging and/or recognized disease process. This same policy documents An individualized program will be developed based on the resident's restorative needs, and include the restorative program on the care plan. 1. On 10/15/24 at 10:10 AM, R8 was observed in bed sleeping in a contracted like fetal position. R8's Minimum Data Set assessment, dated 8/28/24, documents R8 has limits in range of motion with Impairment to bilateral (both sides) lower extremities. R8's current Care Plan does not document a plan of care for R8's range of motion limitations or interventions/programming to prevent further decline. 2. On 10/15/24 at 10:05 AM, R47 was in her room in a bariatric bed. R47 stated she relies on staff to get in and out of bed. R47 denied doing exercises or having staff complete range of motion in her hips, knees or ankles. R47's Minimum Data Set assessment, dated 8/19/24, documents R47 has limits in range of motion with Impairment to bilateral lower extremities. R47's current Care Plan does not document a plan of care for R47's range of motion limitations or interventions/programming to prevent further decline. 3. On 10/15/24 at 11:50 AM and 10/16/24 at 10:45 AM, R90 was observed in common resident areas in her wheelchair. R90's arms were frequently in the bent (contracted at the elbow) position and movements of R90's arms and legs appeared spastic at times. R90's Minimum Data Set assessment, dated 9/16/24, documents R90 has limits in range of motion with Impairment to bilateral upper and lower extremities. R90's current Care Plan, dated 6/13/24 documents R90 has diagnoses of Huntington's Disease and Primary Osteoarthritis. This care plan does not document a plan of care for R90's range of motion limitations or interventions/programming to prevent further decline. On 10/17/24 at 10:30 AM, V19 (Rehabilitation Aide/Certified Nursing Assistant (CNA)) confirmed she is the one who over sees the restorative program for CNAs and Range of Motion therapies. V19 stated she receives the list of residents who are in need of restorative from V20 (Licensed Practical Nurse/Assistant Director of Nursing) and R8, R47 and R90 are not on the list. V19 stated Those three residents are not receiving any active or passive range of motion that I am aware. On 10/17/24 at 10:30 AM, V19 (Rehabilitation Aide/Certified Nursing Assistant (CNA)) confirmed she is the one who over sees the restorative program for CNAs and Range of Motion therapies. V19 stated she receives the list of residents who are in need of restorative from V20 (Licensed Practical Nurse/Assistant Director of Nursing) and R8, R47 and R90 are not on the list. V19 stated Those three residents are not receiving any active or passive range of motion that I am aware.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement non-pharmacological interventions, and failed to identify, document or track behaviors for one (R7) of six residents reviewed for psychotropic medications in a sample of 30. Findings include: Facility policy Psychotropic Medication, undated, documents Each psychotropic medication is tracked for behaviors, mood/depressions. Psychotropic medications are used when non-pharmacological approaches have previously failed. Identify target symptoms/behaviors. R7's medical record documents R7 was alert and oriented, admitted to the facility on [DATE], and has Schizophrenia. R7's current physician orders for October 2024 documents R7 takes the following: Lorazepam 1 MG (milligram) by mouth two times a day for anxiety started 2/17/24; Zoloft 200 mg by mouth at bedtime started 2/27/24; Risperidone (antipsychotic) 5 mg by mouth two times a day started 2/28/24; Olanzapine (antipsychotic) 20 mg by mouth at bedtime started 5/28/24; and Trazodone (antidepressant) 50 mg by mouth at bedtime started 2/16/24. On 10/15/24 and 10/16/24 between the hours of 9 AM and 2 PM multiple observations were made of R7 in her room and in the dining room with no behaviors noted. On 10/17/24 at 11:10 AM, R7 was coming out of her room, no behavior noted, and stated she has hallucinations a lot that tell her to harm herself, and her hallucinations are from the past and present. R7's medical record has no behaviors identified or documented, and no non-pharmacological interventions implemented for the use of psychotropic medications. On 10/17/24 at 11:20 AM, V3 RN/Registered Nurse verified R7's medical record does not have targeted behaviors, or non-pharmacological interventions and should. On 10/17/24 at 11:30 AM, V12 CNA/Certified Nurse Aid stated We chart behaviors in our (online) charting system, it walks us through the system.

Based on observation, interview and record review, the facility failed to ensure a resident's leg wounds were protected from cross contamination during scheduled dressing changes for one of four residents (R47) reviewed for skin conditions in the sample of 30. Findings include: The facility's Treatments policy (undated), documents The treatment will be carried out in accordance with physician orders, pharmacy recommendations and CDC (Centers for Disease Control) guidelines, using universal precautions. The facility's Skin Treatment Protocol, dated 6/5/24, documents The facility strives to ensure that each resident receives care and services necessary to attain and maintain the highest practicable overall well-being, in accordance with the comprehensive assessment and plan of care. This policy also documents when treating a wound: Sterile technique is not necessary, unless ordered by a physician. Clean technique is used for all other dressings and universal precautions are adhered to. If clean, un-sterile dressings are used, then measures must be taken to prevent contamination of unused dressings. R47's current care plan, dated 9/7/23, documents R47 has actual impairment to skin integrity related to occasional urinary incontinence and limited mobility. Right lower lateral leg (wound measurement)7 cm (centimeters) x 2 cm x 0.1 cm. Right posterior lateral thigh (wound measurement) 1.5 cm x 10.5 cm x 0.2 cm. Right lateral calf (wound measurement) 0.9 cm x 0.5 cm x 0.1 cm. This same care plan contains a historical active plan of care that documents (R47) is being treated with antibiotic therapy for a wound on her right thigh. Antibiotic order date 8/22/24-9/5/24. Maintain universal precautions when providing resident care. On 10/17/24 at 10:00 AM, V21 (Registered Nurse (RN)) and V3 (RN/Infection Control Preventionist) went into R47's room to complete wound care to R47's right leg wounds. R47 rolled in bed to her left side for treatments to begin. A moderate amount of brown smeared stool was noted in the center of R47's buttocks when she rolled over. V21 placed a disposable drape on R47's bed under her buttock and hip. V21 then took bandage scissors and cut R47's hip/thigh dressing and without sanitizing, then used the same scissors to cut the lower leg gauze wrap off. A strong odor was noted from lower leg when dressing was removed. After cleansing R47's hip wound, V21 used same (un-sanitized) scissors to cut three pieces of Puracol (collagen treatment) and applied them to R47's hip/thigh wound. V21 used the same (un-sanitized) scissors to cut strips of calcium alginate and then applied them to the hip/thigh wound. While V21 waited for V3 to open a bandage, one square of calcium alginate fell onto the drape (where R47's soiled buttocks was laying) three times. Each time V21 picked up the calcium alginate and reapplied it to the wound before then covering the entire wound with a bandage. V21 proceeded to use the same scissors (still un-sanitized) to cut strips of Puracol for R47's calf wound and applied two cut pieces to the lateral calf wound. After the wound care was completed V21 stated to R47 We are done. I will send (Certified Nursing Assistants) in to get you cleaned up (from stool). On 10/17/24 at 10:12 AM V21 stated the scissors used during R47's wound care are V21's and she did not think about sanitizing them between use when completing R47's wound cares. V21 confirmed that a piece of calcium alginate fell on top of R47's disposable drape three times during her treatment and R47's feces soiled bottom was laying on this drape. V21 stated I think R47 was having a bowel movement during her cares. At this time V21 confirmed the stool should've been cleansed to keep a clean field before performing wound care to avoid wound contamination.

Based on observation, interview and record review, the facility failed to ensure use of a safe sanitation solution, record sanitation solution checks, ensure kitchen trash bins were kept away from food preparation areas and covered, maintain clean floors in the kitchen, and ensure the ice machine scoop was handled and stored appropriately to avoid cross contamination in the facility's kitchen. This failure has the potential to affect all 115 residents living in the facility. Findings include: The facility's Sanitation Checks, dated October 2024, documents Take the designated bleach bucket and fill with luke warm water (70 degrees). Using dispenser add bleach water and mix. Test solution if it is not 100 ppm (parts per million), add more bleach, mix and test. Record results and initial. Procedures are to be done at least prior to the start of each meal. Buckets are changed more often if needed. On 10/15/24 at 10:00 AM, V9 (Dietary Manager) confirmed the facility's sanitizing bucket is used to wipe food preparation surfaces in the kitchen and the solution should be at least 100 ppm but not higher than 200 ppm. V9 then took a solution test strip and tested the sanitizing bucket solution and result was 10 ppm. V9 stated It is too weak for solution at 10 ppm. It should be at 100 ppm and will need remade. On 10/16/24 at 11:00 AM, V9 checked the sanitation solution, and it measured above 200 ppm. V9 stated The solution is too high and needs remade. At this time V9 provided the October 2024 Solution Check list. This checklist did not document any sanitizing solution checks were completed on 10/16/24. The facility's Waste Disposal policy, dated 2017, documents Garbage will be disposed of and as needed throughout the day and at the end of each day. Procedure: Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered when not in use. On 10/15/24 at 9:30 AM, three large barrel trash cans were present in the facility's kitchen. All of the cans were not covered/open to air and placed in random walkways of the kitchen. On 10/15/24 at 11:45 AM, a open large barrel trash can that contained food waste and trash was sitting in the facility's kitchen within two feet of the facility's steam table, which contained prepared food for the noon meal. Another open large barrel trash can containing food and product packaging waste, was directly next to the kitchen's grill where food was being prepared. On 10/16/24 at 11:00 AM, three open large trash barrel trash cans were observed in the kitchen. One was sitting by the reach in cooler and two were located against the wall between the steam table/serving window and the dishwashing machine. All three barrels contained trash, liquid splatter and food contents. At this time V9 stated We should have some lids for those. V15 (Dietary Aide) stated We don't have lids for those. In the five years I have worked here, I have never seen lids on them (kitchen trash cans). The facility's General Sanitation of Kitchen policy, dated 2017, documents Food and Nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. On 10/15/24 at 9:30 AM, a tour of the facility's kitchen was conducted. During this tour the kitchen floor was observed to be dirty with dirty grout and particle debris on the floor in several areas including corners and along the edges of the walls. The floor was also noted to be sticky when walking. During the tour V9 (Dietary Manager) confirmed the floors sticky feeling and debris throughout and stated They (the facility) are looking to replace the floor in here, but it should be getting cleaned multiple times throughout the day. On 10/16/24 at 11:00 AM, the facility's kitchen floor was observed to have debris and particles scattered in several areas of the kitchen. The floor in the juice machine area contained a yellow shiny slime-like substance under the machine, around the cart and by the wall. This same area of floor also contained a brown, thick, gritty substance around the juice cart and against the wall. Two drink sweetener paper packets and approximately one fourth of a full orange was on the floor near the wall. At this time, V9 confirmed the condition of the floor near the juice cart and made kitchen staff aware, stating There is an orange against the wall over here! The facility's Ice policy, dated 2017, documents Ice will be provided and handled in a manner to keep it free from contamination. Ice will not be handled with bare hands, but rather with a sanitized scoop and container for transport and distribution. On 10/16/24 at 11:00 AM, V9 (Dietary Manger) stated the kitchen does not have an ice machine so any ice for the food tables and resident drinks would be obtained from the resident F-hall ice machine and transported to the kitchen via a cooler and cart. At this time V9 walked to the North side nurses' station where halls F, G and H are located. V9 pointed to a cart at the nurses' station and stated it contains the ice scoop and cooler used for kitchen purposes. The second level of this cart contained an ice scoop open to air and resting on a surface with unknown particles, brown specs and debris. V9 grabbed a brown tray from the dining area and placed the scoop on the tray then stated, I will get a bag to cover that (ice scoop). V9 confirmed this ice scoop is the only one used in the ice machine, ice cooler and for kitchen ice purposes. On 10/16/24 at 11:15, R6 walked up to the ice cooler cart and grabbed the ice scoop with bare hands, filled a personal cup and then walked away leaving the scoop on the cart. V22 (Certified Nursing Assistant) was the only staff in the area at this time and confirmed R6 is a resident who resides in the H-hall.

Based on interview and record review, the facility failed to protect a resident from physical abuse by another resident, for two of three residents (R1 and R4), reviewed for abuse, in a sample of eight. FINDINGS INCLUDE: 1. The (facility) Incident Investigation Report, dated 5/23/24 and completed by V3/Licensed Practical Nurse (LPN) documents, (R4) was yelling at (R3) in a wheelchair and approached (R3) while out on the patio area. (R3) kicked (R4), causing (R4) to lose his balance and fall unto (R4's) buttocks. Witnesses stated (R4) did not hit (R4's) head upon falling. The (facility) Witness Statements for R5, R6, R7 and R8, dated 5/23/24 and attached to the Incident Report between R3 and R4 all document that (R4) was yelling at (R3) and approached (R3) at which time (R3) kicked (R4) who fell to the ground. On 7/1/24 at 11:10 A.M., V1/Administrator confirmed the physical altercation between R3 and R4 resulted in R3 kicking R4, who fell to the ground. 2.) The Facility Incident Investigation Report, dated 6/12/2024, documents the following: On 6/5/24 at 7:10AM on south unit, (R1) approached (R2), picked (R2) up from sitting in a chair and pushed (R2) to the ground. (R2) complained of pain in his hands. Residents were separated and counseled by V9/PRSA (Psych Rehab Service Assistant). V10/Police were notified. V10/Police Officer and staff spoke to residents involved. (R1) told (R2) to turn around When (R2) was looking at him. (R2) asked, why, and (R1) lifted (R2) from the chair and pushed him to the ground. (R1) has a diagnosis of Schizophrenia, Bipolar Type. R1's Progress Notes, dated 6/5/2024 at 7:10AM documents, (R1) was in the dining room. (R1) stated, he approached (R2) and grabbed (R2) by the jacket and threw (R2) to the floor. Residents Immediately separated. When (R1) was asked about the events that occurred (R1) ambulated to his room and refused to tell any events. No apparent injuries. No witnesses noted. R2's Progress Notes, dated 6/5/2024 at 7:10AM documents, (R2) stated, (R1) approached him as he sat in the dining room chair, grabbed (R2) jacket and threw (R2) to the floor. (R2) got himself up from the floor and reported incident. Both residents were immediately separated. Head to toe assessment done with no injuries noted. No complaints of pain voiced. Called V10/Police and awaiting arrival. On 7/1/2024 at 9:35AM V1/Administrator stated, After I did the investigation on this altercation, I learned that (R2) was sitting in a chair in the dining room and (R1) with a diagnosis of Schizophrenia felt that (R2) was staring at him. (R2) was asked to turn around by (R1). (R1) then went over to where (R2) was sitting and grabbed his jacket and pushed him to the floor. There were no injuries noted. V10/Police were called. There are times that (R1) is delusional. It is possible that (R1) was thinking that (R2) was staring at him for some reason and did not like it. The facility policy, Abuse Prevention Program, (updated 6/3/24) directs staff, This facility affirms the right of our residents to be free form abuse, neglect, exploitation, misappropriation of property, corporal punishment and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide periodic Diabetic vision exams for one (R1) resident reviewed for vision examination in a sample of three. Findings include: The facility's Diabetes Mellitus Residents Policy, Undated, documents: It is the policy of (Facility) to provide all (Insulin Dependent Diabetes Mellitus/IDDM) Residents with the best possible nursing care. In so doing, certain criteria will be done and is as follows: As Ordered: 1. Yearly eye exams as ordered by physician. The facility's Vision and Hearing Policy, Undated, documents: The comprehensive assessment and plan of care determines the amount of care needed by each individual resident to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. The facility's (Vision) Contract for Ophthalmic Services, dated 3/31/21, documents (Vision) agrees to serve as the Ophthalmic Consultant on the facilities professional staff. (Internet definitions: Ophthalmic means of, relating to, or situated near the eye; ocular, supplying or draining the eye or structures in the region of the eye.) The facility's (Vision) Company Forms, dated 2022, does not document a vision exam for R1. R1's name was not listed as one of the residents seen by the (Vision) company contracted by the facility. Documentation showed that R1 was seen by the (Vision) company in 2021, 2018, and 2017, but not in 2022 or 2023. R1's diagnoses include: Type 2 Diabetes Mellitus. R1's Minimum Data Set (MDS), dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R1's current Care Plan documents: Intervention: (R1) will be compliant with all eye/vision exams as recommended and staff will encourage him to report any signs of vision changes to nurse. R1's Physician Orders document: May have dental, Podiatry, Ophthalmology consults and treatment as needed. R1's Progress Note dated 7/14/23 documents: (R1) approached this writer and reported that he would like to be seen next time the eye doctor was in the facility. R1's Care Plan documents: (R1) is at risk for complications of Diabetes due to meal refusals and noncompliance with diet. On 12/15/23 at 2:00pm, R1 stated that his eyes had not been checked for three years; no eye doctor this year or last year; stated that since he is Diabetic, eyes should be checked once a year. R1 stated, I told (V3 Director of Nursing/DON) and (V4 Care Plan Coordinator) in May 2023 that I needed bifocals; need for reading and distance. (V4) said they would take care of this; the vision doctor was supposed to come in July 2023, but I did not see them. On 12/19/23 at 2:55pm, V9 (Vision Staff) stated that Diabetic residents are seen every six months or annually per protocol, depending on health of eyes and medication; stated that the (Vision) staff comes to the facility to see residents, usually 15 to 20 residents at each visit. V9 stated that R1 had not been seen by (Vision) in 2022 or 2023. V9 stated, We were supposed to be at the facility in June and October of 2023; not sure why we did not come to the facility, maybe the facility or one of our staff had COVID or illness. At this time, V9 stated that they did not notify the facility they were not coming, and the facility did not call them. On 12/19/23 at 3:38pm, V1 Administrator stated that the facility does have a contract with (Vision); was not aware that the (Vision) company had not conducted exams at the facility in 2023 and stated that V6 [NAME] Clerk let her know this. V1 stated, V6 and V2 Director of Nursing/DON are supposed to keep track of this, they have not been doing that. I was shocked that (Vision) had not come to the facility this year. On 12/19/23 at 3:25pm, V5 Primary Care Physician/PCP to R1 stated: If no eye staff to come to facility, if the vision people could not see (R1), could have sent him out to another vision center. I was not aware that the (Vision) staff had not been at the facility this year.

Based on interview and record review the facility failed to notify a resident's family of a hospitalization for 1 resident (R1) of 3 residents reviewed for policy and procedures in the sample of 6. Findings include: The (Facility) Change in Condition/Notification Policy dated 9/20/23 documents The facility will promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, the nurse will notify the resident's representative (within 24 hours unless medical emergency) when: d. It is necessary to transfer the resident to a hospital/treatment center. On 10/2/23 at 12:55 PM, V1 (Administrator) stated that V4 (R1's Power of Attorney) did complain that he came in to visit R1 and R1 was not in the facility. R1 had been sent to the hospital. The nurse did admit that she got busy and forgot to call V4. On 10/4/23 at 12:04 PM, V2 (Director of Nursing) stated that V13 (Licensed Practical Nurse) should have contacted V4 (R1's Power of Attorney) when R1 went to the hospital. On 10/4/23 at 12:49 PM, V13 (Licensed Practical Nurse) stated that R1 was having behaviors and was out of control so R1 was sent to the hospital. R1 was in the hospital a couple of weeks. I did not contact (V4/R1's Power of Attorney) when (R1) went to the hospital. I got busy and forgot. V13 also stated that she knows she should have contacted (V4). R1's Nursing Note dated 8/18/23 at 7:00 PM, documents (R1) was noted with such an increase in behaviors, nursing staff is unable to reach (Psychiatry Consult). (R1) throwing items at staff and peers. (R1) swinging to hit staff. R1 was transported to the hospital. The Grievance Log dated 8/21/23, documents (V4/R1's Power of Attorney) stated (R1) went to the hospital and (V4) was not notified. Grievance was confirmed. Nurse admitted she got busy with another patient and forgot to notify (V4). Disciplinary action completed for nurse. Signed by V1 (Administrator).

Based on observation, interview, and record review, the facility failed to wear personal protective equipment per their policy and current Centers for Disease Control guidelines. These failures have the potential to affect all 112 residents residing in the facility. Findings include: Centers for Disease Control and Prevention online web address Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated May 8, 2023, documents Personal Protective Equipment for healthcare personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On 9/14/23 the facility front entrance had signage on the front door documenting the facility was in a COVID outbreak. On 9/14/23 at 10:40am, V1 Administrator stated We had COVID positive staff on 9/2/23, and a COVID positive resident on 9/5/23 and that is when the outbreak started. We are still in an outbreak. We have been in contact with the health department. We encourage residents to wear masks but don't require them to wear. We keep the CNA/certified nurse aid specific to the COVID hall. Staff are to wear PPE/personal protective equipment which on the COVID hall is N95, gown, gloves, and goggles. We wear an N95 at all times while in outbreak. On 9/14/23 at 11:00am, (COVID hall) had a 3-drawer cart with N95 masks, gowns, gloves, hair, and shoe coverings. Front desk had N95 masks. Contact/droplet/airborne signs posted, and garbage bin outside of the covid unit for PPE. A sign was posted to wear a gown, mask/respirator, goggles/face shield, and gloves. On 9/14/23 between the hours of 10:45am-3:43pm, V7 Activities was observed wearing a N95 mask with the bottom strap unsecured and dangling at this chin/neck area. Between these hours V7 was sitting at a table with 4 other residents (non-COVID unit) who did not have on masks and was interacting with them for an activity. V7 went around to multiple residents in the non-COVID dining room and was interacting/talking with residents who were not wearing masks. At 3:30pm, V7 was observed interacting with residents in the non-COVID dining room and giving them nourishment. At 3:43pm, V7 stated Oh I forgot I did not have my bottom strap secured. It should have been. On 9/14/23 at 2:45-3:45pm, V14 CNA/Certified Nurse Aid was at the non-COVID nurses' desk (located to the side of the dining room) with a surgical mask on. At that same time residents were in the dining room without masks on, which is located next to the nurse's desk. R4 was at the nurse's desk talking to V14 and R4 was not wearing a mask and was roaming the dining room. On 9/14/23 at 3:50pm, V14 CNA was at the nurse's desk on the non-covid unit with a surgical mask on and stated I wear a surgical mask when I am out here on the non-covid unit. I put a N95 on when I go on the COVID unit. On 9/14/23 at 3:00pm, R2 was on the COVID unit and wandering the COVID unit with no mask on. R2's medical record documents R2 was diagnosed with COVID on 9/10/23. On 9/14/23 at 3:00pm, R3 was on the COVID unit, and went out with V15 CNA to smoke out the side door from the COVID unit with no mask on. R3's medical record documents R3 was diagnosed with COVID on 9/7/23 and is a smoker. On 9/14/23 at 3:15pm, V12 CNA was working on the COVID unit with full PPE of N95, gown, gloves, and hair and shoe coverings. At that same time, V12 stated I am not sure why (V15) CNA doesn't have on her PPE, we wear it all the time on the COVID unit. (V15) came on the (COVID) unit without her PPE, and she took (R3) with COVID out the doors to smoke. At that same time, V16 LPN/Licensed Practical Nurse came on the COVID unit with only her N95 on when COVID positive residents were roaming the hallway with no masks on. I am not sure why (V16) came on the unit without her PPE on. (V16) came on the unit and checked who was on it and then went back out the doors. On 9/14/23 at 3:15pm, V15 CNA was working on the COVID unit and did not have on any PPE except her N95. V15 walked down the COVID unit hallway with (R3) out the side door and walked past COVID positive residents that were in the hallway with no masks on. At that same time, V15 stated I just took (R3) outside to smoke, do I need to wear PPE when I took him out to smoke? Yes, I am working on the COVID unit and should have had on my PPE. On 9/14/23 at 3:35pm, V13 LPN nurse day shift was in the storage room where her medication cart was located with full PPE on. At that same time, V17 Housekeeping came on the COVID positive unit with only her N95 mask on while COVID positive residents were roaming the hallway with no mask on. V17 went into the storage room where V13 was and talked for a few minutes and then left the unit. Unable to locate V17 for an interview. On 9/14/23 at 3:40pm, V13 LPN stated V17 came on the (COVID) unit and should have had on her PPE. (V17) had residents' money to get them snacks and drinks they wanted out of the vending machine, but her ride was here, and she didn't have time to get what they wanted so she came on the (COVID) unit to give them their money back. She works day shift and was leaving for the day. On 9/14/23 at 3:45pm, V16 LPN stated, I went on the (COVID) unit to talk to the nurse, I should have had on my PPE, I usually always wear it, and I know I should have on a gown, eye wear, and gloves with my mask. On 9/14/23 at 4:00pm, V1 Administrator verified V17 was on the COVID unit with no PPE as she told V1 before she left. V1 stated We don't require residents to wear masks, we encourage it, and all staff/visitors are to wear N95s when in the building because we don't know who may have COVID and not exhibit signs of it. That is our policy to wear an N95 when there is covid in the building no matter where you are working. Facility Resident Room Roster, dated 9/14/23, documents 112 residents currently reside in the facility.

Based on observation, interview, and record review, the facility failed to notify a patient representative of a room change for two of two residents (R100, R102) reviewed for notification of change in the sample of 37. Findings include: The facility's Room Change policy, dated 6/1/23, documents, As room changes occur, responsible parties will be notified of the changes. On 08/28/23 at 10:34 AM, R100 & R102 were aimlessly wandering back and forth in a closed hallway. 1. R100's Behavior/Incident Charting, dated 8/16/2023 at 10:51 p.m., document, R100 was transferred from north to South to room E10 bed 1 due to less residents with quieter environment to see if she would reduce pacing throughout the night. R100's Electronic Census, dated 8/31/23, documents that R100 changed rooms on 8/16/23. R100's current electronic record has no documentation of V15 (R100's family) being notified of R100's room change. On 08/29/23 at 11:44 AM, V15 (R100's family) stated, I was not aware that she was moved to another room let alone a hallway that's closed. 2. R02's Order Administration Note, dated 8/16/23 at 10:58 p.m., documents, R102 was moved this shift from north to south to room E3 bed 1 to reduce stimulus with less residents to reduce pacing throughout the night. R102's Electronic Census, dated 8/31/23, documents that R102 changed rooms on 8/16/23. R102's current electronic record has no documentation of V34 (R102's family) being notified of R102's room change. On 08/29/23 at 09:55 AM, V34 (R102's family) stated, I didn't know they moved (R102) to a different hallway. Why did they do that? They never told me. On 08/31/23 at 11:32 AM, V11 (Care plan coordinator) stated, The family's should be notified with any room change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free form involuntary seclusion for two of two residents (R100, R102) reviewed for involuntary seclusion in the sample of 37. Findings include: The facility's Abuse Prevention Program policy, dated 8/1/22, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Involuntary Seclusion means separation of a resident from other residents, or from his/her room-or confinement to his/her room against the resident's will or the will of the resident's legal guardian. 1. R100's Care plan, dated 1/7/23, documents, R100 wanders throughout the facility, up and down halls and in common areas. R100 may enter peer's rooms without knowing due to Alzheimer's disease. R100's Behavior/Incident Charting, dated 8/16/2023 at 10:51 p.m., document, R100 was transferred from north to South to room E10 bed 1 due to less residents with quieter environment to see if she would reduce pacing throughout the night. R100's Electronic Census, dated 8/31/23, documents that R100 changed rooms on 8/16/23. On 08/29/23 at 11:44 AM, V15 (R100's family) stated, I was not aware that she was moved to another room let alone a hallway that's closed. 2. R102's Care plan, dated 4/27/23, documents, R102 will wander throughout the facility for long periods of time and go up and down the halls, dining room area, and outside on the patio. [NAME] is often carrying various items (food, drink, linen, etc.). The care plan also documents the following interventions: Staff to assist R102 to maintain appropriate boundaries between himself and his peers; Staff to intervene proactively to help R102 avoid conflict; Staff will monitor R102 for safe passage while walking and redirect from congested areas (people or objects). R102's Order Administration Note, dated 8/16/23 at 10:58 p.m., documents, R102 was moved this shift from north to south to room E3 bed 1 to reduce stimulus with less residents to reduce pacing throughout the night. R102's Electronic Census, dated 8/31/23, documents that R102 changed rooms on 8/16/23. On 8/28/23 at 10:20 AM, upon entering the closed doors of the E-hall way two dressers were in front of the door way blocking the entrance to the hallway, also preventing exiting out of the door. V23 (Certified Nursing Assistant-CNA) confirmed the dressers were in front of the door but stated she didn't know why. On 08/28/23 at 10:24 AM, The E-hall way was dark with no lights on. Approximately 75 feet down the hallway, V22 (CNA) was sitting in a chair with two rolling bedside tables beside him blocking the hallway. R102 was pacing back and forth in the hallway. R102 was not interviewable. The emergency exit door had a chair and a humidifier in front of it blocking the exit. R100 was lying in bed. On 08/28/23 at 10:26 AM, V8 (CNA Supervisor) stated, (R100 & R102) are the only residents who live on this hallway because of wandering. We always have one CNA working on this hallway at all times. These residents have only been back here a week. The dressers just stop (R102) from running into the door. He constantly walks up and down the halls. We have them on this hall because we don't want them going out with the other residents and running into them. They don't know personal space and it wouldn't be safe for them to run into some of the combative residents because they could get hurt. R100 wanders in and out of rooms and lays in the beds. On 08/28/23 at 10:28 AM, V22 stated, This is my first day working back here. The doors have been blocked since I got here at 6:45 a.m. They were there so I just left them that way. I wasn't told anything about what to do with the residents except to just watch them. On 08/28/23 at 10:34 AM, R100 & R102 were aimlessly wandering back and forth in the closed hallway. On 8/28/23 at 2:40 p.m., V20 (Registered Nurse) stated, (R102) tries to go out the door to the dining room, so we put the nightstands/dressers in front of that door so he can't get off the unit and hurt himself. It's for his safety. He wanders and tries to go out that door. There shouldn't be anything in front of the exit door. On 8/28/23 at 3:15 p.m., V14 (CNA) stated, The nightstands are in front of the door because (R102) will push the door open and go out into the dining room. If I'm caring for (R100) I have no way of watching (R102), and he's gone out the door before when I wasn't watching. If the nightstands are there I know he can't go out the door. I didn't put the stuff in front of the exit door, but it was there. I just left it there. On 8/28/23 at 3 p.m., V1 (Administrator) was notified of involuntary seclusion for R100 and R102 by this surveyor. V1 stated, They should not have anything in front of either of the exit doors at any time. They can not seclude the residents to the hallway. If a resident wants to exit out a door, the staff should follow them out of the door. We always have staff on that hallway. A facility Preliminary two hour Abuse Investigation Report, dated 8/28/23, documents, On 8/28/23 at 3:00 p.m., State Surveyors notified Administration that equipment was blocking the hallway restricting the residents' access to the building which is considered involuntary seclusion. A facility's Information Report, dated 8/28/23, documents, Interview with V20 (Registered Nurse): V20 stated that she told the CNAs the doorway should not be blocked, but she did not ensure the staff actually removed any barriers. She stated her intention as to help redirect and keep (R102) safe. Interview with V40 (Security): V40 stated he helped watch the residents, but didn't think it was right to have tables blocking the halls. He did not say anything to question this. Interview with V14 (CNA): V14 stated she did not try to seclude (R102) by moving the tables in front of the hall down the middle. She said she thought the tables and her chair in the middle of the hall would be just like the closed door at the end of the hall. Interview with V19 (CNA): V19 stated she moved a night stand to the front of the hall. Interview with V41 (CNA): She said she didn't work the hall, but did notice the tables. She didn't move them out of the way, but thought was approved for safety. On 8/29/23 at 2:30 p.m., V1 (Administrator) reviewed facility footage with this surveyor for 8/24-8/28/23. Footage showed that at different times there was an object blocking the emergency exit, and staff placed rolling bedside tables across the hallway to block the path of (R100 & R102). V1 stated, After interviewing the staff, they started placing the items in front of the doors on Friday (8/25/23) night. This isn't right. The staff know better. (R100 and R102) should have free will and mobility to go wherever they want to. If they want to open a door and walk out they should be able to go out and the staff should follow them. The staff thought they were helping (R100 and R102) but they were secluding them. This is involuntary seclusion.

Based on observation, interview, and record review, the facility failed to identify a physical restraint, obtain a physician's order for a restraint, obtain an informed restraint consent, perform restraint assessments, and have a plan of reduction for two of two residents (R100, R102) reviewed for restraints in the sample of 37. Findings include: The facility's Restraint policy, no date available, documents, Physical restraints is any manual method or physical or mechanical device that the individual cannot easily remove and which restricts free movement of normal functioning and access to one's body. On 08/29/23 at 08:35 AM, R100 and R102 were sitting behind the inner portion of a c-shaped table that was backed up to the wall. The table was flush with the wall with no gaps between the wall and the table. Both R100 and R102 would repeatedly stand up and sit down. At times, while standing both residents would attempt to push the table out of the way to walk, but the table would not move. On 8/29/23 at 12:35 p.m., R100 and R102 were standing behind the inner portion of a c-shaped table that was backed up to the wall. The table was flush with the wall with no gaps between the wall and the table. On 8/29/23 at 12:40 p.m., R100 and R102 were served their lunch meal and encouraged to sit down. Both R100 and R102 continued to stand up and sit down throughout the meal. 1. R100's Care plan, dated 10/19/22, documents, R100 may sit inside of curved table during meal service. Staff must monitor R100 through duration of meal and assist her in exiting after completion of meal. R100's Physician's orders, dated 8/30/23, have no documentation of an order for R100 to have a physical restraint. On 08/29/23 at 11:44 AM, V15 (R100's family) stated, Why would they be restraining her behind a table. I didn't know about that. 2. R102's Care plan, dated 10/26/22, documents, R102 may sit inside of curved table during meal service. Staff must monitor R102 through duration of meal and assist R102 in exiting area after completion of meal. R102's Physician's orders, dated 8/31/23, have no documentation of an order for R102 to have a physical restraint. R100 nor R102's current medical record contained an informed restraint consent, a restraint assessment nor a restraint plan of reduction. On 8/29/23 at 12:46 p.m., V17 (Registered Nurse) stated, (R100) and (R102) sit behind the table because they don't know to sit down and eat their food. They just want to wander. So the table keeps them sitting down to eat. On 8/29/23 at 12:50 p.m., V16 (CNA-Certified Nursing Assistant) stated, (R100) and (R102) sit behind the table so they don't get up and walk away during. They can't get out from behind the table on their own. V16 confirmed that the table was flush with the wall with no gap between the table and the wall. On 8/29/23 at 2:30 p.m., V1 (Administrator) stated, (R100) is not supposed to be behind the half circle table. It is only supposed to be (R102) behind it, and it should be away from the wall with a gap that would allow him to exit the table if he would like to. On 08/31/23 at 09:05 AM, V11 (Care plan coordinator) stated, We do not consider the table a restraint for (R100) or (R102). So we do not have restraint consents, care plan, assessments, or plans of reduction.

Based on observation, interview and record review, the facility failed to revise a care plan following significant weight loss for one of seven residents (R9) reviewed for weight loss in the sample of 37. Findings include: The facility's Weight Policy, dated 6/1/23, documents, The purpose of this policy is to monitor the residents' weights and track weight changes as they occur. Significant weight change is as follows: 1. if being weighed weekly 2% in one week; 5% or more in one month; 7.5 % or more in three months; 10% or more in six months. Within a week after weights have been received and reviewed by the Nursing Department and Dietary Manager, the weight committee will meet to discuss and recommend the need for any possible dietary interventions or diet order changes. If the dietician is present in the facility, the committee will consult with her. If not they will simply notify the physician for possibility of new orders. Order changes will be recorded in the clinical record as well as any needed care plan intervention changes. On 08/29/23 at 08:55 AM, R9 was sitting at the assisted table eating scrambled eggs, toast, and cereal with a staff member present at table assisting her. R9's RD (Registered Dietician) note, dated 6/7/23, documents that R9's current weight is 91 lbs (pounds) which is a 6 lb/6.2% weight loss in one months and 25 lbs/21.6% weight loss in three and six months. R9's RD note, dated 7/11/23, documents that R9's current weight is 91 lbs (pounds) which is a 25 lbs/21.6% weight loss in six months. R9's RD note, dated 8/23/23, documents that R9's current weight is 92 lbs (pounds) which is a 25 lbs/21.4% weight loss in six months. R9's Care plan, dated 7/26/21, documents, R9 is at risk for weight loss due to leaving 25% of most meals uneaten and refuses some meals. R9's care plan has no revision to include R9's significant weight loss. On 08/31/23 12:27 PM, V6 (Dietary Manager) confirmed that R9's care plan was not revised to include R9's significant weight loss.

Based on observation, interview, and record review, the facility failed to provide meaningful activities for residents residing on a closed unit for two of two residents (R100, R102) reviewed for activities in the sample of 37. Findings include: The facility's Activities policy, dated 6/1/23, documents, The facility has an on-going program of activities designed to meet in accordance with the comprehensive assessment, the interest and the physical mental and psychosocial well-being of each resident. A balance of recreational activities including physical, social, religious, arts and crafts, diversional and intellectual activities will be offered to meet the psychological well-being needs of the patients. On 08/28/23 at 10:24 AM, The E-hall way was dark with no lights on. Approximately 75 feet down the hallway, V22 (CNA-Certified Nursing Assistant) was sitting in a chair with two rolling bedside tables beside him blocking the hallway. R102 was pacing back and forth in the hallway and R100 was lying in bed. No activities were occurring. On 08/28/23 at 10:26 AM, V8 (CNA Supervisor) stated, (R100 & R102) are the only residents who live on this hallway because of wandering. We always have one CNA working on this hallway at all times. These residents have only been back here a week. (R102) constantly walks up and down the halls. We have them on this hall because we don't want them going out with the other residents and running into them. R100 wanders in and out of rooms and lays in the beds. On 08/28/23 at 10:28 AM, V22 stated, This is my first day working back here. I wasn't told anything about what to do with the residents except to just watch them. I don't know about activities. On 08/28/23 at 10:34 AM, R100 & R102 were aimlessly wandering back and forth in the hallway while the V22 was sitting in a chair in the hallway. V22 confirmed no activities were occurring. On 8/29/23 at 12:50 p.m., V16 CNA confirmed that she was assigned to caring for R100 and R102 for the shift. V16 stated, Activity wise I try to take them outside at times to get them off of their hall, but otherwise there isn't any activities that go on back there. The activity department doesn't come back to them to do activities with them, and they don't go out to group activities. On 08/30/23 at 12:00 PM, R100 was lying in bed sleeping. No activities were occurring on the hallway. V9 (CNA) was sitting in a chair in hallway while R102 was pacing aimlessly up and down the hallway. V9 confirmed no activities were occurring. 1. R100's care plan, dated 10/27/22, documents, R100 is up and out daily, she likes to wander around the facility, she is very confused and has a low attention span to participate in general activities. Staff does get her to attend some group activities but she does not stay for duration of time. R100 does enjoy folding clothes and holding pillows. The care plan also documents the following intervention: R100 will be offered short term, simple activities. R100's Quarterly/Annual Activity Participation Review, dated 7/10/23, documents, Describe resident's favorite activities, special accomplishments, and/or new interests: R100 enjoys folding clothes, holding pillows, and enjoying snack. On 08/29/23 at 12:35 PM V15 (R100's family) stated, She just walks around looking for something to do. She likes to stay busy and active if she isn't laying down. She likes to do things with her hands even just like folding towels. She needs to be stimulated. R100's Monthly Activity Participation, dated 8/23, documents that as of 8/30/23, R100 passively participated in four activities (8/4, 8/8, 8/9 & 8/12/23) R100's POC (Point of Care) Response History Activity Participation, dated 8/30/23, documents for the last 30 days (8/1-8/30/23) R100 attended a group activity on 8/2/23 and 8/22/23. The rest of the days are documented as not applicable. 2. R102's Care plan, dated 2/1/23, documents, R102 is up and out of his room daily mostly walking around the facility, having a snack, or in the T.V. room sitting watching television. R102 does not participate in group activities but will enjoy leisure activities such as walking around the facility socializing with his favorite staff, having a snack, and watching Television. The care plan also documents the following intervention: Staff will personally invite R102 to daily activities of interest. R102's Quarterly/Annual Activity Participation Review, dated 7/18/23, documents, R102 is up and out of his room daily mostly walking around the facility, having a snack, or in the T.V. room sitting watching television. R102 enjoys walking, going outside when the weather is nice, Television, and snacks. R102's POC (Point of Care) Response History Activity Participation, dated 8/30/23, documents for the last 30 days (8/1-8/30/23) R102 attended a group activity on 8/2/23 and 8/27/23. The rest of the days are documented as not applicable. On 08/31/23 at 09:12 AM, V4 (Activity Director) stated, There are puzzles and toys for (R100) and (R102) to use on their hallway. The CNAs should be interacting with them with these. There are no formal activities planned for the two residents on their hallway. On 08/31/23 at 12:23 PM, V1 (Administrator) stated, The staff should be doing activities with (R100 & R102) while they are working with them especially since that CNA is only assigned to those two residents. (R100 & R102) can also go out to activities with the other residents. The staff have to realize they aren't stimulating them if they aren't doing anything with them.

Based on observation, interview and record review, the facility failed to implement fall interventions and report/investigate a resident reported fall for 2 of 7 resident (R102, R410) reviewed for falls in a sample of 37. Findings include: 1. The facility's Fall Prevention Policy, no date, documents, It is the policy of this facility to prevent falls and serious injury outcomes by recognizing multi-factorial risks and causes, and institute recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care. R102's Care plan, dated 1/31/23, documents, has a history of Depression and catatonic schizophrenia. The care plan also documents the following interventions: R102 will be encouraged to attend group skills to build his social skills when around his peers and staff that he is unfamiliar with. R102's Care plan, dated 2/1/23, documents, (R102) is up and out of his room daily mostly walking around the facility, having a snack, or in the T.V. room sitting watching television. (R102) does not participate in group activities but will enjoy leisure activities such as walking around the facility socializing with his favorite staff, having a snack, and watching Television. The care plan also documents an intervention of staff will personally invite R102 to daily activities of interest. On 08/29/23 at 10:49 AM, R102 was aimlessly wandering up and down the hall. R102 stopped at the door to the dining room, and started banging on the door. V16 (Certified Nursing Assistant-CNA) was standing in hallway supervising. She stated, This is how he is all day. He walks back and forth all day long. This is his room. R102's room had two beds in his room with both beds having the head board directly against the wall. V16 confirmed that R102's bed was not turned against the wall. R102's Care plan, dated 8/21/23, documents, R102 is at risk for falls related to poor communication/comprehension, unaware of safety needs, wandering, convulsions. R102 is often noted carrying various objects (blanket, wet floor sign, clothing, food, etc). R102's Nurses' notes, dated 7/22/2023 at 3:10 p.m., document, Per peer witness, R102 was walking from the grassy area onto the patio and tripped bumping his forehead on the arm of a chair. 3 cm (centimeter) slightly raised area noted to mid forehead. R102's Nursing Note Text, dated 7/24/2023 at 3:51 p.m., documents, IDT (Interdisciplinary team) review of 7/22/23 fall. R102 was tripped when ambulating on patio from grass to concrete. Intervention: Redirect R102 from the smoke patio and assist him when ambulating on uneven surfaces. R102's Fall Care plan, dated 8/21/23, documents an intervention on 7/24/23 of redirect R102 from the smoke patio and assist him when ambulating on uneven surfaces. R102's Nursing Note, dated 8/6/2023 at 07:30 p.m., documents, CNA reported entering R102's room and R102 noted on the floor between head of bed and wall. Resident stated he fell. Abrasion noted to upper mid back and right side of back. R102's Plan of Care Note, dated 8/7/2023 at 12:13 p.m., documents, IDT review of 8/6/23 fall. R102 fell between headboard and wall. Bed was noted to be moved away from wall. Bed was moved against wall and locked into place. Intervention: Ensure that R102's headboard and side of bed are pushed against the wall and locked into place. R102's Nursing note, dated 8/11/2023 at 11:10 a.m., documents, CNA alerted this nurse that R102 was found lying on the grass sustaining a cut measuring about 0.5 cm x 0.5 cm at left eye brow not in active bleeding. Resident is pacing and loss his balance and slipped on wet surface. Emphasized to the CNA that the patio door should be lock on its scheduled time so no resident will go out since its raining outside. R102's Incident Investigation Report, dated 8/11/23, documents, CNA alerted nurse that R102 was noted lying in the grass on the patio. Noted with abrasion to left brow 0.5 cm. Action plan: Staff re-education about importance of monitoring patio door. Continue to redirect R102 from smoke patio and assist him when ambulating on uneven surfaces. R102's Plan of Care Note, dated 8/14/2023 at 09:55 a.m., documents, IDT review of 8/11/23 fall while on smoke patio. Intervention: Continue to redirect R102 from smoke patio and assist him when ambulating on uneven surfaces. On 8/31/23 at 12:15 p.m., V1 (Administrator) stated, (R102) fell (7/22/23) on the smoke patio and after that he fall he was not supposed to be on the smoke patio without supervision. That obviously didn't happen because he fell out there again. They didn't follow his plan of care. 2. The facility's Procedure for Responding to a Resident Fall, dated 6/1/23, noted a licensed nurse shall perform a head to toe assessment which includes vital signs, skin breakdown, pain; notify physician document the incident by reporting the facts and notify the facility supervisor. On 8/28/23 at 11:15 AM, R410 was alert and oriented sitting up in her wheelchair. R410 stated that she fell out of bed while sleeping at approximately 2:00 AM this morning. R410 rated a pain level of an 8 (0-no pain to 10-worst pain). R410 stated R410 called out for help but staff did not respond. R410 got up and into wheelchair independently and went to the nurse's station and notified V13 (registered nurse) of the fall, reported back pain and Tylenol was administered. R410 stated in the morning, V5 (Social Services/Associate Director) was notified of the fall and pain. On 8/28/23 at 11:40 AM, V12 (registered nurse) stated that she was unaware R410 had a fall and/or experienced pain. R410's Care Plan, dated 8/15/23, documents that R410 is a fall risks and interventions to prevent falls such as ensure call light was in reach, wear appropriate footwear and follow fall protocol. The care plan had no documentation of R410's activity intolerance deficit with interventions related to being wheelchair bound. R410's current electronic record lacked documentation by V13 that R410 fell, an assessment was conducted/documented per policy nor documented Tylenol was administered with improvement of symptoms. R410's Progress Note, dated 8/28/23 at 12:02 p.m., documents that V12 (Licensed Practical Nurse) spoke with R410 and a fall was reported, and experiencing pain. On 8/29/23 at 9:31 AM, V13 stated R410 came to the medication room (where V13 was) and said My back Hurts and asked for Tylenol. V13 stated Tylenol was administered but forgot to document the administration of Tylenol. On 8/29/23 at 2:30 PM, V1 (Administrator) confirmed that V13 should have documented the Tylenol administration, conducted a pain assessment, investigated the reason for the new onset of pain and reported the fall to the supervisor. On 8/30/23 at 11:20 AM, V5 (Social Service/Associate Director) stated we (V5, Certified Nurse Aides and agency nurse aides) were at the nurse's station around 8:55 AM on 8/28/23. V5 stated R410 told the staff at the nurse's station R410 had fallen and the night time nurse wouldn't do anything about it (pain). V5 stated V12 was not at the nurse's station when R410 reported the fall. V5 confirmed that she failed to ensure the fall was reported or investigated.

Based on observation, record review and interview, the facility failed to implement nutritional interventions to prevent further weight loss and failed to notify the physician after weight loss occurred for one of three residents (R70) reviewed for weight loss in a sample of 37. Findings include: The facility's Weight Policy (dated June 2023) documents, Significant weight change is as follows: 5% or more in one month, 7.5% or more in 3 months, and 10% or more in 6 months. Within a week after weights have been received and reviewed by the Nursing Department and Dietary Manager, Weight Committee will meet to discuss and recommend the need for any possible dietary interventions or diet order changes. If the dietician is present in the facility, the committee will consult her. If not, they will simply notify the physician for the possibility of new orders. At any time when the dietician is in the facility, any recommendations she makes will be referred to the physician for approval. On 8/29/2023 at 12:30 PM, R70 ate less than 50% of his lunch. R70 did not receive any staff assistance during mealtime. On 8/30/2023 at 1:00 PM R70, ate 25% of his lunch, with no assistance given. R70's Weight Log (dated 12/7/20-8/31/23) documents, June weight is 141 pounds, July's weight 133.4 pounds this is a 5.3 % weight loss in one month. R70's Progress Note (dated 7/27/2023) documents,R70 has not met his goal. R70 has displayed significant weight loss in the last 30 days. R70 continues to refuse meals and leave 25% or more of meals uneaten. R70's current medical record has no documentation that R70 was seen by a dietician, or R70's physician was notified of the significant weight loss that triggered in July 2023. On 8/31/2023 at 9:15 AM, V6 (Dietary Manager) stated, (R70) had a significant weight loss in July 2023. (R70) lost 8 pounds in one month, which is 5.3% weight loss in a month. (R70's) physician was not notified and should have been. (R70) was not seen by the dietician and should have been. There should have been new interventions put in place to prevent further weight loss. The facility's dietician should have reviewed the weight loss and put a new interventions in place.

Based on record review and interview, the facility failed to identify/treat the residents pain, manage effectiveness of interventions implemented for 2 of 2 residents (R48, R410) reviewed for pain in the sample of 37. Findings include: The facility's Medication Administration policy, no date, noted the Medication Administration Record should be initialed immediately after administrating medication. The facility's Pain Management Protocol, no date, noted pain is assessed each shift, describe pain and document accordingly. 1. R48's physician's order for Tylenol 325 mg (milligram) 2 tablets by mouth every 4 hours as needed for headache and pain was initiated 5/2/17. R48's Pain Level Summary dated 8/29/23 at 8:46 AM noted a pain level of 8. R48's Medication Administration Record dated 8/23 lacked documentation that pain medication was administered on 8/29/23 following her assessment of pain at 8:46 a.m. On 8/30/23 at 1:00 PM, R48 stated pain medication was not given until later in the afternoon (8/29/23) around shift change (2:45 PM-3:15 PM). R48 stated in regards to nursing pain assessments every shift It depends on which nurse gives you meds (medications). They don't usually ask. You just have to tell them. On 8/31/23 at 8:45 AM, V12 (registered nurse) stated R48's Tylenol was administered with morning medications on 8/29/23. V12 stated R48 has headaches every morning. 2. On 08/28/23 11:15 AM, R410 stated R410 fell out of bed at approximately 2:00 AM this morning. R410 rated a pain level of an 8 (0-no pain to 10-worst pain). R410 stated V13 (registered nurse) was notified of the fall, reported back pain and Tylenol was administered. R410 also stated They never ask me about pain. On 8/28/23 at 11:15 AM, V12 (registered nurse) stated V12 was unaware R410 experienced pain the previous evening and was treated with Tylenol. R410's Pain Level Summary, dated 8/28/23, noted pain assessments at 12:02 AM and 7:56 AM pain was noted to be at a level 0 and at 2:59 PM pain was noted to be at a level 4. R410's Medication Administration Record, dated 8/23, lacked documentation Tylenol was administered to R410 on 8/28/23. R410's current electronic record has no documentation of pain description and interventions for R410's pain management. On 8/29/23 at 9:31 AM, V13 stated R410 came to the medication storage room (V13 was in the medication storage room) and said My back Hurts and asked for Tylenol. V13 stated Tylenol was administered but forgot to document the administration of the Tylenol.

Based on observation, interview, and record review, the facility failed to obtain an informed consent when increasing an antipsychotic and failed to document justification to warrant the increase of an antipsychotic for one of five residents (R100) reviewed for antipsychotics in the sample of 37. Findings include: The facility's Psychotropic Medication policy, no date, documents, The facility follows the state and federal regulations related to the use of psychotropic medications in the long term care facility's to ensure the absolutely best care for the resident. Psychotropic medications will never be used for the purpose of disciplinary action or inappropriate usage. Psychotropic medications are used when non-pharmacological approaches have previously failed. Track and record each psychotropic medication is being documented with triggers and behaviors. Consent must be signed by the resident or responsible party such as a guardian. On 08/28/23 at 10:24 AM, R100 was lying in bed. On 08/28/23 at 10:34 AM, R100 was aimlessly wandering back and forth in the hallway. On 8/29/23 at 12:40 p.m., R100 was standing behind the inner portion of a c-shaped table that was backed up to the wall eating lunch. On 08/30/23 at 12:00 PM, R100 was lying in bed sleeping. R100's Care plan, dated 8/2/22, documents, Behaviors related to Alzheimers, visual/auditory hallucinations, dementia. R100 has a history of being verbally and physically aggressive with staff and residents. R100's Physician's orders, dated 8/30/23, document that R100 has an order to receive Olanzapine (antipsychotic) 5 mg (milligrams) by mouth at bedtime for auditory and visual hallucinations dated 6/15/23. R100's Psychiatrist visit, dated 3/10/23, documents, R100 seen/evaluated via telehealth in the RN (Registered Nurse) office. R100 appeared to be in no physical distress. She did not remember me by name or role. She appeared confused and anxious. Her speech was quite disorganized. She stated I feel pretty bad, I cant feel where I'm supposed to be. She was unable to answer my questions and would often mention I want to pillows, next .the pillows. She would mention pillows as she would answer my screening questions with non-sensical responses. At one point in the session, she stated do you see that? and seemed to respond to internal stimuli, if it was a visual hallucination, she could not describe it. No reports of aggression/combativeness/care or medication refusal. Support provided, New orders relayed to RN. Plan: -increase Olanzapine from 2.5 mg po (by mouth) qhs (every bedtime) Monday thru Saturday to Monday thru Sunday. R100's Behavior Observation, dated 3/23, documents that for the entire month of March that R100 had five episodes of behaviors, with four of those (3/12, 3/14, 3/15, & 3/16/23) being the behavior of wandering and the other episode is delusions (3/12/23). R100's Progress/Nursing notes, dated 3/1-3/10/23, have no documentation of an increase in behaviors nor any psychotic behaviors occurring. R100's Psychiatrist visit, dated 6/15/23, documents, R100 seen/evaluate via telehealth. She was confused and wandering the hall with staff assist. She was responsive though unable to answer questions. She exhibited non-sensical responses and stated I don't know the check when I attempted to engage with simple yes/no questions. Per staff, she continues to perseverate about pillows and is often restless/too restless to sit and allow staff to feed her. This has led to weight loss. Assessment & Plan: Increase Olanzapine 5 mg by mouth at bedtime. R100's Behavior Observation, dated 6/23, documents that for the month of June R100 had five episodes of behaviors, three of those being for wandering (6/1 and 6/14/23 on two shifts) and the other two were for being hard to redirect (6/1 & 6/28/23). R100's Progress/Nursing notes, dated 6/1-6/15/23, have no documentation of an increase in behaviors nor any psychotic behaviors occurring. R100's Consent for Psychotropic Medication Use, no date, documents that R100 signed the consent on 3/10/23 for R100's increase in Olanzapine. However, the consent has no documentation of consent being obtained for R100's increase in Olanzapine on 6/15/23. On 08/29/23 at 11:44 AM, V15 (R100's family) stated, A few months ago, she was in another resident's bed. That resident got angry and hit her. After that incident they told me they were going to have the physician look at her medications since she was confused more. I didn't know she was on an antipsychotic. She gets confused and talks to herself, but I think that is her dementia. She's not psychotic. She doesn't have any kind of psychotic history either. Her dementia is just getting worse. V15 confirmed that she was not notified of R100's antipsychotic increase on 6/15/23. On 08/31/23 at 11:32 AM, V11 (Care plan coordinator), I am responsible for tracking the use of psychotropics. I cannot find any documentation as to why her Zyprexa was increased on 3/10/23 or 6/15/23. V11 confirmed that there was no signature of receiving consent for R100's 6/15/23 increase in Olanzapine.

Based on observation, interview, and record review, the facility failed to ensure residents were protected from physical abuse for 13 of 13 residents (R1, R12, R18, R27, R28, R48, R50, R58, R93, R100, R102, R105, R106) reviewed for abuse in the sample of 37. Findings include: The facility's Abuse Prevention Program policy, dated 8/1/22, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 1. On 08/28/23 at 10:34 AM, R100 was aimlessly wandering back and forth in a closed hallway. On 08/29/23 at 11:44 AM, V15 (R100's family) stated, A few months ago, she was in another resident's bed. That resident got angry and hit her. R100's Care plan, dated 1/11/23, documents, R100 wanders throughout the facility, up and down halls and in common areas. R100 may enter peer's rooms without knowing due to Alzheimer's disease. The care plan also documents the following interventions: Distract R100 from wandering by offering pleasant diversions, structured activities, food, conversation, television; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? is R100 looking for something? Does it indicate the need for more exercise? Intervene as appropriate; Staff to assist R100 in maintaining appropriate boundaries between herself and peers/redirect from peers rooms. R100's Care plan, dated 8/16/23, documents, R100 ambulates with a propulsive gait, with head and neck bent forward. (R100) is unaware of her safety needs and requires constant redirection from staff. R100's Nursing note, dated 10/18/2022 at 11:00 a.m., documents, R100 went to R48's room and stated she was going to take her television. R48 yelled at R100 and told her to get out of her room and pushed her to the floor. The facility's Final Abuse Investigation Report, dated 10/18/23, documents, On 10/18/22 at 10:50 a.m. on F hall, R48 pushed R100 who fell on her right side. CNAs (Certified Nursing Assistants) intervened and notified nursing. Nursing assessed no visible injuries. R100 was confused and entered R48's room to 'take her TV.' The females argued and R48 reacted by pushing R100. R48 admitted to pushing R100 because she thought she was taking her stuff. The facility Information Report, dated 10/18/22, documents, Interview with R100: R100 was confused and thought she was told to get the TV in F2 and take it to someone. She stated, 'that lady wouldn't let me have it and pushed me. I was just trying to do my job.' Interview with R48: 'I didn't know why she wanted my TV. I yelled at her to get out of my room and pushed her because she was trying to take my stuff.' Interview with V35 (CNA): 'I was at the desk and saw R48 walk in R100's room. Then, I heard her yelling for someone to help. By the time I got to the room, R48 pushed R100 who fell to the ground and landed on her bottom. R100's Nursing Note, dated 10/23/2022 at 2:24 p.m., documents, R100 noted in R27's room. R27 ask her to leave when she did not he hit on the left side. The facility's Final Abuse Investigation Report, dated 10/28/23, documents, On 10/23/22 at 1:30 p.m. on G-Hall, R100 had entered R27's room. R27 allegedly hit R100 on her left side. R100 was assessed with no injuries noted. Staff witnessed R100 come out of R27's room and heard R27 yell. R100 stated R27 hit her side but no witnesses saw the interaction. R100 was taken to the nurse for assessment. R27 was unable to say what happened, but stayed in his room. The facility's Information Report, dated 10/23/22, documents, V21 (CNA) interview, After lunch I came down the hall to make a resident bed before they return to their room and heard R27 yelling down in his room for someone to get out his room. As I walked down the hall to see what was going on, R100 was coming out the room saying he punched me and almost killed me, then R27 slammed the door and I went and reported in to the nurse. R100's Nursing Note, dated, 1/7/2023 at 3:13 p.m., documents, R100 was observed walking on F hallway wondering to R48's room, R48 came to the door as resident was wondering into R48's room, R48 slammed door on resident causing resident to turn and fall and hit her head on the ground sustaining a laceration above her right eye with mild bleeding (measures) 2.5 cm (centimeters) x 1.0 cm. The facility's Final Abuse Investigation Report, dated, 1/7/23, documents, On 1/7/23 at 2:25 p.m. on F Hall, R100 approached a R48's room. R48 got mad and closed the door in R100's face causing her to fall and sustained a laceration to her eyebrow. R48 thought R100 was trying to take her pillows and got angry. Incident occurred due to R48's diagnosis of misunderstanding of circumstances. Staff reminded and educated related to monitoring residents with dementia. The facility's Information Report, dated 1/7/23, documents, Interview with R48: R48 stated she thought R100 was trying to take her pillows and was just trying to shut the door. She didn't mean to hurt R100. Interview with V37 (Housekeeper): She heard the door slam and R100 fell. She went immediately to assist R100/call for other staff. R100's Nursing Note, dated 7/8/2023 at 1:45 p.m., documents, Summoned to room per resident yell out. As this writer enter room, R93 pulling arm/body resulting in her falling to floor bedside table within close Proximity. Residents immediately separated. R100 with hematoma to lateral forehead. The facility's Final Abuse Investigation Report, dated 7/8/23, documents, On 7/8/23 at 1:45 p.m. on G hall, R100 was noted in R93's bed. R93 attempted to pull her out of the bed causing her to fall to the floor. R100 bumped her head on the bedside table. Sustained bruise to right lateral forehead. The facility's Information Report, dated 7/8/23, documents, Interview with R93: 'She was in my bed and I tried to move her. I'm a doctor, but she shouldn't be in my bed.' Interview with V38 (Licensed Practical Nurse-LPN/V39 (CNA): V38 and V39 were across the hall providing care and heard a female yell out. As they entered the room, they saw R93 pulling on R100's arm to get her out of his bed. Before they could intervene, R100 hit her head on the bedside table and fell to the floor. They assessed her for injuries. R93 left the room. They redirected R100 and spoke to the staff about increased monitoring/placed on fall vitals. R100's Social Service Note, dated 7/10/2023 at 09:11 a.m., documents, R100's observation period has ended this week, social services attempted to do her assessments and she did not partake due to her Alzheimer's disease. During R100's observation period she displayed behaviors such as wandering, delusions and anxiousness. R100 has delusions that she is looking for pillows to keep safe and wanders throughout the facility at times into peers room and lay in their bed causing agitation in some peers. During her observation period R100 invaded peers room resulting in her getting physically thrown out the room. On 8/31/23 at 12:15 p.m., V1 (Administrator)stated, Staff that are working with (R100) should redirect her when they see her wandering on the hall, walk with her, monitor to see if doors are closed, monitor to keep her safe, and be attentive to her needs. That practice wasn't happening obviously. 2. On 08/28/23 at 10:34 AM, R102 was aimlessly wandering back and forth in a closed hallway. R102's Care plan, dated 1/31/23, documents, R102 has a history of Depression and catatonic schizophrenia. R102's Care plan, dated 5/26/23, documents, R102 displays verbal and physical aggression during ADL cares at times. R102 may react aggressively toward internal stimuli without staff/peer provocation when confused in his surroundings or uncomfortable (IE: incontinent). R102's Care plan, dated 4/27/23, documents, R102 will wander throughout the facility for long periods of time and go up and down the halls, dining room area, and outside on the patio. R102 is often carrying various items (food, drink, linen, etc.). The care plan also documents the following interventions: Staff to assist R102 to maintain appropriate boundaries between himself and his peers; Staff to intervene proactively to help R102 avoid conflict; Staff will monitor R102 for safe passage while walking and redirect from congested areas (people or objects). R102's Care plan, dated 7/6/23, documents, R102 believes that residents are talking to him while pacing the halls and will become physically aggressive if he feels they are trying to harm him. The care plan also documents a goal of R102 having a minimum of two physical incidents prior to the next review date. R102's Social Service Note, dated 5/6/2023 at 5:30 p.m., documents, R102 was in a physical altercation with R1. R102 stated that his peer hit him. Social Services reminded R102 that physical aggression is a negative response. The facility Final Abuse Investigation Report, dated 5/6/23, documents, On 5/6/23 at 5:45 p.m. in the main dining room R1 hit R102 on the nose with a closed fist. R1 stated he felt like R102 was following him and was going to hit him. Staff reported both residents were pacing through the facility at the same time. R1 told R102 to get away and R102 repeated the phrase which caused R1 to be paranoid. R102's Social Service Note, dated 5/18/2023 at 2:55 p.m., documents, This writer witnessed R102 wandering when he walked upon a R1 and started hitting the R1 on his arm with close fist. R1 screamed for R102 to stop then proceeded to hit R102 in the mouth with close fit. Staff intervened and R102 was redirected to his room where staff tried to dress him for a nap. The facility's Final Abuse Investigation Report, dated 5/23/23, documents, On 5/18/23 at 2:05 p.m. in the main dining room, R102 approached R1 and hit him on the arm/chest/body. R1 then hit R102 in he mouth with a closed fist. R102 was incontinent and walking through the dining room. He began hitting R1 in his upper arm, chest, and body. R1 stated he asked R102 to stop, which alerted staff. R1 then hit R102 in the mouth with a closed fist before staff was able to intervenes. R102 was redirected and incontinence was addressed calmed with staff. The facility's Information report, dated 5/18/23, documents, Interview with R1: R1 stated he was standing on the wall in the dining room when R102 approached him and began hitting him in the arm, chest, and mid-body. R1 said he asked R102 to stop before he hit R102 in the mouth. When asked if R1 said anything to R102, R1 denied making any comments. When asked if he could have gotten away without hitting R102, R1 said he didn't think of that. R1 said it happened quickly and staff came and separated them right away. Unable to interview R102. Interview with V27 (Case Manager): V27 was in her office and heard R1 yelling for someone to stop. As V27 approached, she was R102 was hitting R1 and R1 hit R102 in the mouth before she and other staff could intervene. Interview with V28 (CNA-Certified Nursing Assistant): V28 stated that she came to help intervene and saw both R102 and R1 hit one another. V28 stated that R102 was incontinent and can get aggressive when he's uncomfortable. R102's Nursing Note, dated 5/19/2023 at 2:44 p.m., documents, R102 hit in arm with ukulele by R18. The facility's Final Abuse Investigation Report, dated 5/23/23, documents, On 5/19/23 at 2:10 p.m. on G-hall, R18 hit R102 on his left arm with his ukulele. R102 was walking in the hall and passed R18. R18 stated R102 was to close to him so he hit R102 with his ukulele. The facility's Information Report, dated 5/19/23, documents, Interview with R18: R18 stated R102 was walking down the hall and got too close to him. R18 just reacted and hit R102 with his ukulele not knowing what else to do at the time. Unable to interview R102. Interview with V29 and V30 (Both CNAs): Both CNAs were working on the hall and saw R18 hit R102 with the ukulele before they could intervene. R102's Nursing Note, dated 7/1/2023 at 6:27 p.m., documents, R102 was in an altercation with R106. Per witness R102 was hit in face. The facility's Final Abuse Investigation Report, dated 7/5/23, documents, On 7/1/23 at 6:15 p.m. in the north TV room, R106 hit R102 in the face with a closed fist. R102 and R106 were sitting in TV room. R102 got up and approached R106. R106 has a diagnosis of paranoid schizophrenia and got up not knowing what R102 wanted. R106 admitted to hitting R102 before staff could intervene. The facility's Information Report, dated 7/1/23, documents, Interview with R106: R106 stated he was sitting in the TV room and R102 got up and moved toward him. He didn't know what R102 was going to do so he got up and backed away from him. R102 walked toward him and R106 said he punched him in the face, but staff then got involved. R106 stated he knew he shouldn't have hit him but he was confused. Interview with V31 (Registered Nurse): V31 was passing medication when she heard something from the CNAs about fighting. She rushed over and R106 hit R102 before staff could intervene. R102's Nursing Note, dated 7/5/2023 at 6:15 p.m., documents, R102 walked up near R105 seated at the dining room table & bumped into R105's walker. R105 asked this R102 to move and R102 hit R105 on the left shoulder. R105 then hit R102 on the left eye area causing 1.5 cm x 1 cm raised area with slight bruising. The facility's Final Abuse Investigation Report, dated 7/5/23, documents, On 7/5/23 at 6:15 p.m. in the main dining room, R102 walked up to R105 sitting at a table and bumped his walker. R105 asked R102 to move and R102 hit R105 on the left shoulder. R105 then hit R102 in the left eye. R102 had a 1.5 cm x 1 cm raised area with slight bruising. On 8/28/23 at 12:40 p.m., V21 (CNA), stated, Those residents (R100 & R102) are back there on the unit because they would constantly wander and the other residents would get irritated with them. The other residents with their behaviors don't understand that (R100) nor (R102) wouldn't hurt them. (R102) just walks up to people really close and doesn't say anything. The other residents think he's going to him them. On 8/31/23 at 12:15 p.m., V1 stated, (R102) walks with his head down and paces. He has no spacial awareness. Staff should be intervening early if they see him wandering around other residents. They should also alerted if he's in the area to keep an eye on him and know where he's at. If I'm assigned to that hall I should know where he is. The staff needed to be proactive with him and they weren't. 3. The facility's Abuse Investigation (dated 10/5/22) documents the following: On 10/05/22 at 01:15 PM in the main dining room, (R18) hit (R12) in the back with a closed fist. (R12) repeatedly called (R18) a racial slur and (R18) admitted to hitting (R12) to make him stop. On 08/28/23 at 02:37 PM, R18 was propelling in the hall near the nurse's station. R18 stated he did punch R12 in the back on 10/05/22, He was calling me a Jap so I let him have it. On 08/30/23 at 04:10 PM, V1 (Administrator) confirmed that R18 physically struck R12 in the back on 10/05/22. 4. The facility's Abuse Investigation (dated 10/25/22) documents the following: On 10/25/22 at 10:23 AM by the nurse's station, (R27) was passing by and hit (R18) in the back of the head. On 08/28/23 at 02:37 PM, R18 was propelling in the hall near the nurse's station. R18 stated he was struck in the back of the head by R27 on 10/25/22 and stated, He karate chopped me in the back of the head. On 08/30/23 at 04:10 PM, V1 (Administrator) confirmed that R27 did physically abuse R18 on 10/25/22. 5. The facility's Abuse Investigation (dated 12/16/23) documents the following: On 12/16/22 at 2:00 PM, (R18) approached (R50) at the nurse's station and made a 'joking' gesture like he was going to hit (R50). (R50) yelled at (R18). (R18) kicked (R50) and (R50) hit (R18) in the back of the head. Incident occurred. Both parties have mental illness and poor impulse control. On 08/30/23 at 04:10 PM, V1 (Administrator) verified that R18 and R50 were involved in a physical altercation on 12/16/22. 6. On 08/28/23 at 02:13 PM, V33 (R58's sister) stated, I think things are going well. The only issue (R58) has had is that someone hit her in the head once when she was going to the bathroom several months ago. The facility's Abuse Investigation Report (dated 04/17/23) documents R58 was struck on the head by R28 in their shared bathroom. This same report documents, (R58) stated she was using the bathroom when (R28) came in from the other side and needed to use the bathroom. (R28) then hit (R58) in the head and (R58) called out for help. On 08/30/23 at 4:10 PM, V1 (Administrator) stated R28 did physically strike R58 on the head while they were in their bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review the facility failed to ensure a range of motion program was in place for residents with functional limitations in range of motion for six of nine residents (R45, R55, R58, R67, R72, R83) reviewed for range of motion in the sample of 37. Findings include: The facility's Restorative Program Policy, dated 6/1/23, documents It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the individual's comprehensive assessment, to achieve and maintain the highest practicable outcome. Our goal is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible, and to achieve and preserve their highest level of mental, physical and psychosocial functioning. Restorative nursing is available seven days a week and is provided for the residents with assessed needs according to program criteria. Purpose: The restorative nursing program is designed to Preserve function, Promote optimal improvement, Increase independence, self esteem and dignity, Promote safety, Minimize deterioration within the limits of normal aging and/or recognized disease process. 1. R45's Minimum Data Set assessment, dated 8/22/23, documents R45 is cognitively intact and has impairments in range of motion to both lower extremities and one upper extremity. On 8/30/23 at 1:45 PM V3 (Assistant Director of Nursing) confirmed that R45 has limits in range of motion. V3 stated We do not have restorative programing for (R45). She may participate if they were offered. To be honest we lost a lot of staff during COVID and I am just one person so having all of the needed programs is impossible. We don't have the staff. On 8/30/23 at 2:00 PM, R45 was laying in bed in her room. R45 stated Ever since I was a kid they have done exercises with me for my joints. I can't move my legs much and my left arm is limited. I would like exercises. I told someone that a long time ago and they said they'd look into it but nothing ever came of it. 5. R67's current POS's/Physician Order Sheets documents R67 has diagnoses of Hemiplegia affecting his left side and Cerebral Infarction and has orders May Participate in Restorative Programs. R67's MDS/Minimum Data Set assessment dated [DATE] documents, R67 has a BIMS (Brief Interview of Mental Status) of 15 (cognitively intact), requires extensive assist with ADL's (Activities of Daily Living) and has limitations to one side of his upper and lower extremities. This same MDS documents R67 does not receive any Restorative Programs. R67's current plan of care documents R67 has limited physical mobility related to left side hemiplegia due to cerebral infarction. He requires mechanical lift and extensive to total assistance from staff of two or more to complete all task of daily living including transfers. On 8/28/23 at 1:15 PM, R67 was sitting in his wheelchair in his room, alert and oriented. R67 stated, I had a stroke and I have trouble with my left side because of it. I would like to have the staff work with my left side so I don't get contractures etc. No one has offered to do any ROM/range of motion with me. On 8/30/23 at 11:30 AM, V24 (CNA/Certified Nursing Assistant) stated, No I do not do any Restoratives with any of the residents. I don't know of any staff that does. On 8/30/23 at 11:45 AM, V25/CNA stated, I have never done range of motion or any restoratives with any of the residents. I don't think we have any restorative aides at this time. On 8/30/23 at 1:48 PM, V3 ADON/Assistant Director of Nursing stated, No (R67) is not on any restorative programs. I don't think he would participate but we have not tried any with him. Since COVID we lost a lot of restorative staff. 6. R83's current POS's documents R83 has diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side and has orders May Participate in Restorative Programs. R83's MDS/Minimum Data Set assessment dated [DATE] documents, R83 has a BIMS (Brief Interview of Mental Status) of 14 (cognitively intact), requires limited assist of one with ADL's (Activities of Daily Living) and has limitations to one side of his upper and lower extremities. This same MDS documents R83 does not receive any Restorative Programs. R83's current plan of care documents R83 has limited physical mobility related to left side hemiplegia due to cerebral infarction. He requires mechanical lift and extensive to total assistance from staff of two or more to complete all task of daily living including transfers. On 8/28/23 at 1:45 PM, R83 was sitting in his wheelchair in his room, alert and oriented. R83 stated, I had a stroke and I have trouble with my left side. My hand keeps clinching closed, I would like to have the staff work with my left side so I don't get contractures etc. No one has offered to do any ROM/range of motion with me. On 8/30/23 at 1:48 PM, V3 (ADON/Assistant Director of Nursing) stated she has never been told by (R83) that he had trouble with his left hand clinching shut all the time and would like to have ROM (Range of Motion) and a brace for his hand. V3 stated, (R83) is not on any restorative programs at this time. 2. R55's current Diagnoses include the following: Muscle Weakness, Thoracogenic Scoliosis, Abnormal Posture, and Arthritis. R55's current Physician Order Sheet documents the following order: May participate in Restorative Programs; May participate in psychiatric rehabilitative specialized services 1-7 days per week as indicated. R55's Mobility Assessment (dated 08/18/23) documents the following range of motion limitations for R55: moderate impairment of his head, trunk, left and right shoulder, and left and right ankle. R55's Minimum Data Set Assessment (dated 07/05/23), Section G Functional Limitation in Range of Motion, documents R55 has impairment on both sides of his lower extremities. On 08/28/23 at 01:45 PM, R55 was sitting in his wheelchair at the table in the dining room. R55 had his eyes closed and his head slumped forward. R55 opened his eyes and raised his head when addressed, and R55 stated that he does not perform any type of daily range of motion exercises. 3. R58's current Physician's Order Sheet documents the following order: May participate in Restorative Programs May participate in psychiatric rehabilitative specialized services 1-7 days per week as indicated. R58's Mobility Assessment (dated 07/10/23) documents the following range of motion limitations for R58: moderate impairment in her right and left hip; and moderate impairment in her right and left knee. R58's Minimum Data Set Assessment (dated 07/11/23), Section G Functional Limitation in Range of Motion, documents R58 has impairment on both sides of her lower extremities. 4. On 08/30/23 at 01:30 PM, V3 (Assistant Director of Nursing) stated R72 currently does not have any type of range of motion/restorative programming in place. R72's current Diagnoses include the following: Repeated Falls and Pain in unspecific knee. R72's current Physician Order Sheet documents the following order: May participate in Restorative Programs; May participate in psychiatric rehabilitative specialized services 1-7 days per week as indicated. R72's Mobility Assessment (dated 07/03/23) documents the following range of motion limitations for R72: moderate impairment in her right and left hip; poor range of motion in her left knee and ankle; and moderate impairment in her right knee and ankle. R72's Fall Investigation (dated 12/13/22) documents R72 slipped and fell on a puddle of water in her room and sustained a left distal femur fracture and required surgical intervention. R72's Minimum Data Set Assessment (dated 07/05/23), Section G Functional Limitation in Range of Motion, documents R72 has impairment on both sides of her lower extremities. On 08/28/23 at 11:32 AM, R72 was sitting on the side of her bed sorting through paperwork on her bedside table. R72 stated that on 12/13/22, she slipped and fell in her room and sustained a fracture in her left leg near her knee. R72 then stated she currently has some weakness and pain in her left leg. R72 denied participating in any type of range of motion/restorative program. On 08/30/23 at 01:30 PM, V3 (Assistant Director of Nursing) stated R72 currently does not have any type of range of motion/restorative program in place.

Based on record review and interview, the facility failed to conduct annual testing on opportunistic waterborne pathogens. This failure has the potential to affect all 111 residents who reside in the facility. Findings Include: The facility's Water Management Plan policy (undated) documents, The facility is actively involved in preventing the occurrence and spread of legionella bacteria. In the latter regard, a proactive system of water management has been implemented. While Legionella has never been a problem affecting residents it is recognized that vigilance must be ongoing both within and external to the site. Within facility itself, a buildup of scale and sediment, construction/renovation equipment changes/failure, system startup/shut down and alterations in water pressure are prime areas to be monitored. Mixing valves, heat loss and/or hot weather-related overheating of pipes containing cold water are less commonly observed bacterial sources but must be considered. Lack of use of a specific faucet or showerhead may also encourage biofilm growth merely because of stagnation. The Maintenance Department must therefore conduct routine testing of bacteria levels. The latter testing is conducted once each month at varying locations throughout the facility. The Maintenance Assistant will ensure that a log is kept documenting the test date. The location, results and type of fixture. The facility Water Chlorine Tests log (dated 1/10/23 -8/8/23) documents,Date, Location, Fixture and Results of Chlorine Test. This log was blank and does not document Legionella test results. On 8/31/2023 at 9:15 AM, V32 (Maintenance Director) stated, No, the legionella testing is not being done in this facility. We have a recirculating water pump which keeps the water circulating. I do not have any idea how to do this test. The Resident Census and Condition of Residents form 672, dated 8/29/2023 and signed by V1 (Administrator), documents 111 residents currently reside in the facility.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff for one resident (R1) of three residents reviewed for abuse in a sample of seven. Findings include: The facility's Abuse Prevention Program policy dated 8/1/22 documents This facility is committed to protecting our resident from abuse by anyone including, but not limited to, facility staff, other resident, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. Definitions - Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. R1's medical record documents a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 15 indicates the resident is cognitively intact. The facility's Abuse Prevention training dated 1/26/23 documents V3 (Certified Nursing Assistant/CNA) was in attendance. On 2/9/23 at 7:33 AM, V3 (CNA) was observed by surveyor in the dining room jerking R1's reclining chair away from the wall and table to reposition it. Once V3 got the chair away from the table, she backed it up close to the wall then stopped, walked to the head of the chair where an oxygen cart was sitting between the chair and the wall, and forcefully grabbed the oxygen cart jerking it out from behind the chair. V3 then walked back to the front of the chair and hit the foot rest of the chair with her legs using the weight of her body causing the chair to slam hard enough into the wall to cause R1's body to bounce up. V3 then walked to the back of the chair and forcefully kicked the wheel lock down and yelled Anything else? to R1. R1 responded saying, You should work on the other side if you don't like working here. V3 could be heard stating, I work . as she walked away continuing to talk a loud. V4 (CNA) was standing next to R1 and witnessed the entire interaction between V3 (CNA) and R1. On 2/9/23 at 7:40 AM, R1 stated, I asked (V3/CNA) to move my chair away from the table because I like to have my phone plugged into the wall. V3 then got pissed and started getting rough with me. She jerked my chair away from the table and wall and then slammed it against the wall. My whole body came up in the chair that's how hard she hit the wall. After she moved the chair, she yelled 'anything else?' at me. This isn't the first time I've had issues with her. She's been like this all morning. She shouldn't be working here. On 2/9/23 at 8:23 AM, V4 (CNA) stated, (R1) asked (V3/CNA) to move his chair away from the wall. (V3/CNA) pulled his chair out aggressively. (R1)'s reclining chair is not that hard to move. It moves pretty easily. (V3) was already irritated for some reason when I arrived. I'm not sure what happened in the room between (R1) and (V3) because I wasn't there. I arrived when (V3) was getting ready to transport him down the hall. I did witness a verbal exchange between them in the hall. (R1) has arthritis and the reclining chair he's in can bounce during transportation causing pain. Well, (R1) asked (V3) to slow down because it was bouncing and she responded saying, 'You can't tell me how to walk.' She came off as irritated and verbally aggressive. I'm not sure if that's where her (V3) agitation started or not. What (R1) said to her was 'If you don't like working here, you should work on the other side,' to which (V3) responded saying, 'I work on the side I'm assigned' as she was walking away. On 9/23/23 at 9:44 AM, V1 (Administrator) stated, We just did an abuse inservice and (V3/CNA) was in attendance. She should have known better. (R1) can be difficult to handle sometimes, but that's no excuse of why (V3) acted the way she did. We teach the staff that the wheelchair is a part of the resident's body. On 2/9/23 at 11:22 AM, V1 (Administrator) stated, Since we believe the wheelchair or in (R1's) case his (reclining chair) is an extension of the resident's body, (V3) hitting his wheelchair into the wall jarring him, like you witnessed, would be considered physical abuse. On 2/9/23 at 11:27 AM, R1 stated, I have arthritis from the waist down and when (V3/CNA) hit my chair into the wall, my pain jumped to an eight out of 10. It really hurt for a second.

Based on observation, interview, and record review, the facility failed to ensure resident to resident verbal and physical abuse did not occur for two (R1 and R2) of three residents reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prevention Program policy, updated 8-1-22, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and 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 mistreatment, neglect or abuse of our residents . The facility's Residents' Rights for People in Long-term Care Facilities, undated, documents You have the right to .safety and good care: You must not be abused by anyone - physically, verbally, mentally, financially or sexually. R1's current Physician Order Sheet includes the following diagnoses: Dementia, Schizoaffective Disorder, and Anxiety. R1's Minimum Data Set/MDS assessment, dated 10-25-22, documents R1 is cognitively intact. On 1-24-23 at 10:58am, R1 sat in a wheelchair in the main dining room. Pointing a finger towards R2, R1 stated He (R2) hit me in the back of the head. He outright don't like me. I didn't do anything to him. R2's current Physician Order Sheet includes the following diagnoses: Schizoaffective Disorder Bipolar type, Antisocial Personality Disorder, and Post Traumatic Stress Disorder. R2's MDS assessment, dated 1-3-23, documents R2 is cognitively intact. On 1-24-23 at 11:07am, R2 sat in a wheelchair in the main dining room. At this time R2 stated (R1) has a bad habit talking about others. (R1) called my mother a name so without thinking I swung around and hit him. R2 confirmed that R2 intentionally hit R1 and stated I'm not gonna let him talk about my mother without defending her. The facility's Final Abuse Investigation Report, dated 12-28-22 and signed by V1 (Administrator) documents On 12-28-22, at 11:50am in the main dining room, (R1) was hit in the back of the head by a male peer (R2) .Staff and resident witnesses confirmed (R1) was making inappropriate statements about (R2's) mother when (R2) hit (R1). (R2) was not hit in the incident. This report includes interviews with R1 and R2: R1 stated He hit me in the head. I didn't touch him. R2 stated He was talking about my mom so I hit him. This report also includes a Witness Statement by V4 (Certified Nursing Assistant/CNA Supervisor): I witness(ed) (R2) roll up to the back of (R1) and punch (R1) in the back of (R1's) head. Afterward, (R1) started yelling 'resident needs assistance,' while yelling (R2) told (R1) to shut the f**k up before I punch you again. On 1-24-23 at 11:23am V4 (CNA Supervisor stated that V4 heard (R1) say that (R2) hit (R1) on the back of the head. V4 asked (R2) why, but V4 does not recall (R2's) reason. V4 stated (R2) told me he hit (R1) and would do it again. On 1-24-23 at 3:10pm, V1 (Administrator) confirmed that the incident between R1 and R2 did occur on 12-28-22. V1 stated that (R2) did hit (R1). V1 stated (R1) makes inappropriate comments and doesn't think through consequences. V1 stated that V1 asked (R2) if it was intentional and (R2) said I hit him. V1 stated that (R2) lacks impulse control but is much more alert and oriented and can make his own choices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent resident to resident abuse for one resident (R1) of four residents reviewed for abuse. Findings include: Facility Policy/Abuser Prevention Program dated/revised 8/1/22 documents: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Current Physician's Order Sheet indicates R1 was admitted to the facility on [DATE] with diagnoses that include Catatonic Schizophrenia, Depression and Seizure Disorder. Current Care Plan indicates the following Focus area was initiated on 11/3/22 (R1) will wander throughout the facility for long periods of time, go up and down the halls, dining room area and outside on the patio. Current Comprehensive Assessment indicates R1 has moderately impaired cognitive skills for decision making, has behaviors of wandering/pacing, is sometimes understood, and sometimes understands. On 1/11/23 at 10:am R1 was observed slowly walking throughout the unit hallways to the end/ back. At that time R1 did not attempt to go into any other residents' rooms. R1 then walked through the dining room and went out the exit door to the enclosed smoking area - no staff intervened at that time. Several minutes later while asking CNA (Certified Nurse Assistant) about another resident who was outside in smoking area, the CNA saw R1 and immediately redirected R1 back into the building. Final Abuse Investigation Report dated 12/14/22 indicates on 12/8/22 at 4:25pm R1 was hit by R3 in the face in the dining room. Report indicates R1 did not sustain any injuries. Report indicates R1 was attempting to ambulate through a congested area with a number of residents and R3 was attempting to propel his wheelchair in the opposite direction. R3 then yelled at R1 to move and before staff could intervene R3 stood up and hit R1. On 1/10/23 V5 (Registered Nurse) stated that she was at the medication cart near dining room when she heard R3 raise his voice, saw R3 was trying to go one way and R1 the other way. R3 yelled at R1 to get out of the way, then stood up and hit R1. V5 stated two male staff were nearby and immediately intervened and separated R1 and R3. V5 stated that R1 repeats everything you say, so when R3 told R1 Move out of my way, R1 most likely said that back to R3, who thought R1 was provoking him, then stood up and hit R1. V5 stated R1 was assessed and had no injuries. Final Abuse Investigation Report dated 12/29/22 indicates on 12/22/22 at 8:52am R2 hit R1 in the face with a closed fist. Report indicates R1 was walking with the nurse in the hallway when the nurse had to briefly step away, R1 walked into a male peer's room and was hit by R2. On 1/10/23 at 1:45pm V4 (Licensed Practical Nurse) stated she was passing medications outside of R2's room and R1 was ambulating through the hallway and entered R2's room. V4 stated as she was actually redirecting R1 out of R2's room, R2 hit R1. On 1/10/23 at 1:50pm V8 (Housekeeper) stated she was in the same hallway when R1 walked into R2's room. V8 stated that R2's roommate started yelling for R1 to get out and as V4 was redirecting R1 out of the room, R2 jumped up and hit R1. On 1/11/23 at 12:50pm V1 (Administrator) stated both R2 and R3 did act willfully when they hit R1.

Based on interview and record review, the facility failed to use equipment per the manufacture's recommendations in the care for the residents to provide a safe transfer for 1 of 3 residents (R1) reviewed for falls in the sample of 5. Findings include: The Fall Prevention Policy dated 11/10/22, documents It is the policy of this facility to prevent falls and serious injury outcomes by recognizing multi-factorial risks and causes, and institute recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care. Nursing Care Strategies Institute general safety precautions according to facility protocol, which may include, use 2 staff, if necessary, while assisting resident with transfers, balance or walking. The Using a Portable Lifting Machine policy (not dated) documents The primary purpose of using a portable lifting machine is to help lift residents who may be too heavy to lift. The portable lift is also used to promote comfort and to maintain good body alignment while the resident is being moved. This procedure requires the assistance of two persons. R1's current Care Plan documents (R1) is at risk for falls. She has hemiplegia and hemiparesis affecting her left side. (R1) is wheelchair dependent and requires assistance of 2 staff and mechanical lift to transfer. On 11/21/22 at 11:10 AM, V1 (Administrator) stated (R1) had a fall when (V6/Certified Nursing Assistant) was getting (R1) up using a sit to stand mechanical lift. (V6) was doing the transfer by herself. (V6) should have had someone helping her with the transfer. It is our policy to have two staff for all mechanical transfers. On 11/21/22 at 1:43 PM, V2 (Director of Nursing) stated There should always be two staff for all mechanical transfers. They (Certified Nursing Assistants'/CNA's) are taught that when they are hired. On 11/21/22 at 1:20 PM, V3 (Assistant Director of Nursing) stated (V6/CNA) was doing (R1's) transfer alone. I'm sure (V6) knew she was supposed to have help. On 11/22/22 at 12:40 PM, V6 (Certified Nursing Assistant) stated (R1) said that she wanted to get up. I told her she would have to wait for another CNA to be able to help me transfer her. I knew there is supposed to be two staff but (R1) was throwing a fit and said she was going to call the police because I wouldn't get her up. I was by myself and got (R1) changed and dressed then I hooked (R1) up to the sit to stand. When it started to lift (R1) up she let go of the bar and started to slide out of the belt. I got behind her and lowered (R1) to the floor. The mistake I made was not having help to transfer (R1). On 11/21/22 at 4:55 PM, R1 stated that when she fell from the sit to stand there was one staff doing the transfer. R1's Incident Report dated 11/14/22, documents a staff assisted fall at 12:15 PM, in R1's room. V6 (CNA) was transferring R1 from bed to her wheelchair using the sit to stand. R1 let go of the handle and started to slide down. V6 was able to prevent the fall and lowered R1 to the floor. V6 will be educated on the proper use of a mechanical lift.

Based on observation, interview, and record review, the facility failed to keep a blind resident's pathway clear of obstacles for one (R62) of three residents reviewed for incidents/accidents in a sample of 45. Findings include: On 7-1-22, at 7:25am, R62 sat in a wheelchair in the dining room. R62 stated that she had an accident and hit her nose. R62 stated, They put the (mechanical lift) on the wrong side (of the hall). They are not to put things on a certain side of the hall. R62's Progress Note, dated 8-4-22, documents, (R62) reported to this nurse that (R62) ran in to the (mechanical lift) and (R62's) peer told (R62) that (R62) had a bruise under (R62's) left eye. R62's current Physician Order Statement/POS, includes diagnoses of Blindness of left and right eyes. On 7-18-22, at 10:40am, R62 sat in a wheelchair in R62's room. At that time, V12 Certified Nursing Assistant/CNA, exited R62's room and verified there was a mechanical lift just outside of R62's room in the hall along the railing and a wheeled walker a few doors down along the same side. V12 stated that R62 has bumped into things before and, If a (mechanical lift) like this one, (pointing to the one right outside of R62's door,) is in the way, (R62) will bump into it. It is not supposed to be there. On 7-18-22, at 10:47am, R62 came self-propelling in a wheelchair down the hallway towards the walker. V12 CNA ran over and moved the walker out of R62's way just as R62 was about to run into it. V12 sighed and said, Good timing. That was close! R62's current Care Plan includes (R62) is at high risk for incident/injury/fall related to total blindness and impaired mobility. (R62) is often noted moving too fast and running over peers. Interventions include: Staff to ensure that (R62's) hallways are free from clutter and equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain timely pressure ulcer/wound treatment orders from a Physician, perform weekly wound checks, and implement pressure relieving interventions for one of one resident (R78) reviewed for pressure ulcers in a sample of 45. Findings include: The facility's Skin Treatment Protocol (undated) documents, Decubitus ulcers are commonly referred to as bedsores or pressure sores. Pressure sores are usually formed when the skin breaks down because the resident remains in the same position for an extended period of time. When a resident remains in the same position for an extended period of time, there is a loss of circulation to that area, which destroys the tissues. The most common site of a pressure sore is where the bone is near the surface of the body. These include the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, toes, and under the breasts. The comprehensive assessment and plan of care determines the amount of care needed by each individual resident to ensure that a resident who enters the facility without a pressure sore does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable, and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Clinical conditions may demonstrate pressure sores were unavoidable only if preventive care was provided. Adequate preventive care includes turning and proper positioning, application of pressure relief devices, providing clean and dry bed linens, and maintaining adequate nutrition. Clinical conditions that are the primary risk factors for developing pressure sores are: The resident has two or more of the following diagnoses: a severe chronic pulmonary obstructive disease, diabetes, severe peripheral vascular disease, chronic bowel incontinence, chronic urinary incontinence, paraplegia, quadriplegia, sepsis, terminal cancer, chronic or end-stage renal, liver and/or heart disease, disease or drug related immunosuppression, full body cast. Based on the outcome of the comprehensive assessment and as change warrants skin deficits are addressed as appropriate with the Physician. Treatment is provided as described and a plan of care is developed. The facility DON (Director of Nursing) is to review any skin conditions/concerns weekly and as needed to ensure proper treatment is delivered and care planned accordingly. Pressure sores are the most serious skin condition for the resident. Report any signs of a developing pressure sore to the staff/charge nurse immediately. Facility Pressure Ulcer Management Protocol Stages I-IV, upon admission and at least weekly, residents who have been identified to have a pressure ulcer will have the following-supportive device i.e. wheelchair cushions, waffle boots, therapeutic mattress, etc will be used to alleviate pressure points. Daily skin checks will be done by CNAs (Certified Nursing Assistants) during bathing, toileting, ADLs (Activities of Daily Living), etc, Any red or open areas will be reported to the nurses. The Physician will be notified for treatment orders. Skin checks by licensed nurse will have progress documented on treatment sheets weekly. R78's Facesheet documents R78 admitted to the facility on [DATE] with diagnoses to include but not limited to: Paraplegia, unspecified and Type II Diabetes Mellitus with unspecified complications. R78's Minimum Data Set Assessment, dated 6/7/22, documents R78 with moderate cognitive impairment and requires extensive assistance of one person physical assist for bed mobility, transfers, dressing, and personal hygiene. R78's current Care Plan states, (R78) has Diabetes Mellitus and is insulin dependent. (R78) is not compliant with blood glucose monitoring and insulin administration times. (R78) is at risk for complications. This same Care Plan documents, Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness as an intervention with an initiation date of 5/20/21. R78's current Care Plan states, (R78) has potential for impairment to skin integrity due to (R78's) paraplegia and incontinence and documents interventions as Complete wound treatment as ordered by wound MD (Medical Doctor). Notify MD of any changes in condition; Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, (signs and symptoms) of infection, maceration, etc to MD (Medical Doctor); Weekly treatment documentation to include measurement of each area of skin breakdowns' width, length, depth, type of tissue and exudate and any other notable changes or observations. R78's Braden Scale for Predicting Pressure Sore Risk, dated, 6/1/22 documents R78 at risk for pressure ulcers. R78's current Physician Order Sheet (POS) documents an active order for diabetic foot checks weekly and to notify the Physician with any concerns. This order has a start date of 8/18/21. R78's Nursing Note signed and dated by V7 (Registered Nurse) on 6/30/22 at 1:08 PM states, (R78) has a small scab on (R78's) right inner foot. (R78) states it hurts a little and it may be rubbing on his shoe. I put some TAO (Triple Antibiotic Ointment) and a (adhesive bandage) on it. Keeping eye on it, so it doesn't open or get bigger. R78's Nursing Note signed and dated by V7 on 7/13/22 at 11:37 AM states, (R78) has a sore on (R78's) right inner foot.07 cm (centimeters) x (by) .07 cm. (R78) states it doesn't hurt. On 07/17/22 at 6:30 AM, R78 was noted to be lying in bed with eyes closed, white shin-high socks with black tennis shoes were in place to R78's bilateral feet. On 07/18/22 at 10:12 AM, R78 was noted to be lying in bed with eyes closed, white shin-high socks with black tennis shoes were in place to R78's bilateral feet. On 7/19/22 at 9:59 A.M. V8 (Registered Nurse/Treatment Nurse) denied being aware of any type of wound to R78's right inner foot. At this time, R78 was lying in bed with shin-high socks and black tennis shoes in place. No other pressure relieving methods were noted to be in place to R78's feet or bilateral lower extremities. At this time, R78 refused to allow any observations/care to R78's feet to take place. V8 stated as the treatment nurse, V8 should have been notified if new areas were found. On 07/19/22 at 10:03 AM V2 (Assistant Director of Nursing) stated V2 was not aware of any newly identified skin conditions for R78. V2 stated the nurse should create a skin observation sheet for the new area and get treatment orders. At this time, V2 denied seeing a skin observation sheet for R78's newly identified skin area or any treatment orders. On 07/19/22 at 10:16 AM V7 (Registered Nurse) stated V7 recalls finding a new scabbed area to R78's right ankle bone. V7 stated, (R78) said it was from his shoe rubbing. I put some TAO on it and loosened his shoe. I don't recall notifying (R78's Physician) or the wound nurse (V8). I should have. At this time, V7 verified no treatment orders were in place for R78's right ankle wound. On 07/20/22 at 9:25 AM, a skin assessment of R78's bilateral feet was performed by V3 (Care Plan Coordinator/Registered Nurse). On top of R78's left foot in the center, over a bony prominence, a reddened-purplish area, which did not blanch when pressed was noted. This area measured 1.5 cm x 0.5 cm. A round, dark reddish-purple area with pink edges to R78's posterior heel was noted. This area did not blanch when pressed in the center and measured 2 cm x 2 cm. An open area was noted to R78's right interior ankle bone. This area measured 1.5 cm in length and was noted to be 0.8 cm across at the top and 0.6 cm across at the bottom. The top part of the wound was open with broken skin and a pink center. The bottom portion of the wound was partially open with a round scabbed area hanging from the center of the wound. At this time, V3 stated, I will create a skin observation tool and get the Physician notified now to get treatment orders (for the skin impairments). V3 encouraged R78 to keep R78's shoes off, but R78 stated, Put them back on, I am going to be getting up soon and no one is ever around to help him put them back on. As of 7/20/22 at 9:15 AM, R78's medical record did not contain any documentation regarding treatment orders obtained for R78's right ankle wound, right heel wound, or left foot wound, weekly wound measurements of R78's right ankle wound, or any implemented pressure relieving interventions for R78's feet/heels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure range of motion services were provided for three residents (R7, R13 and R31) of four residents reviewed for limited mobility and range of motion in a sample of 45. Findings include: Facility Restorative Program Policy, updated 5/24/21, documents: It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the individual's comprehensive assessment, to achieve and maintain the highest practicable outcome; Goal is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible and to achieve and preserve their highest level of mental, physical and psychosocial functioning; that restorative nursing is available seven days a week; Restorative nursing program and documentation of the interventions and resident response will be completed with each implementation. Facility Description for Nursing Rehabilitation Aide, undated, documents: Under direction and supervision of a Licensed Therapist to improve function or prevent any further degeneration; Is directly responsible to the Director of Nursing/DON on a daily basis; and complies with procedures, observe, record and report the condition, reaction and responses related to assigned duties. Facility Resident List of Contractures documents that R7 and R13 have contractures. R7's Physician Order Sheet, dated 4/6/22, documents an order that R7 may participate in Restorative Programs one to seven days a week. R7's Mobility Assessment, dated 7/12/22, documents that R7 admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side related to cerebrovascular disease. The Assessment also documents that R7 has poor range of motion and/or muscle strength in the left shoulder, left elbow, left wrist/fingers, left hip, left knee and left ankle. On 7/17/22, at 1:14 pm, R7 was sitting in high back wheelchair in R7's room and was unable to move R7's left arm and leg with full range of motion. R7 stated, I am unable to move my left side because of my stroke. I have not had any therapy at all, for a long time, and I mean months. R7's left arm and hand were moderately contracted. R13's Physician Order Sheet, dated 4/11/15, documents an order that R13 may participate in Restorative Programs one to seven days a week. R13's Mobility Assessment, dated 4/17/22, documents that R13 admitted to the facility on [DATE]. This assessment also documents that R13 has moderate to poor range of motion and/or muscle strength to the left/right shoulder, left/right wrist/fingers, left/right hip, left/right knee and left/right ankle. On 7/17/22, at 7:48 am, R13, was lying in bed with moderate impairment R13's lower extremities and unable to fully position self. R13 was unable to fully move R13's lower extremities. R31's Physician Order Sheet, dated 8/21/20, documents an order that R31 may participate in Restorative Programs one to seven days a week. R31's Mobility Assessment, dated 4/25/22, documents that R31 admitted to the facility on [DATE]. The assessment also documents that R31 has moderate to poor range of motion and/or muscle strength to the left/right hip, left/right knee and left/right ankle. On 7/21/22, at 10:05 am, R31 was sitting in a chair in R31's room and stated, I have not had any type of therapy since earlier this year, probable since February. They did just give me a walker because they do not want me to fall, but I have gotten any therapy to build up my strength. R7, R13 and R31's Medical Records did not contain documentation that range of motion had been completed to address R7, R13's and R31's contractures and limitations in range of motion. On 7/19/22, at 1:42 pm, V1 (Administrator) stated, We do not have any Restorative Assessments or Restorative notes for at least the last three months for any of our residents, because we have not had a Restorative Aide for quite some time. The only thing I have to give you to review is the Resident Mobility Assessments, but they do not document any restorative therapy.

Based on observation, interview and record review, the facility failed to obtain a Physician order for oxygen use for one of two residents (R66) reviewed for oxygen in the sample of 45. Findings include: The facility's Oxygen Administration policy, undated, states, Documentation: In the progress notes, record: date and time of oxygen administration, type of delivery device, oxygen flow rate, resident's vital signs, skin color, respiratory effort, and lung sounds, and resident's response before and after initiation of therapy. The facility's Oxygen Concentrator policy, undated, states, Setting up the Concentrator: 2. Turn to the proper flow rate as ordered by the Physician. R66's Facesheet documents R66 with a diagnosis of malignant neoplasm of upper lobe, left bronchus of lung. On 7/17/22 at 6:52 AM, R66 was sitting up in the wheelchair in R66's room. At this time R66 stated, I wear it (oxygen) when I sleep which is basically all the time. An O2 (Oxygen) concentrator was noted in R66's room at the foot of R66's bed. Nasal cannula tubing was connected to the concentrator laying on R66's bed. At this time, R66's oxygen tubing was dated 7/11/22. On 7/18/22 at 10:42 AM, R66 was noted to be lying in bed with eyes closed. R66 was wearing R66's nasal cannula with oxygen flowing at 2.5 liters via oxygen concentrator. R66's current Care Plan documents R66 is often short of breath on exertion and when lying flat. This same Care Plan also documents R66 is on hospice care for a diagnosis of malignant neoplasm of upper lobe, left bronchus. As of 7/19/22 at 8:22 AM, R66's medical record did not document a Physician order for R66's oxygen use. On 7/19/22 at 8:22 AM, V3 (Care Plan Coordinator/Registered Nurse) verified R66's current Physician orders did not contain an order for R66's oxygen use and it should. V3 stated, Even if hospice ordered the oxygen, it should be an active order on this (R66's) POS (Physician Order Sheet) and it's not.

Based on observation, interview, and record review, the facility failed to ensure resident wheelchairs were clean for four (R41, R70, R84, and R101) of 45 residents reviewed for homelike environment in the sample of 45. Findings include: The facility Resident Council Minutes, dated 5/27/22, documents there were twenty residents in attendance and documents: Old Business: Any unresolved issues from last month: WheelChairs stopped getting washed after a few times. On 7/20/22 at 12:09 pm, V2 ADON (Assistant Director of Nursing) stated the resident wheelchairs are cleaned following the undated resident Shower Schedule three times a week and as needed. V2 stated the third shift CNAs (Certified Nursing Assistants) are responsible to wash the residents wheelchairs during the third shift prior to the resident scheduled shower three times a week. On 7/20/22 at 9:59 am, V9 CNA (Certified Nursing Assistant) Scheduler provided the undated resident Shower Schedule the facility uses to also clean resident wheelchairs. This Shower Schedule lists each resident room number and the three days a week the resident is to be offered showers and the resident wheelchairs are to be cleaned. The facility's undated Shower Schedule, documents Showers are to be offered according to the following schedule: 1. Monday, Wednesday, Friday - First shift - Rooms 2, 4, 6, and 8. 2. Monday, Wednesday, Friday - Second shift - Rooms 10, 12, 14, and 16. 3. Tuesday, Thursday, Saturday - first shift - Rooms 1, 3, 5, and 7. 4. Tuesday, Thursday, Saturday - Second shift - Rooms 9, 11, 13, 15, and 17. 1. On 7/17/22 at 10:09 am, R84's wheelchair was soiled with thick dust to the edges of the seat cushion, dry shriveled food debris and thick crusty substance in various areas of R84's wheelchair including bilateral leg rest connection areas, arm rests, and wheels. On 7/18/22 at 9:00 am and 7/19/22 at 3:20 pm, R84 was sitting in his wheelchair which continued to be soiled with dry shriveled food debris and thick crusty substance in various areas as it was on 7/17/22. The undated Shower Schedule, documents R84's shower days are scheduled for Monday, Wednesdays and Fridays therefore; R84's wheelchair should be cleaned on Sunday, Tuesday, and Thursdays during the third shift. 2. On 7/19/22 at 3:35 pm, R41 was sitting in a wheelchair with thick brown substance, food debris on the seat and edges of wheelchair cushion. There was a dried tan substance running down the left side of R41's wheelchair, on top of wheelchair cushion and bars on the bottom of the wheelchair. On 7/19/22 at 3:35 pm, R41 stated he doesn't know when the CNAs wash wheelchairs and stated, They should clean it more often. 3. On 7/19/22 at 3:30 pm, R70's wheelchair had a dark black/brown substance on the wheelchair brake. On 7/19/22 at 3:30 pm, R70 stated, This is my new wheelchair and it is filthy, not sure where they got it from. 4. on 7/18/22 at 1:45 pm, R101's wheelchair had sporadic thick visible dust and old food debris visible on R101's wheelchair brake. On 7/18/22 at 1:45 pm, R101 stated that the staff do not clean her wheelchair during the day or night and would be awake if they came in to clean it if she was sleeping.

Based on observation, interview and record review, the facility failed develop personalized Care Plans for seven residents (R7, R31, R40, R78, R95, R99 and R109) of 45 residents reviewed for personalized Care Plans in the sample of 45. Findings include: Facility Care Plan Policy, updated 7/8/22, documents: Residents admitted to the facility will have a Care Plan initiated within 48 hours of admission and completed no later than 21 days after admission; Care Plan revised at least quarterly, whenever there is a significant change in the patient's condition and on an as needed basis; Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment or disability; the date obtained from the assessment is used to determine and prioritize the patient's plan of care; and modifications should be made following any incident/change of condition as indicated. The facility undated Smoking Safety Policy and Procedure, documents, Level I (Fully Independent): Full Independent smokers will be allowed to keep one pack of cigarettes on his/her person during a 'probationary' period. Those individuals that have demonstrated the capacity and willingness to use tobacco products safely, follow all rules/regulations concerning tobacco use, and are able to manage/budget these products effectively will be allowed to keep and carry their own smoking materials. Level III (Supervised): These individuals have demonstrated that they are incapable or unwilling to use tobacco products safely due to physical or cognitive limitations, and/or have had significant or repeated violations of the rules/regulations concerning tobacco use. These individuals will be given 1 cigarette at a time. Residents will be given their cigarettes at 7:30 am, 9:30 am, 1:30 pm, 4:30 pm, 7:30 pm, and 9:30 pm. 1. R7's Smoking Risk Assessment, dated 7/19/22, documents that R7 is a Level Two Smoker and is able to carry own eight cigarettes a day and uses chewing tobacco. R7's current Care Plan does not document R7's smoking and tobacco use. 2. R31's Smoking Risk Assessment, dated 4/25/22, documents that R31 is a Level Three Smoker and requires supervision for smoking. R31's current Care Plan does not document R31's smoking level or supervision requirement. On 7/18/22 at 9:41 am, V3 (Care Plan Nurse) stated, I do not see that (R7 and R31) have smoking on their Care Plan. I just started here in May, and I am working on getting the Care Plans all updated as they come due. 5. R95's current Physician Order Statement/POS includes a diagnosis of Unspecified Dementia with Behavioral Disturbance and also an order for Risperdal 1 milligram two times a day related to R95's diagnosis of Personal history of Traumatic Brain Injury. R95's current Care plan does not include any focus, goals or interventions for Dementia/cares or psychotropic medications with target behaviors. On 7-20-22, at 8:45am, V3 Care plan Coordinator confirmed that R95's care plan does not include Dementia. V3 stated that R95's Care Plan needs to address Dementia and their cares. V3 also confirmed that R95's Care Plan does not include psychotropic medications or behaviors and it should. V3 stated that R95's behaviors are becoming anxious or mad and saying she's going home, but (R95) never tries to leave. 3. R78's Smoking Risk Assessment dated, 6/4/22, documents R78 as a Level I (Full Independent) smoker. On 7/19/22 at 1:12 P.M., V6 (Certified Nursing Assistant) stated that R78 is a Pack per day smoker and can go out when R78 chooses and R78 does not have designated smoke times. R78's current Care Plan does not document that R78's smoking or tobacco use. On 07/19/22 at 8:40 AM, V3 (Care Plan Coordinator/Registered Nurse) verified R78's Care Plan does not document that R78 is a smoker and that it should. 4. R109's admission Record dated 7/19/22 at 1:11 PM, documents R109 has a diagnosis of, Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance with an onset date of 3/13/2013. R109's current Care Plan documents R109 has diagnoses which include Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance however there was not a Care Plan developed with any Focus, Goal, or Interventions for Dementia related care. On 7/18/22 at 1:35 PM, V3 (Care Plan Coordinator) stated (R109) does not have a Care Plan specifically for Dementia but he should. I just started this job in May, and I have been reviewing the Care Plans as they come due and making the necessary changes. I have not got through them all yet. 6. The Order Summary for R40 documents the following Physician orders, dated 6/8/22 as: 18 French 10 cc (cubic centimeter) Supra-Pubic Indwelling (Urinary) Catheter to gravity drainage, Change catheter and catheter bag as needed, and Change catheter and catheter bag every day shift starting on the 15th and ending on the 15th every month. On 7/18/22 at 1:25 pm, R40 was sitting in her room in a wheel chair, next to her bed. R40 raised her shirt to reveal a supra pubic indwelling urinary catheter that was attached to a drainage bag underneath R40's wheelchair. R40 stated she has had the catheter for a long time. R40's current Care Plan does document or include the care and treatment of R40's Indwelling Urinary Catheter. On 7/18/22 at 12:44 pm, V2 ADON (Assistant Director of Nursing), verified and stated R40 has had the supra pubic catheter for a long time. V2 stated that V2 does not see the catheter documented on R40's Care Plan and R40's urinary catheter should be included on the Care Plan. 7. The Smoking Risk Assessment for R99, dated 6/25/21, documents R99 was assessed and determined a Level 1 (Independent to smoke unsupervised). The current Care Plan for R99 does not include R99's risk or ability to smoke cigarettes while residing at the facility. 07/19/22 3:17 PM, V8 ICP (Infection Control Preventionist), stated R99 is an independent smoker and he has been talked to before about lighting other resident cigarettes and should not be doing that. When asked if R99's smoking status and behaviors during smoking were on R99's Care Plan, V8 stated, I don't see anything on (R99's) Care Plan and confirmed it should be on the Care Plan.

Based on observation, interview, and record review, the facility failed to supervise residents requiring smoking supervision and failed to ensure safe smoking practices were implemented for four (R8, R76, R99 and R101) of 12 residents reviewed for smoking in the sample of 45. Findings include: The facility undated Smoking Safety Policy and Procedure, documents, Level I (Fully Independent): Full Independent smokers will be allowed to keep one pack of cigarettes on his/her person during a 'probationary' period. Those individuals that have demonstrated the capacity and willingness to use tobacco products safely, follow all rules/regulations concerning tobacco use, and are able to manage/budget these products effectively will be allowed to keep and carry their own smoking materials. Level III (Supervised): These individuals have demonstrated that they are incapable or unwilling to use tobacco products safely due to physical or cognitive limitations, and/or have had significant or repeated violations of the rules/regulations concerning tobacco use. These individuals will be given 1 cigarette at a time. Residents will be given their cigarettes at 7:30 am, 9:30 am, 1:30 pm, 4:30 pm, 7:30 pm, and 9:30 pm. The facility undated Cell Phone Policy documents, (The facility) believes that the use of personal phones and similar devices by employees while working detracts from giving full attention to caring for our consumers in the way they deserve. Cell phones are not to be used while on duty. Any use of cell phones in resident areas is prohibited. Authorized areas include break room, car, and outside of the building while on break only. Making and receiving personal telephone calls while on duty is prohibited. Employees may not use their personal cell phone or similar devices at any other time during working hours or at any other place in the facility (including without limitation, on the way to or from breaks or meal periods). The facility undated Smoking Safety Policy Rules, documents, Residents are not to light other resident cigarettes. Supervised smokers are not to be in smoking areas during unsupervised times. The facility Smoking List, dated 7/17/22 documents R8 and R76 are Level III smoking residents and R99 is a Level I smoking resident. The Smoking Risk Assessment for R8, dated 4/6/22 and the Smoking Risk Assessment for R76, dated 6/1/22 document R8 and R76 were respectively determined to be a Level III smoking risk and require supervision while smoking. 1. On 7/17/22 at 7:25 am, R99 was sitting outside in smoking patio area and pulled a lighter out of his pocket and proceeded to light R101's cigarette. On 7/19/22 at 3:17 pm, V8 Infection Preventionist/Wound Nurse stated R99 was assessed as an independent smoker and has been talked to before about lighting other resident's cigarettes and should not be doing it. 2. On 7/18/22 at 1:20 pm, R8 and R76 were sitting outside in wheelchairs during supervised smoking time. V11 Activity Director was sitting on a bench, approximately twenty feet from R8 and R76 with her head bent down looking at her phone. During this same time, R76 pulled a lighter out of his pocket and lit R8's cigarette. 3. On 7/19/22 at 1:12 PM, V10 HCA (Health Care Assistant) was sitting outside in smoking area smoking a cigarette and on her personal cellular telephone approximately twenty feet away from R8 and R76 while R8 and R76 were smoking cigarettes. On this same date at 1:28 pm, V10 HCA got up from sitting on the bench, walked past R8 and R76 while they were still smoking and came into the facility leaving both residents unsupervised. On 7/19/22 at 1:52 pm, V2 ADON (Assistant Director of Nursing) stated R8 and R76 are to be supervised while they are smoking. V2 stated staff shouldn't be on their cellular telephones during resident smoking times, they should be supervising residents. V2 also stated R99 is an independent smoker but regardless resident's are not allowed to light cigarettes for other residents and R99 has been talked to about this before. 4. On 7/20/22 at 9:15 am, R8 and R76 were sitting in wheelchairs in the smoking area smoking cigarettes. V10 HCA was sitting outside in this same smoking area smoking a cigarette, with her head down looking at her personal cellular telephone, approximately twenty feet from R8 and R76. V10 HCA stood up and walked past R8 and R76 and entered the facility leaving R8 and R76 outside without supervision while they continued to smoke cigarettes. On 7/19/22 at 2:58 pm, V1 Administrator stated, Staff should not be on their phones in resident care areas or when supervising residents who are smoking. V1 Administrator confirmed residents requiring supervision should not be left unsupervised.