Based on observation, staff interview, resident interview, and facility policy review, the facility failed to maintain call lights in reach for 1 of 4 residents reviewed (Resident #2). The facility identified a census of 24 residents. Findings include: An observation and interview 1.3.25 at 1:30 p.m. revealed Resident #2 positioned in his wheel chair in his room as he called out for assistance. Upon entry the resident requested to go to bed at which time an observation revealed one (1) call light wrapped around the bottom of a positioning bar on the left side of his bed. The other call light positioned across the cushion and under an unknown item of his easy chair. The Surveyor turned on the call light. At 1:40 p.m. Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA responded and confirmed the cal lights were out of reach. During an interview 1.3.24 at 3:38 p.m. a family member confirmed during his regular visits to Resident #2 he observed the call lights out of reach on several occasions.

Based on clinical record review, resident interview, family interview, staff interview, and facility policy and procedures review the facility failed to provide an environment free from physical assault/physical injury and failed to report the suspected abuse to the State Agency in a timely manner as required for 2 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 24 residents. Findings include: A MDS assessment form dated 8.22.24 indicated Resident #2 with diagnosis that included a Traumatic Brain Injury (TBI), absence of a right hip joint, Osteoarthritis, Obesity, Combined Systolic and Diastolic Heart Failure and Chronic Respiratory Failure. The assessment indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (cognitively intact) and with no Delirium, behaviors or moods. The assessment indicated the Resident as non-ambulatory, dependent on staff with transfers and personal hygiene. A Care Plan addressed the following Focus areas and Interventions as dated: a. The Resident's ability to have completed ADL's had been deteriorated related to pain, a wound and a TBI. (revised 12.15.23) 1. Provision of assistance with a.m. and p.m. cares. (initiated 12.25.24) b. At risk for falls. (initiated 12.15.23 and revised 11.7.24) 1. Non-ambulatory. (initiated 1.12.24) 2. Transferred with 2 staff assistance and a sit and stand lift device. (initiated 12.15.23 and revised 1.9.25) An Incident Report dated 10.25.24 at 10:00 p.m. indicated the nurse as called to the Resident's room and found the resident positioned in bed with a skin tear on his left forearm. The staff reported the Resident had been hitting and verbally abusive during cares. The Resident reported the girls tried to kill him and asked why the facility hire staff like that as he had to defend himself. A Non-Pressure Skin Condition Report dated 10.25.24 indicated the Resident sustained a skin tear on his left wrist that measure five (5) cm in a Z form which contained a moderate amount of serosanguinous drainage. During an interview 1.7.25 at 1:11 p.m. Staff F, CNA confirmed she had been present during the situation with the Resident and she knew the incident had not been reported. The staff member confirmed she had been present with Staff E when the Resident sustained his skin tear as they assisted him with p.m. cares while positioned in his wheel chair but perineal cares had been performed while he stood in the lift device for the transfer. The staff member recalled as she cleaned him and Staff E controlled the lift device he said enough, enough as he routinely disliked the process due to pain. Staff F continued to clean him up due to the dried bowl movement on his buttocks. Staff F denied having known what Staff E said to him but she noted him as he swatted Staff E and eventually called her a Bitch. After proper cares had been performed the staff members positioned him in bed as Staff E said stuff to him like stop that verbiage and what would your family think in a really bad tone further defined as kind of yelling/loud and with a stern facial affect which upset the Resident more. As Staff F tried to clean the Resident's anterior perineal area Staff E stood by his head and he tried to swat at her again. Staff E then grabbed his forearms bilaterally and he said let go of me, let go of me. At this time he started kicking as she restrained his arms. At that time Staff A entered the room Staff F said they are done and Staff E left the room and that had been when they noted his arm as it bled. The Resident stated she scratched me, she scratched me. The staff members calmed him down, put a wet washcloth on it, situated him and left the room. Staff F described the skin tear (ST) as in a straight line which bled pretty good. Staff E tried to blame the ST on the lift device but that could not have been the case because they would have noted blood and when Staff F first observed the site it had just begun to bleed at a pretty good clip. Staff F indicated she would not have allowed Staff E to care for any of her family members due to her tone she used and confirmed she should not have restrained the Resident rather she should have stepped away. During an interview 1.9.25 at 1:04 p.m. Staff I, Registered Nurse (RN) confirmed she worked the evening the Resident sustained his ST when she received a walkie message from an unknown staff member who reported the Resident as combative and they required assistance. When she entered she noted the Resident as he yelled at Staff E and directed Staff I to remove her from his room with an adamant affect due to her physical behavior. Staff I requested Staff E to leave as she treated the ST. During an interview 1.7.25 at 3:49 p.m. the Director of Nursing (DON) indicated she never thought to report the skin tear injury from Resident #2 following the same type of injury to Resident #1 approximately 10 days later that both occurred by Staff E, CNA. The DON indicated when Staff G, RN and Staff H, LPN called her and reported the injury to Resident #1 they never gave any indication there would have been a suspicion for abuse. As the situation had been further described to the DON during the investigation the DON just shook her head up and down in the motion of yes and no but failed to directly answer the question. A Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7.2024 indicated the Training of Employees segment included the following: The training educated staff on: (a) activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (b) procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and (c) management of situations in which a higher risk for abuse to occur (i.e.: dementia, behaviors, mental health diagnoses, etc.) and resident abuse prevention.

Based on clinical record review, resident interview, family interview, staff interview, and facility policy and procedures review the facility failed to provide an environment free from physical assault/physical injury and investigate potential abuse as required by Federal regulations for 2 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 24 residents. Findings include: 1. A Minimum Data Set (MDS) form dated 10.24.24 indicated Resident #1 had diagnoses that included Cervical Spinal Fusion, Cervical Disc Disorder with Myopathy, malnutrition, Anemia, Heart Failure (HF), Coronary Artery Disease, and Atrial Fibrillation (AF). The assessment indicated the Resident had the ability to make himself understood and understand others, with a Brief Interview for Mental Status (BIMS) score of 7 out f 10 (severely impaired cognitive skills), no delirium/moods or behaviors, non-ambulatory, dependent on staff with lower body dressing and undressing and transfers, required substantial/maximum assistance of staff with toileting hygiene, dressing and undressing his upper body, and personal hygiene. A Care Plan identified the following Focus areas and Interventions as dated: a. Resident's ability for completion of activities of daily living (ADL's) deteriorated. (revised 12.31.20) 1. Assistance with morning (am) and evening (p.m.) cares. (initiated 3.23.21) b. At risk for skin breakdown related to incontinence, HF and malnutrition. (initiated 12.31.20 and revised 11.7.24) 1. History of skin tears. (revised 11.7.20) c. Resident with a skin ear of the right forearm, left 3rd finger and left elbow. (initiated and revised 11.7.24) 1. Inform/instruction to staff of causative factors and measures of prevention to skin tears. (initiated 11.7.24) An Incident Report form dated 11.5.24 at 8:45 p.m. indicated the nurse had been called to the resident's room by a Certified Nursing Assistant (CNA) as he received a skin tear to the right forearm in the shape of a U that measured 24 centimeters (cm) from one (1) end to the other. The resident also sustained a small skin tear to his left upper elbow that measured approximately 3 cm and a small skin tear to his left hand between the 3rd and 4th finger that measured approximately 1.3 cm. During an interview 1.3.24 at 2:46 p.m. Staff A, Certified Nursing Assistant (CNA) confirmed she worked 11.5.24 from 2 p.m. until 10 p.m. but had not been directly assigned to care for the resident. At approximately 3 ish she brought a snack to his room while she observed him positioned in his recliner. At that time he wore his short sleeved white t-shirt and plaid long sleeved shirt. That staff member could not recall if at that time had been when herself and Staff D, CNA or later transferred him to bed per an assistive lift device and laid him down, removed his pants, and offered him his oxygen which he refused. The staff member indicated at no time during the transfer that occurred that evening the resident hit his arm, said ouch, and/or any blood had been noted on his person or the recliner chair. The staff member indicated the next time she had any contact with the resident had been around 8:30 p.m. when she went to look for the nurse to retrieved a cream for another resident when she found the nurse, along with Staff E, CNA with the resident, still positioned in bed, covered up with a blanket to his waist, with the white t-shirt on but then with a bandage over his arm but denied any conversation about the resident's arm rather informed the nurse about the need for the cream and left the room. The staff member confirmed she worked with Staff E prior to the above stated event and observed an incident with Resident #2 approximately one (1) week prior at which time she knocked on the resident's door, entered, and observed Staff E as she held the resident's wrists because he had not wanted to get cleaned up by Staff F, CNA who also had been present. Staff A indicated it had been obvious the resident had not been happy about having his hands held because he tried to bite Staff E at which time she appeared mad as noted by her firm facial affect and how she talked to the resident with an elevated tone of voice. Staff A denied having heard any threats by Staff E however when she entered the room Staff E let go of the resident's wrists, grabbed the linens and left the room. Staff F and Staff A remained in the resident's room and covered his left arm with a towel due to the blood oozing from a noted new skin tear. The resident presented as upset related to what occurred with Staff E but showed no signs of having been combative with Staff E. The resident informed Staff A that Staff E twisted his wrist during the above stated encounter. Staff A confirmed from her experience Staff E failed to handle the situation correctly because when a resident refused cares staff had been directed to walk away and absolutely not grab and/or restrain a resident's wrists. During an interview 1.9.24 at 4:38 p.m. Staff D confirmed she assisted the resident to bed the night of the injury along with Staff A at which time he had not been combative at all. The staff members kept the resident in his clothes, she noted no signs of bleeding and the resident never complained of pain. Staff D then confirmed she worked with Staff E within days after the resident sustained his skin tear at which time the Resident yelled at Staff E. The staff member could not recall all that was said but he presented as upset because he said she was the one who caused the skin tear to his arm. During this interaction Staff E yelled back at the resident in an angry tone and verbalized it had not been her fault. During an interview 1.7.24 at 2:30 p.m. a family member indicated the resident told her three (3) nights in a row Staff E looked at the resident's bottom for sores. On the fourth night, the night of the election, the resident refused because he wanted to watch the results. The family member indicated the resident told her all of a sudden the staff member's face appeared viscous, further described as stern and she grabbed and twisted his arm and said your going to do this, as she laid almost right on him. The resident confirmed she restrained him with her hands which made him angry and caused a feeling of helplessness. The resident indicated he yelled for help and said, no, and he went over all of the injuries he sustained during that encounter which presented as scars, showed the surveyor the scars. Per the family member she received a call on 11.5.24 at 11:27 p.m. at which time the night nurse apologized profusely because the male nurse should have called her at the time of the incident because the resident had been crying in pain. The family member arrived at the facility around 11:55 p.m. when the night nurse came in to check the resident's blood pressure as he became combative and said Oh I thought you were that bitch coming after me. 2. A MDS assessment form dated 8.22.24 indicated Resident #2 with diagnoses that included a Traumatic Brain Injury (TBI), absence of a right hip joint, Osteoarthritis, Obesity, Combined Systolic and Diastolic Heart Failure, and Chronic Respiratory Failure. The assessment indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (cognitively intact) and with no Delirium, behaviors, or moods. The assessment indicated the Resident as non-ambulatory, dependent on staff with transfers and personal hygiene. A Care Plan addressed the following Focus areas and Interventions as dated: a. The Resident's ability to have completed ADL's had been deteriorated related to pain, a wound and a TBI. (revised 12.15.23) 1. Provision of assistance with a.m. and p.m. cares. (initiated 12.25.24) b. At risk for falls. (initiated 12.15.23 and revised 11.7.24) 1. Non-ambulatory. (initiated 1.12.24) 2. Transferred with 2 staff assistance and a sit and stand lift device. (initiated 12.15.23 and revised 1.9.25) An Incident Report dated 10.25.24 at 10:00 p.m. indicated the nurse was called to the Resident's room and found the resident positioned in bed with a skin tear on his left forearm. The staff reported the Resident had been hitting and verbally abusive during cares. The Resident reported the girls tried to kill him and asked why the facility hired staff like that as he had to defend himself. A Non-Pressure Skin Condition Report dated 10.25.24 indicated the Resident sustained a skin tear on his left wrist that measure five (5) cm in a Z form which contained a moderate amount of serosanguinous drainage. During an interview 1.7.25 at 3:49 p.m. the Director of Nursing (DON) indicated she never thought to report the skin tear injury from Resident #2 following the same type of injury to Resident #1 approximately 10 days later that both occurred by Staff E, CNA. The DON indicated when Staff G, RN and Staff H, LPN called her and reported the injury to Resident #1 they never gave any indication there would have been a suspicion for abuse to be investigated. A Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7.2024 indicated the Key Definitions segment included the following: A physical injury to, or injury at a variance with the history given of the injury, or unreasonable confinement, unreasonable punishment, or assault of a dependent adult which involved a breach of skill, care, and learned ordinarily exercised by a caretaker in similar circumstances. Assault of a dependent adult meant the commission of any act which generally intended to cause pain or injury to a dependent adult, or which generally intended to result in physical contact which would had been considered by a reasonable person to have been insulting or offensive or any act which intended to have placed another in fear of immediate physical contact which would have been painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.

Based on observation, resident interview, family interview, staff interview, Resident Council Minutes, and facility policy review, the facility failed to answer resident call lights in a timely manner and within the required 15 minute time frame. (Resident #2, #4 and #5). The facility identified a census of 24 residents. Findings include: During an interview 1.9.25 at 4:05 p.m., Resident #4, identified by the facility as interviewable, indicated last night she timed her call light being on over one (1) hour as she used the clock on the wall in her room to watch the time which made her feel unwanted. During an interview 1.9.25 at 4:01 p.m., Resident #5, identified by the facility as interviewable, indicated he timed his call light being on for up to 1/2 hour as he used the clock on the wall in his room to watch the time which pissed him off. During an interview 1.3.24 at 3:38 p.m. a family member confirmed he timed the call light being on for Resident #2 for 45 minutes to 1 hour at various times but especially at meal times. During an interview 1.9.25 at 3:11 p.m., Staff A, Certified Nursing Assistant (CNA) indicated staff answered resident call lights within 15 minutes unless they were tied up in a residents room who required two (2) staff assistance. According to a form (not dated) the facility management staff identified 9 of 24 residents who required 2 staff to assist with personal cares. Review of the facilities Resident Council Minutes revealed residents verbalized concerns with slow staff response to call lights on 12.31.24. A Call Light Response policy effective 10.31.24 indicated the Objective as an assurance of a timely and efficient response to resident call lights which enhanced resident safety and satisfaction. The policy listed the response time as within 15 minutes of activation.