Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#51 and #70) of 5 (#35, #51, #65, #70, and #78) residents' rooms observed. The failed practice was evidenced by resident's air/heating units needed cleaning. Findings: Resident 51 On 03/17/2025 at 12:27 p.m. observation of the air/heating unit in resident #51's room revealed the vents contained a black substance. On 03/18/2025 at 1:00 p.m. observation of the air/heating unit in resident #51's room with S1Executive Director confirmed the vents contained a black substance and needed to be cleaned. Resident 70 On 03/17/2025 at 12:28 p.m. observation of the air/heating unit in resident #70's room revealed the vents contained a buildup of dust and grime. On 03/18/2025 at 1:10 p.m. observation of the air/heating unit in resident #70's room with S1Executive Director confirmed the vents contained a buildup of dust and grime and needed to be cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure a resident's comprehensive plan of care was implemented for 2 (#2 and #34) of 2 residents reviewed for care plans by, not providing heel protectors and /or a palm protector as ordered by the physician. Findings: Resident 34 Review of the record for resident #34 revealed an admission date of 05/17/2024 with diagnoses including cerebral infarction, contracture to right and left hand, diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, heart disease, anemia, schizophrenia, right below the knee amputation, hyperlipidemia, and diabetic neuropathy. Review of the physician's orders revealed an order dated 11/04/2024 to ensure heel protectors in place every shift related to diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #34 was independent with cognition for daily decision making. Resident #34 was totally dependent on staff for mobility, transfers and toilet use and required extensive assistance with eating. Review of the current care plan revealed resident #34 had an activities of daily living (ADL) self-care performance deficit related to activity intolerance. The interventions included to use heel protectors while in the bed. On 03/17/2025 at 1:00 p.m., and 3:00 p.m. observations of resident #34 revealed she was in the bed without a heel protector on her left foot. On 03/17/2025 at 3:05 p.m. S16Licensed Practical Nurse (LPN) confirmed resident #34 should have on a heel protector on the left foot while in the bed. On 03/19/2025 at 2:00 p.m. S2Director of Nursing (DON) was notified that resident #34 did not have the heel protector on while in the bed on 03/17/2025. Resident #2 Review of the medical record revealed resident #2 was admitted to the facility on [DATE] with diagnoses that included in part, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, and Schizophrenia. Review of the March 2025 medication administration record revealed an order dated 02/20/2025 at 6:00 p.m., to monitor placement for palm protectors to left hand contractures each shift. On 03/17/2025 1:43 p.m., 03/18/2025 at 8:45 a.m., and 03/18/2025 at 1:45 p.m., observations revealed resident #2 was lying in bed with a contracture observed to his left hand. Further observation revealed there was no type of splint device in place to the resident's hand. On 03/18/2025 1:49 p.m., an observation revealed resident #2 was lying in bed with a contracture observed to his left hand with no type of splint device in place. S5Registered Nurse (RN) / Wound Care Nurse (WCN) was present and observed resident #2's contracted hand. She confirmed that resident #2 did not have any type of splint device in place at that time. After reviewing the March 2025 physician's orders with S5RN/WCN, she confirmed resident #2 was to have a palm protector to the left hand contracture and be monitored for placement every shift. On 03/18/2025 at 10:34 a.m., S1Registed Nurse/Unit Manager was notified the above findings regarding resident #2's contracted hand. On 03/19/2025 at 3:30 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the Licensed Practical Nurse (LPN) must have the appropriate competencies to provide nursing and related services necessary to care for resident's needs as identified and described in the plan of care for 1 (#2) of 7 (#2, #4, #12, #15, #43, #44, and #50) residents reviewed for accidents. Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] with diagnoses that included in part, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, and schizophrenia. Review of the March 2025 Medication Administration Record (MAR) revealed an order dated 02/20/2025 to monitor placement for palm protector to left hand contractor each shift every day and night shift. Further review of the March 2025 MAR revealed S9LPN had initialed on the MAR on 03/18/2025 (day shift), to indicate that resident had been monitored for the palm protector placement to resident #2's left hand. On 03/17/2025 at 1:43 p.m., and 03/18//2025 at 8:45 a.m., observations revealed resident #2 was lying in bed with a contracture observed to his left hand. Further observation revealed there was no type of splint device in place to the resident's hand. On 03/18/2025 at approximately 2:35 p.m., S9LPN was notified of resident #2's physician's order to monitor placement for palm protector to resident #2's left hand contracture on the day shift. She was further notified of the observations of resident #2 not having the palm protector in place during the observations. S9LPN confirmed that she had initialed the monitoring of the device. She further confirmed that she did not actually observed the hand protector in resident #2's left palm at the time she documented the monitoring on 03/18/2025 for the day shift. On 03/18/2025 at 10:34 a.m., S1Registered Nurse/Unit Manager was notified the above findings regarding resident #2's contracted hand. On 03/19/2025 at 3:30 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain good personal hygiene for 1 (#73) of 6 (#15, #26, #27, #56, #65, and #73) residents reviewed for ADL care. The provider failed to ensure resident #73's fingernails were trimmed and cleaned. Findings: Review of the medical record revealed resident #73 was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed that resident #73 was severely impaired with his daily decision making skills and he required substantial/maximal assistance with personal hygiene. Review of the medical record revealed resident #73 was care planned for an ADL self-care deficit and he required extensive assistance with ADLs related to Alzheimer's disease. The documented approaches included in part, bathing/showering: check nail length, trim and clean on bath days and as necessary. On 03/17/2025 at 9:40 a.m., and 03/18/2025 at 9:54 a.m., observations revealed resident #73 sitting in a wheelchair in front of the nurse's station. Further observation revealed resident #73 had long fingernails to both hands, they were long, untrimmed and had thick buildup of grime underneath the nail beds of both hands. On 03/18/2025 at 9:55 a.m., S15Certified Nursing Assistant (CNA) was notified of the observations of resident #73's fingernails being long, untrimmed with a buildup of grime underneath the nail beds of both hands. After observing resident #73's hands, S15CNA confirmed that resident #73's fingernails needed to be trimmed and cleaned. On 03/18/2025 at 11:04 a.m., S10Registered Nurse (RN), Unit Manager was notified of the above findings. After observing resident #73's hands, she confirmed that resident #73's fingernails needed to be trimmed and cleaned.

Based on observations, review of the Order Listing Report, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by 1) having exposed and unlabeled food items in the freezer and refrigerator, 2) placing contaminated food preparation utensils on top of and in direct contact with resident foods, and 3) testing the dishwasher sanitizer level with expired test strips. According to the Order Listing Report provided by S11Dietary Manager (DM), there was a total of 79 residents that received a meal tray from the kitchen. Findings: On 3/17/2025 at 8:30 a.m., an observation of the kitchen with S11Dietary Manager (DM) revealed there was one upright freezer that had one opened box of riblet pork patties and one opened box of hamburger patties that were exposed to air and not labeled with an open date. Further observation of the upright freezer revealed one opened box of chicken bread that was not labeled with an open date. Further observation of the kitchen revealed one refrigerator that had an opened box of pie dough and a second refrigerator that had one opened box of sausage patties that were not labeled with an open date. S11DM confirmed the opened, air exposed, unlabeled food items should not have stored inside of the freezer and refrigerator and available for resident consumption. Observation of the kitchen further revealed S11Dietary Manager testing the dishwasher for the sanitizer level. After she had completed the testing, on observation of the test strip bottle revealed an expiration date of 12/2024. S11Dietary Manager was present and confirmed the bottle of test strips was expired. On 03/17/2025 at 11:30 a.m., an observation of the steam table revealed one large pan of cornbread that had been cut into individualized pieces. Further observation revealed a large spatula and a pair on tongs lying inside of the pan of cornbread. During the food service, S12Dietary [NAME] was observed handling both the tongs and spatula with her bare hands. She was further observed handling and placing them on top of the cornbread with her bare hands. Both the tongs and spatula were on top of and in direct contact with the cornbread that was served to the residents. S13Dietary [NAME] was observed preparing the resident's plates for the meal service. During the observation, S13Dietary [NAME] touched the inside of the plates with her bare fingers and /or thumb. On 03/17/2025 at 12:40 p.m., S11Dietary Manager and S18Regional Director of Nutritional Services were notified of the above observations and confirmed that S12Dietary [NAME] should not have placed the spatula and tongs on top of and in direct contact with the cornbread and further confirmed that S13Dietary [NAME] should not have touched the inside of the plates with bare fingers and or/hands due to cross contamination. On 03/18/2025 at 3:30 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure staff maintained infection control practices by not following Enhanced Barrier Precautions (EBP) for 2 (#61, #65) of 2 residents observed during care who were on EBP and by having staff personal items in the medication storage room. Findings: Review of the facility's EBP policy and procedure dated April 2024 revealed: Policy Subject: Enhanced Barrier Precautions Policy: Enhanced Barrier Precautions are indicated for residents with infections or colonization with a Centers for Disease Control (CDC)-targeted Multi Drug Resistant Organisms (MDRO) when contact precautions do not apply or for residents with wounds and/or indwelling medical devices without secretions/excretions that are unable to be covered/contained & are not known to be infected/colonized with any MDRO during high-contact resident care activities as these residents are at an increased risk of being infected. Definition 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in Nursing Homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). 2. Enhanced Barrier Precautions only require use of gown/gloves when performing high contact resident activities: a. Dressing b. Bathing/showering c. Transferring (in room, shower/tub rooms, and therapy gyms) d. AM/PM Care e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy, or ventilator h. wound care: any skin opening requiring a dressing 3. Duration: Enhanced Barrier Precautions are intended to remain in effect for the duration of the resident stay or until the wound in closed/medical device removed. Responsibility All Staff Equipment 1. Door sign that reads Enhanced Barrier Precautions or Visitors Must See Nurse Before Entering. 2. Supply of gowns, gloves and plastic bags. Procedure 1. A private room is not required. Residents may be out of the room, attend activities and therapies and any other activities of their choosing. 2. Education family and/or resident on the precaution being initiated and procedures to be maintained. 3. Apply protective equipment as indicated prior to providing any high contact resident care as listed above. a) Gloves- utilized during the course of providing high contact care. Remove gloves before leaving the room. b) Gown- apply gown before providing high contact care. Additional Personal Protective Equipment (PPE) may be indicated under Standard Precautions if splashing is anticipated such as tracheostomy care or wound irrigation. c) Resident Care Equipment- normal procedure of cleaning and disinfecting equipment before use on another resident. d) Explain all procedures to the resident before initiating care. e) Bag used linen(s), dispose of gown and gloves in waste receptacle after care is completed. f) Wash hands before leaving the room and transfer bagged linen to holding room. g) Sanitize hands Resident 61 Review of the record for resident #61 revealed diagnoses in part of obstructive and reflux uropathy, diabetes insipidus, benign prostatic hyperplasia without lower urinary tract symptoms, and chronic kidney disease. Review of the Physician's order dated 02/20/2025 revealed an order for EBP due to indwelling catheter. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #61 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Further review of the MDS revealed resident #61 required partial/moderate assistance with toileting hygiene. Review of the current plan of care revealed resident #61 was at risk for injury/infection. Resident #61 had a Foley catheter due to diagnosis of benign prostatic hypertrophy. Further review of the current plan of care revealed resident #61 required EBP. On 03/17/2025 at 9:20 a.m. observation of the outside of resident #61's door revealed a sign that indicated resident #61 was on EBP. Further observation revealed gloves and gowns were available for use. On 03/17/2025 at 9:22 a.m. S9Licensed Practical Nurse (LPN) was observed going into resident #61's room and only applied gloves. Further observation revealed S9LPN touched the indwelling Foley catheter. On 03/17/2025 at 9:53 a.m., an interview with S9LPN confirmed she only wore gloves when she went in resident #61's room and handled the indwelling catheter. Resident 65 Review of the record for resident #65 revealed diagnoses in part of Alzheimer's disease, dysphagia, seborrheic dermatitis and aphasia. Review of the Physician's order dated 02/03/2025 revealed an order for EBP due to Percutaneous Endoscopic Gastrostomy (PEG) tube. Review of the quarterly MDS assessment dated [DATE] revealed resident #65 had a BIMS that was unable to be assessed. Resident #65 required substantial or maximal assistance with all activities of daily living skills. Review of the current plan of care revealed resident #65 required assistance with activities of daily living due to his cognitive impairment related to Alzheimer's. On 03/19/2025 at 8:40 a.m. observation of resident #65's door revealed a sign that indicated resident #65 was on EBP. Further observation revealed there was a supply of gloves and gowns in a cart hanging on the resident's door. On 03/19/2025 at 8:45 a.m. observation of resident #65 during a shower revealed S6Certified Nursing Assistant (CNA) and S7CNA transferred resident #65 from the wheelchair to the shower chair only wearing gloves. S6CNA and S7CNA did not wear a gown. Further observation of the shower performed by S6CNA revealed she only wore gloves and no gown during the shower. Observation of transferring resident #65 from a shower chair to the wheelchair revealed S8CNA and S6CNA transferred resident #65 back to the wheelchair only wearing gloves. S6CNA and S8CNA did not wear a gown. S6CNA then placed a shirt on resident #65, a clean brief and put on his pants. S7CNA assisted S6CNA with standing resident #65 to pull up his pants. S6CNA and S7CNA only wore gloves and no gown. On 03/19/2025 at 9:43 a.m., an interview with S6CNA, S7CNA and S8CNA confirmed they only used gloves and did not put on a gown while performing the resident's shower or transferring the resident. S7CNA further stated that she was unaware that she had to use a gown when she assisted resident #65 in the shower. On 03/19/2025 at 2:30 p.m. S2Director of Nursing (DON) and S3Clinical Operations were notified that S6CNA, S7CNA and S8CNA did not use appropriate personal protective equipment (PPE) when providing care to resident #65. Medication Storage Room On 03/18/2025 at 11:10 a.m., an observation of the medication storage room with S5Registered Nurse (RN)/Wound Care Nurse (WCN) revealed two large purses lying on top of and in direct contact with the medication preparation countertop. On 03/18/2025 at 11:13 a.m., S10Registered Nurse (RN) Unit Manager was notified of the above findings. She confirmed that the purses should not have been stored inside of the medication storage room and on the top of and in direct contact with the countertop due to cross contamination. On 03/19/2025 at 3:25 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the findings regarding the purses being stored in the medication storage room.

Based on observations and interview the facility failed to ensure all mechanical equipment was maintained in safe operating condition by having a can opener in the kitchen with a large buildup of metal shavings and by having the deep fryer with grease buildup in lower compartment. Findings: On 03/17/2025 at 8:30 a.m. observation of the kitchen with S11Dietary Manager revealed the large commercial can opener had a large buildup of metal shavings underneath the blade. Further observation of the kitchen area with S11Dietary Manager of the deep fryer revealed there was an oil spill and buildup of thick greasy particles on the inside of the fryer's lower compartment. On 03/19/2025 at 3:25 p.m. S1Executive Director, S2Director of Nursing (DON) and S3Clinical Operations were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (#56, #65, and #75) of 3 (#56, #65, and #75) sampled residents reviewed for dignity. Resident #56 and resident #65 were pulled backwards in their gerichairs down the hall to their rooms. Resident #75 was assisted with eating by a staff member who stood beside him at the table in the dining room. Findings: Resident #56 Review of the medical record for resident #56 revealed the resident was admitted on [DATE] with diagnoses including dementia, joint replacement surgery, osteoarthritis, heart disease, edema, and pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had independent cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfer and toilet use. Observation on 02/19/2024 at 10:00 a.m. revealed the resident was up in his gerichair in front of the nurse's station. Observation on 02/19/2024 at 10:11 a.m. revealed S6Certified Nursing Assistant (CNA) pulled resident #56 backwards in his gerichair down the hall to his room. An interview with S2Corporate Nurse and S3Director of Nursing (DON) on 02/21/2024 at 11:00 a.m. confirmed S6CNA should not have pulled resident #56 backwards down the hallway to his room. Resident #65 Review of the medical record for resident #65 revealed the resident was admitted on [DATE] with diagnoses including hypertensive heart disease, Alzheimer's, dysphagia, cerebral infarction, dementia, flaccid hemiplegia, and gastrostomy. Review of the admission MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident had range of motion impairment on one upper extremity and both lower extremities. The resident was dependent for mobility. Observation on 02/20/2024 at 3:00 p.m. revealed resident was up in her gerichair in front of the nurses station. Observation on 2/20/2024 at 3:45 p.m. revealed S6CNA pulled resident #65 backwards down the hallway to her room. An interview with S2Corporate nurse and S3DON on 02/21/2024 at 11:00 a.m. confirmed S6CNA should not have pulled resident #65 backwards down the hallway to her room. Resident #75 Review of the medical record for resident #75 revealed the resident was admitted on [DATE] with diagnoses including dementia, epileptic seizure, pain, chronic obstructive pulmonary disease, hypertension, emphysema, insomnia, diabetes, edema, and cardiac pacemaker. Review of the yearly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Review of the care plan revealed one person assist with activities of daily living as needed or requested by resident. Observation on 02/19/2024 at 12:05 p.m. revealed S7Licensed Practical Nurse (LPN) was standing up beside resident #75 while assisting the resident with eating at the dining room table. An interview with S2Corporate nurse and S3DON on 02/21/2024 at 11:00 a.m. confirmed S7LPN should not have been standing while assisting resident #75 with eating.

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained free of accident hazards by failing to conduct a smoking safety assessment for 1 (#67) of 1 (#67) sampled residents reviewed for smoking. Findings: Review of the medical record revealed resident #67 had diagnoses which included Schizophrenia, seizures, major depression and Bipolar disorder. Review of the Smoking Evaluation Tool dated 12/15/2023 indicated the resident did not smoke. On 02/20/2024 at 10:00 a.m., interview with S4Certified Nursing Assistant (CNA) revealed resident #67 smoked cigarettes. On 02/20/2024 at 11:10 a.m., observation of resident #67 revealed he was smoking a cigarette during the designated smoke break. On 02/20/2024 at 12:25 a.m., interview with S5Licensed Practical Nurse (LPN) revealed at the time of the assessment on 12/15/2023, the resident did not smoke. She also reported when the resident resumed smoking a smoking safety assessment was not conducted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assist residents in obtaining routine dental care for 1 (#50) of 1 sampled resident reviewed for dental. Findings: Review of the medical record for resident #50 revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction, hemiplegia right dominant side, diabetes, edema, aphasia, depression, hypertension, heart disease, and pain. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. An interview with resident #50 on 02/19/2024 at 10:30 a.m. revealed his right upper back tooth hurt. Resident #50 stated he reported it to someone. Review of resident #50's dental note dated 01/18/2023 revealed: extraction, erupted tooth or exposed root - the patient needs a new consent form to proceed with the extraction. The current consent is older than 6 months. Review of resident #50's dental note dated 10/24/2023 revealed: pain with upper teeth, would like them extracted. Discussed outstanding consent with Director of Nursing and will get that re-signed due to expiration of previous consent being outdated. An interview with S8Social Services on 02/21/2024 at 9:45 a.m. revealed the resident and the resident's physician are to sign the consent form that was completed by the dentist. Interview with S8Social Services confirmed she had not sent the consent to the physician at this time. An interview with S2Corporate Nurse and S3Director of Nursing on 02/21/2024 at 11:00 a.m. confirmed resident #50's dental needs should have been addressed timely.

Based on observations and interviews, the facility failed to ensure it was equipped to allow residents' to call for staff assistance through a communication device by failing to ensure call lights were accessible for 4 (#4, #10, #37, #84) of 4 (#4, #10, #37, #84) sampled residents reviewed for call light accessibility. Findings: Resident #4 On 02/19/2024 at 9:47 a.m., observation of resident #4 revealed resident was in bed and the call bell was hanging on the wall out of the resident's reach. Resident #4 was able to state he could use the call bell if he needed something. On 02/20/2024 at 8:45 a.m. observation of resident #4 again revealed the resident was in the bed and the call bell was hanging on the wall out of the resident's reach and observation again at 2:00 p.m. the call bell remained hanging on the wall out of the resident's reach. Resident #10 On 02/19/2024 at 10:56 a.m., resident #10 was sitting in her room. The call light cord was draped around the call light box and was not within her reach. Interview with the resident revealed she was alert and oriented x4. The resident reported she was blind and that she could use the call light if it were within her reach. On 02/19/2024 at 02:00 p.m., observation of resident #10 revealed she was seated in her room and the call light was out of her reach. On 02/20/2024 at 9:50 a.m., observation of resident #10 revealed she was seated in her room and the call light was out of her reach. On 02/20/2024 at 1:30 p.m., observation of resident #10 revealed she was seated in her room and the call light was out of her reach. On 02/21/2024 at 8:30 a.m., observation of resident #10 revealed she was in bed and the call light was out of her reach. S1Administrator confirmed the call bell was not accessible to the resident. Resident #37 On 02/19/24 at 9:25 a.m., observation of resident #37 revealed the resident was in bed and the call bell was hanging on wall out of the resident's reach. Resident #37 was able to state he could use the call bell if he needed something. On 02/19/24 at 10:25 a.m., resident #37 was in his room in his bed and requested another snack but the resident call bell was hanging on the wall out of the resident's reach. On 02/19/24 at 1:39 p.m., resident #37 was heard hollering through the closed door for someone to help him. The door was opened and observation revealed resident #37 attempting to transfer unassisted calling for someone to help him. Further observation revealed the call bell was hanging on the wall out of the resident's reach. On 02/20/24 at 8:49 a.m., observation of resident #37 revealed he was in the bed and the call bell was hanging on the wall out of the resident's reach. On 02/21/24 at 8:50 a.m. observation of resident #37 revealed he was asleep in bed. Further observation revealed the call bell was hanging down between the bed and wall and out of the resident's reach. Resident #84 On 02/19/2024 at 9:24 a.m., observation of resident #84 revealed he was lying in bed with the call bell hanging on the wall out of the resident's reach. Attempted interview with resident #84 revealed he spoke mostly Italian and was difficult to understand but would be physically able to use the call bell if it were within reach. On 02/20/24 at 8:47 a.m., observation of resident #84 revealed he was lying in the bed and the call bell was hanging on the wall out of the resident's reach and observation again at 2:30 p.m. revealed the call bell remained out of the resident's reach. On 02/21/24 at 10:45 a.m., interview with S2 Corporate Nurse agreed the call bells should not be hanging on the wall out of the resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's readmission to the facility from an acute care hospital was permitted for 1(#1) of 5(#1, #2, #3, #4, #5) residents reviewed for readmission after discharge. Findings: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. Review of the clinical record revealed Resident #1 had the following admitting diagnoses in part: Traumatic Brain Injury, Human Immunodeficiency Virus, Insomnia, and Schizophrenia. During a telephone interview on 12/12/2023 at 01:38 p.m. S2 Former Administrator confirmed readmission of Resident #1 back to the facility from the acute care hospital would not be permitted. S2 Former Administrator reported around 8 days after Resident #1's discharge to an acute care hospital, the acute care hospital reached out to her several times throughout the following week checking if placement had been found for Resident #1 and on all occasions, S2 Former Administrator reported she could not find another long term care facility that would accept Resident #1 and Resident #1 would not be permitted back to the facility.

Based on record review and interview the facility failed to have a facility assessment which identified the staffing needs of the secure unit to ensure residents were free from physical abuse. The deficient practice had the potential to effect the care and safety of the 32 residents residing on the secure unit. Findings: Review of the 12/30/2022 Facility Assessment had documentation that listed a different Administrator and Director of Nurses (DON) at the time the assessment was completed. The 12/30/2022 Facility Assessment had not been updated to show the current S1 Administrator and S4 DON . S1 Administrator was hired on 09/27/2023 and S4 DON was hired within the past couple of months. Review of the facility assessment revealed the last dated update to the facility assessment was on 09/08/2023. In the section of action to be taken showed there would be an increase in staffing for the secure unit from 3 to 4 Certified Nursing Assistants. Review of complaint survey results for the past 3 months revealed the facility was cited for deficient practice related to resident abuse on 10/25/2023 and on 11/21/2023. Review of the State incident reports since 07/20/2023 revealed there had been 11 incidents of resident to resident physical abuse altercations on the secure unit. On 12/14/2023 at 09:50 a.m. an interview with S1 Administrator confirmed she became the administrator of the facility after the facility assessment was last updated on 09/08/2023. S1 Administrator also confirmed the facility assessment has not been updated to address the care and safety needs related to the continued resident to resident physical abuse altercations occurring on the secure unit for the 32 residents residing on the secure unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to protect residents' right to be free from physical abuse by another resident for 4 (#2, 4, 6, and 7) of 8 (2, 3, 4, 5, 6, 7, 8 and 9) residents reviewed for abuse. The facility failed to protect residents #2, 4, 6, and 7 from being physically abused. Findings: Review of the facility's Abuse Prevention Policy revealed: Definitions: a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse may be resident-to-resident. Resident #4 Review of the medical record revealed resident #4 had diagnoses of history of alcohol abuse, history of cocaine abuse, paranoid schizophrenia, encephalopathy, heart disease, and rheumatoid arthritis. Review of the current plan of care revealed the resident was at risk for injury related to daily psychotropic medication regimen related to paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with cognition for daily decision making. Resident # 4 was independent with transfers, and was independent with use of a motorized wheelchair for ambulation. Resident #5 Review of the medical record for resident #5 revealed diagnoses including dementia, hypertension, mood disorder, and unspecified psychosis. Review of the current plan of care revealed resident #5 was at risk for alterations in psychosocial wellbeing. Review of the MDS dated [DATE] revealed the resident was independent with cognition for daily decision making. Resident #5 was independent with ambulation. Review of the facility's investigation revealed on 10/21/2023 resident #4 and #5 had an altercation. Review of the Resident Incident Report dated 10/21/2023 at 1:30 p.m. revealed resident #4 and resident #5 had a physical altercation in the smoking area. Resident #5 hit resident #4 in his face with a closed fist. A scratch was noted above resident #4's left eyebrow and the center of his forehead. Review of the medical record for resident #4 revealed a skin and wound assessment dated [DATE] revealed two abrasions were noted above his left eye. On 11/07/2023 at 12:10 p.m. an interview with S7 Certified Nursing Assistant (CNA) revealed she witnessed the altercation between resident #4 and resident #5 on 10/21/2023. S7CNA revealed resident #4 and resident #5 were outside in the smoking area. S7CNA revealed resident #4 and resident #5 were not sitting close to each other in the smoking area. Both of the residents started cursing each other and resident #5 walked over to resident #4, whom sits in a motorized wheelchair, and began to hit him in the head approximately 8 times. S7CNA revealed she separated the residents and another staff member got the nurse. On 11/08/2023 at 12:25 p.m. S1Administrator was informed of the abuse deficiency related to resident #4 and resident #5 had a physical altercation on 10/21/2023 resulting in resident #4 having 2 abrasions over his left eyebrow. Resident #6 Review of the medical record revealed resident #6 had diagnoses which included traumatic subarachnoid hemorrhage with loss of consciousness, major depressive disorder, schizophrenia, hemiplegia following cerebral infarction affecting left side, hypertensive heart disease without heart failure, human immunodeficiency virus, chronic hepatitis C, essential hypertension, insomnia, and type 2 diabetes mellitus with diabetic neuropathy. Review of the current plan of care revealed the resident was at risk for complications related to psychotropic medication use related to schizophrenia and major depressive disorder. Resident was verbally abusive to staff and at risk for inappropriate behavior related to targeted behaviors including physical/verbal aggressiveness towards others. Review of the MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating he was cognitively intact. On 11/07/2023 at 11:35 a.m. interview with resident #6 reported that resident #7 kicked his wheelchair and hit him on his right jaw with his fist. Resident #6 reported then he hit resident #7. Resident#7 Review of the medical record revealed resident #7 had diagnoses which included paranoid schizophrenia, violent behavior, generalized anxiety disorder, major depressive disorder, atrial fibrillation, essential hypertension, and dementia with behavioral disturbance. Review of the current plan of care revealed the resident was at risk for being socially inappropriate and disruptive behavior. Resident was at risk for side effects from antipsychotic drug usage r/t schizoaffective disorder, bipolar disorder, and generalized anxiety disorder. Review of the MDS dated [DATE] revealed the resident had a BIMS score of 10 indicating he was moderately cognitively impaired. Review of the facilities investigation revealed on 11/04/2023 resident #6 and Resident #7 had a physical altercation. Review of the Resident Investigation Report dated 11/04/2023 at 6:11 p.m. S5LPN (Licensed Practical Nurse) observed resident #7 hitting resident #6 and resident #6 hitting resident #7 while they were in the hallway on the secured unit. On 11/07/2023 at 11:45 a.m. interview with resident #7 reported he was hit on the left side of his neck by resident #6. On 11/08/2023 at 9:05 a.m. a telephone interview with S5LPN revealed on 11/04/2023 she was in the hallway and had just finished counting the narcotics with the nurse that was working off when she observed resident #6 and resident #7 were both sitting in their wheel chairs next to each other in the hallway. S5LPN revealed she observed resident #7 kick resident #6's wheel chair and punch him with a closed fist. S5LPN reported resident #6 then started hitting resident #7 with his closed fist. S5LPN revealed she yelled out for them to stop and immediately went to separate the residents. S5LPN revealed S6CNA was on the hallway at the time and they separated the residents. On 11/08/2023 at 12:25 p.m. S1Administrator was informed of the abuse deficiency related to resident #6 and resident #7 physical altercation which had the potential to cause harm to both residents. Resident #2 Review of the medical record revealed resident #2 had diagnoses which included metabolic encephalopathy, schizophrenia unspecified, unspecified intellectual disabilities, anxiety disorder unspecified, and personal history of traumatic brain injury. Review of the current care plan revealed the resident was at risk for injury due to psychotropic medication usage related to schizophrenia and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating he was moderately cognitively impaired. Resident #3 Review of the medical record revealed resident #3 had diagnoses which included paranoid schizophrenia, generalized anxiety disorder, mild intellectual disabilities, and depression. Review of the current plan of care revealed the resident was at risk for alterations in psychosocial wellbeing related to behaviors due to paranoid schizophrenia and intellectual disabilities. Review of the MDS dated [DATE] revealed the resident had a BIMS score of 9 indicating he was moderately cognitively impaired. Review of the facility investigation revealed on 10/14/2023 resident #3 hit resident #2 in the right shoulder. Review of the Resident Incident Report dated 10/14/2023 at 4:38 p.m. S4LPN was providing 1:1 monitoring with Resident #2, who was standing in the hallway on the secured unit. Resident #3 was walking down the hallway on the secured unit and as he passed by resident #2, he touched resident #3's arm. Resident #3 responded by punching resident #2 in the right shoulder. On 11/08/2023 at 8:20 a.m. telephone interview with S4LPN revealed on 10/14/2023 around 4:38 p.m. she was providing 1:1 monitoring of resident #2. Residentt#2 was standing beside her in the hallway on the secured unit and resident #3 was walking down the hallway. S4LPN reported that as resident #3 walked by resident #2 called out resident #3's name and touched him on his arm to get his attention. S4LPN reported resident #3 responded by punching resident #2 with a closed fist in his right shoulder. S4LPN reported that the residents were immediately separated. S4LPN revealed resident #3 does not like to be touched. On 11/08/2023 at 12:25 p.m. S1 Administrator was informed of the abuse deficiency related to resident #3 punching resident #2 on 10/14/2023 which had the potential to cause harm to resident #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to provide an interim care plan with interventions for 1 (resident #10) of 26 residents reviewed, and provide the daily care guide to staff for all 26 residents that currently reside on the unit on 11/20/2023. Findings: Review of the record for resident #10 revealed date of admission to the facility on [DATE]. Resident #10 was admitted from an inpatient psychiatric hospital with the following diagnoses: Unspecified dementia with behavioral disturbances, wandering, anxiety disorder, major depressive disorder and cellulitis of right lower limb. According to the discharge summary from the psychiatric hospital, resident #10 was admitted for increasing aggressive behavior and frequent elopements from another nursing home. Further review of the discharge summary revealed resident #10 stole a cigarette lighter and burned off his tracking bracelet. Further review of the summary revealed when the staff at a nursing home attempted to take the lighter, he became aggressive and threatened to throw a chair through a window and elope. Further review of the record revealed no care plan was available for resident #10. Interview with S10Certified Nursing Assistant (CNA) on 11/20/2023 at 9:25 a.m. revealed she had not been told anything about resident #10 that they just got as a new resident on 11/14/2023. Interview with S11CNA on 11/20/2023 at 9:45 a.m. revealed resident #10 was a new resident to the unit and no one had provided any information about him. Interview with S9CNA on 11/20/2023 at 10:00 a.m. revealed resident #10 had been in the unit for about a week and they have not told her anything about the resident. Interview with S9CNA on 11/20/2023 at 10:43 a.m. revealed that the care plan pocket guides for staff to use are usually kept at nurses' station. Observation at this time revealed that the care plan pocket guides were not available. Interview with S8LPN (Licensed Practical Nurse)/Unit Manager on 11/20/2023 at 10:44 a.m. confirmed no care plan guides were available for the staff at this time. Further interview with S8LPN/Unit Manger confirmed that she was unable to locate the initial care plan for resident #10 at this time, and the care plan guides were not available to staff. Interview with S13Interim Director of Nursing (DON) on 11/20/2023 at 11:30 a.m. confirmed that the only information listed in the daily care guide for resident #10 that was printed on 11/20/2023 at 10:46 a.m. was an intervention to shower (role CNA). Further interview with S13Interim DON revealed that the interim care plan for resident #10 should be made available for staff. Further interview with S13Interim DON confirmed that the daily care plan guides were not on the unit for staff to utilize on 11/20/2023.

Based on record reviews and interviews the facility failed to implement, and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health care and services that is appropriate and effective as determined by the facility assessment. The facility failed to ensure all staff (direct, indirect, and contract) were trained on the behavioral health care needs and services for all 91 residents residing in the facility. The facility failed to ensure: 1) 9 staff providing direct care on the secured unit or the hallway (S3LPN (Licensed Practical Nurse), S4LPN, S5LPN, S6CNA (Certified Nursing Assistant) S7CNA, S8LPN, S9CNA, S10CNA, S11CNA) out of 9 staff reviewed had training on behavioral health care, 2) 3 (S4LPN, S5LPN, S6CNA) of 4 (S4LPN, S5LPN, S6CNA, S7CNA) staff members reviewed had retraining after resident to resident altercations, and failed to ensure 3) 6 (S12CNA, S14CNA, S15CNA, S16LPN, S17CNA, S18LPN) of 11 (S12CNA, S14CNA, S15CNA, S16LPN, S17CNA, S18LPN, S19LPN, S20LPN, S21CNA, S22LPN, S23LPN) contract staff received orientation and behavioral health care training prior to working at the facility. Findings: Review of the current Facility Assessment Tool revealed the resident profile included a specialty unit for admission of behavioral diagnoses such as, but not limited to, Schizophrenia, Schizoaffective Disorder, Bipolar, etc. Other diagnoses also listed included Psychiatric/Mood Disorders - Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. The facility assessment listed under Special Treatments and Conditions: Mental Health - Behavioral Health Needs with the number of residents documented as 84. The facility assessment listed under the heading of Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies included: Staff training/education and competencies. The areas documented for staff training/education and competencies that are necessary to provide the level of care required for our residents includes caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing nonpharmacological interventions. 1) On 11/20/2023 at 9:10 a.m., interview with S8LPN/Unit Manager revealed she worked on the locked unit and the residents on the unit have behavioral issues. S8LPN/Unit Manager revealed the staff have not received any specialized training to work with residents with behaviors. On 11/20/2023 at 9:25 a.m., interview with S10CNA revealed she worked on the locked unit. S10CNA revealed she had not had any training to work on the locked unit with residents that have behaviors. S10CNA further revealed when she had the recent abuse training, she was told to just read the form and sign it, but no one went over the information with her. On 11/20/2023 at 9:45 a.m., interview with S11CNA revealed she worked on the locked unit, and had not had any training to work with residents that have behaviors. S11CNA further revealed she was told to read the top of the recent abuse training form, and sign it, but no one talked to her about it. On 11/20/2023 at 10:00 a.m., interview with S9CNA revealed she worked on the locked unit. S9CNA stated there had not been any training on how to work with the residents in the unit. S9CNA revealed she was told to read the top of the recent abuse training form and to sign it, but no one went over it with her. On 11/20/2023 at 11:19 a.m., interview with S7CNA revealed she did not work on the locked unit but worked on the regular hall. S7CNA stated the residents that live on the hallway also have behaviors. S7CNA revealed she has not had any specific training on how to handle residents with behaviors. S7CNA revealed she was told to read the summary at the top of the recent abuse in-service form and sign the sheet. S7CNA stated no one went over the abuse in-service training with her. On 11/20/2023 at 1:26 a.m., interview with S3LPN revealed she has not received training on how to handle psychiatric residents or residents with behaviors issues. S3LPN revealed she read the summary at the top of the recent abuse in-service sheet and signed the form. S3LPN revealed she did not receive training or education of the abuse in-service. On 11/20/2023 at 2:20 p.m., interview with S12CNA revealed she was an agency CNA and prior to working with the residents on the locked unit she did not sign or read any facility policies and/or procedures. S12CNA revealed she had not had any training on how to handle residents with any type of behaviors. Review of the personnel records revealed no documented evidence that the staff noted above had received training in behavioral health care. 2) Review of the 11/04/2023 and 11/06/2023 facility's Abuse Prevention and Resident to Resident Altercations in-service sign in sheets revealed no documented evidence of S4LPN, S5LPN and S6CNA signature on the sign in sheet as having read the policy. These 3 staff were listed on the facility's incident report as having intervened in recent resident to resident altercations. On 11/21/2023 at 1:20 p.m. S24Corporate Registered Nurse (RN) and S13 Interim Director of Nursing (DON) confirmed S4LPN, S5LPN and S6CNA signatures were not on the Abuse Prevention and Resident to Resident Altercations in-service forms dated 11/04/2023 and 11/06/2023. 3) On 11/21/2023 at 12:45 p.m. interview with S13Interim DON revealed when any agency staff comes to work; there is a binder located on the locked unit that they are to read and sign that tells them the policies of the facility. S13Interim DON revealed when the staff sign the binder located on the locked unit the staff are saying that they have received training and orientation prior to working with the residents. Review of the facility sign in binder located in the locked unit revealed there was no documented evidence of any staff agency signatures since 2022. S12CNA that worked 11/21/2023 did not sign the binder. Review of the agency staff list that worked the weekend of 11/18/2023 and 11/19/2023 provided by S1Administrator revealed S14CNA, S15CNA S16LPN, S17CNA and S18LPN revealed no signatures were in the binder. Review of the contract agency's printouts provided by S1Administrator revealed no documented evidence the agency staff received orientation or any type of behavioral health care training prior to providing care to the residents. On 11/21/2023 at 1:00 p.m., S13Interim DON was informed that the agency staff had signed the binder located on the unit since 2022. On 11/21/2023 at 2:00 p.m., S1Administrator was informed that staff revealed they were handed the Abuse Prevention and Resident to Resident Altercations in-service and was told to read the top of the form and sign the sign in sheet but no one explained the in-service to them. S1Administrator was informed that there was no documented evidence that the staff received training in behavioral healthcare prior to working with the residents, including those with behavioral health needs on the unit. S1Administrator was informed that the above agency staff did not have documented evidence of orientation or behavioral health training prior to working on the unit. S1Administrator was informed that S4LPN, S5LPN and S6CNA (staff named in resident to resident altercations) signatures were not on the Abuse Prevention and Resident to Resident Altercations in-service forms dated 11/04/2023 and 11/06/2023.

Based on record reviews and interviews the facility failed to protect residents' right to be free from physical abuse by another resident for 3 (#2, #5, and #6) of 12 (# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) residents reviewed for abuse investigations. The facility failed to protect residents #2, #5, and #6 from being physically abused during 2 separate physical altercations. Findings: Review of the facility policy on Abuse prevention revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Resident #2 Review of the medical record revealed resident #2 had diagnoses which included Schizoaffective disorder, Bipolar Disorder, anxiety and attention deficit hyperactivity disorder. The resident's care plan also indicated he was at risk for injury due to psychotropic medication us and psychiatric diagnoses. Review of the Minimum data set revealed the resident had a BIMS (Brief Interview for Mental Status) score of 5 indicating he was severely cognitively impaired. Resident #5 Review of the medical record revealed resident #5 had diagnoses which included Schizophrenia and Major Depression. The resident's care plan indicated he was at risk for alterations in psychosocial wellbeing related to behaviors due to psychiatric diagnoses. Resident #6 Review of the medical record revealed resident #6 had diagnoses which included Schizophrenia, Depression and Bipolar disorder. The resident's care plan also indicated he was at risk for injury due to psychotropic medication us and psychiatric diagnoses. Review of the Minimum data set revealed the resident had a BIMS score of 6 indicating he was severely cognitively impaired. Review of a facility investigation revealed on 10/01/2023, residents #2 and #6 had a physical altercation. Review of the incident report revealed resident #6 was observed pushing resident #2 out of his room and into the hallway. The two residents began hitting each other before staff could intervene. As a result of the altercation, resident #2 sustained a scratch on the right side of his neck. Review of the skin and wound evaluation dated 10/01/2023 also revealed resident #2 sustained a scratch on the right side of his neck. On 10/23/2023 at 10:40 a.m., interview with S2CNA (Certified Nurse Aid); who worked on the secured unit; revealed she saw resident #2 and Resident #6 fighting in the hallway and quickly intervened by separating the residents. At this same time, S3CNA also stated she saw resident #2 and resident #6 fighting in the locked unit hallway and helped to separate the residents. Review of a facility investigation revealed on 10/06/2023, residents #2 and #5 had a physical altercation. Review of the incident report revealed resident #2 and resident #5 were in a room on the locked unit and began fighting. The staff on the hallway heard them. They entered the room and both residents were on the floor. As a result of the altercation, resident #2 sustained a bruise above his right eyebrow. Review of the skin and wound evaluation dated 10/06/2023 also revealed resident #2 sustained a bruise above his right eyebrow. On 10/25/2023 at 9:00 a.m., interview with #S1Administrator confirmed the two physical altercations noted above had occurred and involved residents #2, #5, and #6. S1 Administrator further confirmed that resident #2 had been injured in both altercations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 (#1) of 3 (#1, #5, #7) sampled residents reviewed for pressure ulcers. The facility failed to 1.) provide consistent documentation of the location of resident 1's pressure ulcers from 06/2023 - 09/2023, 2.) ensure complete pressure ulcer assessments were conducted for resident 1 upon admit (06/07/2023) and readmit (07/11/2023), and 3.) ensure complete documentation for resident 1's pressure ulcer treatments in June 2023 and August 2023. Findings: Record review revealed resident 1 was admitted to the facility on [DATE] with diagnoses including: paraplegia, history of chronic pressure ulcers to his buttocks, neuromuscular dysfunction of bladder, major depressive disorder, epilepsy, chronic pain syndrome, and cardiac arrhythmia. Record review of resident 1's admission Minimal Data Set (MDS) dated [DATE] revealed he had the following skin conditions: two, stage 1 pressure ulcers and a history of chronic pressure ulcer to his buttocks. Record review of resident 1's Quarterly MDS dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was not cognitively impaired. Further review revealed he required limited to extensive, 1-2 person assistance for most activities of daily living. Record review of resident 1's Evaluation of Pressure Ulcer Risk dated 07/10/2023 revealed he was assessed to be at a high risk for pressure ulcers. Review of his current care plan revealed a problem onset dated 06/07/2023: altered skin integrity due to ulcers (failed to document what type ulcer) noted to his left and right ischial tuberosity. There was no documentation of the stages of resident 1's wounds. On 09/25/2023 at 3:55 p.m., an interview with resident 1 revealed the nurse was currently providing his wound care but he had a problem in the past with the nurses missing some of his dressing changes. Resident 1 was unsure when this occurred, but said he had several different nurses that changed his dressings in the past. Record review of resident 1's admission Skin assessment dated [DATE] revealed there was a wound to his coccyx. Further review revealed there was no measurements, staging, or complete assessment of the wound and there was no documentation of the left and right ischial tuberosity ulcers identified upon admit in resident 1's care plan. Record review of resident 1's Physician Orders dated 06/07/2023 revealed an order for Zinc Oxide 20% ointment topically every night for wounds. Further review of the medical record revealed no documentation the Zinc Oxide was applied as ordered from 06/07/2023 and 06/08/2023. Record review of resident 1's Initial Weekly Wound assessment dated [DATE] revealed S6Licensed Practical Nurse (LPN) had assessed resident 1 and documented the following pressure ulcer assessments (S2Former Director of Nursing (DON) signed the assessment): -Stage 1 pressure ulcer to left thigh: 15.0 centimeters (cm) x 15.0cm, reddened intact skin -Stage 1 pressure ulcer to right buttock: 15.0cm x 13.0cm, reddened intact skin -Stage 2 pressure ulcer to right thigh: 2.5cm x 2.5cm x 0.1cm Record review of resident 1's Telephone Physician order dated 06/09/2023 revealed the following order for the resident's stage 2 to right posterior thigh pressure ulcer: clean with wound cleanser, pat dry, apply Silver Alginate to wound bed, cover with border foam dressing, and change every other day and as needed. Review of resident 1's June 2023 Treatment Administration Record (TAR) revealed the above treatment was not provided as ordered for resident #1's stage 2 to right posterior thigh pressure ulcer on 06/23/2023, 06/25/2023, 06/27/2023, and 06/29/2023. Record review of resident 1's Telephone Physician order dated 06/09/2023 revealed the following order for the resident's right and left buttocks: apply Zinc Oxide every other day and after each diaper soilage. Review of resident 1's June 2023 TAR revealed the above treatment was not provided as ordered for resident #1's right and left buttocks on 06/27/2023 and 06/29/2023. Record review revealed resident 1 was hospitalized from [DATE] - 07/11/2023. Further review revealed there was no wound assessment upon his return to the facility on [DATE]. Record review revealed resident 1's current care plan was revised on 07/21/2023 to include two stage 3 pressure ulcers on the left and right ischium. Further review revealed the care plan was revised again on 08/25/2023 with a stage 3 pressure ulcer on the right buttock. Record review of resident 1's Weekly Wound assessment dated [DATE] revealed S10LPN had assessed resident 1 and documented the following pressure ulcer assessments (S2Former DON signed the assessment): -Stage 3 pressure ulcer to left ischial tuberosity: 4.59cm x 1.5cm x 0.2cm -Stage 3 pressure ulcer to right ischial tuberosity: 7.49cm x 1.3cm x 0.2cm Record review of resident 1's August 2023 Physician Orders revealed an order for the following: cleanse right and left ischial with normal saline, pat dry with gauze, apply Triad cream 3 times daily (tid) and as needed. Review of resident 1's August 2023 TAR revealed the above treatment was provided daily instead of three times a day from 08/01/2023 - 08/11/2023 and 08/18/2023 - 08/30/2023. Further review revealed the above treatment was not provided as ordered on 08/12/2023-08/17/2023 and 08/31/2023. On 09/25/2023 at 2:55p.m., an interview with S5RN/Wound Care Nurse revealed she had recently been hired by the facility and had only provided wound care for resident 1 for three days. She confirmed the facility has had several different wound care nurses in the past few months. On 09/27/2023 at 2:30 p.m., an interview with S4Consultant Registered Nurse (RN) confirmed the following: 1.) documentation of the location of resident 1's pressure ulcer sites were not consistent from 06/2023 - 09/2023 which made it unclear if the pressure ulcers were the same or had healed and new areas had developed, 2.) the facility failed to ensure complete pressure ulcer assessments were conducted for resident 1 upon admit (06/07/2023) and readmit (07/11/2023), and 3.) there was incomplete documentation for resident 1's pressure ulcer treatments in June 2023 and August 2023. On 09/27/2023 at 2:30 p.m., an interview with S3Director of Nursing (DON) confirmed the facility failed to ensure complete pressure ulcer assessments were conducted for resident 1 upon admit (06/07/2023) and readmit (07/11/2023). S3DON also confirmed there was incomplete documentation for resident 1's pressure ulcer treatments in June 2023 and August 2023. On 09/27/2023 at 3:00 p.m., S1Administrator was informed that the facility failed to ensure complete pressure ulcer assessments were conducted for resident 1 upon admit (06/07/2023) and readmit (07/11/2023). S1Administrator was also informed of the incomplete documentation for resident 1's pressure ulcer treatments in June 2023 and August 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations, the facility failed to ensure a resident, with an indwelling catheter, received the appropriate care and services to prevent urinary tract infections for 1 (#5) of 3 (#1, #2, & #5) sampled residents reviewed for urinary catheters. The facility failed to ensure resident #5's urinary catheter tubing was positioned off the floor and the facility failed to obtain a urinalysis and urology appointment timely for resident #5. Findings: Review of the medical record for resident #5 revealed the resident was admitted on [DATE] with diagnoses, in part of: diabetes, candida cystitis and urethritis, retention of urine, elevated prostate specific antigen, and urinary tract infection. Review of the physician order dated 04/26/2023 revealed to change 16 french Foley catheter every month and when necessary for occlusion. Review of the physician orders revealed there were orders dated 08/25/2023 for Ceftriaxone (antibiotic) 1 gram Intramuscular (IM) everyday x 5 days and repeat the urinalysis on 09/01/2023. Review of the labwork revealed the urinalysis was obtained on 09/08/2023. Review of the primary physician's progress note date 07/18/2023 revealed: the resident complained of swollen penis and his plan was to arrange a follow up appointment with urology. Review of a physician order dated 07/18/2023 revealed an order to arrange follow up appointment with urology. Review of the nurses notes dated 09/25/2023 revealed the resident complained of penis/scrotum pain, 650 milligrams Tylenol administered, this nurse called urologist's office to schedule appointment for Tuesday, 09/26/2023 at 1:30 p.m. Observation on 09/25/2023 at 11:52 a.m. revealed the resident was in his wheelchair propelling himself from the smoking area door to the dining room. His urinary catheter tubing was touching the floor. There were staff present. Observation of 09/25/2023 at 12:05 p.m. revealed the resident was in his wheelchair eating lunch at the dining room table. His urinary catheter tubing was on the floor. There were staff present in dining room. Observation on 09/25/2023 at 12:23 p.m. revealed the resident was in his wheelchair propelling himself out of the dining room and his urinary catheter tubing was touching the floor. There were staff present. Further observation revealed S7Licensed Practical Nurse (LPN) propelled the resident to his room with his urinary catheter tubing dragging the floor down the hall. Observation on 09/27/2023 at 8:30 a.m. revealed the resident was in his wheelchair in the hallway by the dining room with his urinary catheter tubing on the floor. There were staff present. Observation on 09/27/2023 at 10:25 a.m. revealed the resident was in his wheelchair outside on the front porch with his urinary catheter tubing on the ground. There were staff present. Observation on 09/27/2023 at 11:55 a.m. revealed the resident was in his wheelchair in the dining room with his urinary catheter tubing on the floor. There were staff present. Observation of resident #5 on 09/27/2023 at 2:05 p.m. with S8Certified Nursing Assistant (CNA) revealed the resident's urinary catheter tubing was on the floor. S8CNA reported whoever positioned his urinary catheter bag didn't place the tubing into the privacy bag correctly to keep the catheter tubing off the floor. An interview with S9Licensed Practical Nurse (LPN) on 09/27/2023 at 2:10 p.m. revealed she was not aware that the resident's urinary catheter tubing was touching the floor today. An interview with S3Director of Nursing (DON) on 09/27/2023 at 4:45 p.m. confirmed that resident #5's urinary catheter tubing should not be touching the floor. S3DON further confirmed the urinalysis and urology appointment should have been done timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to protect residents' right to be free from physical abuse by another resident for 1 (#10) of 6 (# 1, 3, 4, 5, 9, and 10) residents reviewed for completed abuse investigations. The facility failed to protect resident #10 from being physically abused by resident #5; which resulted in resident #10 sustaining scratches and a bruise during the physical altercation with resident #5. Findings: Review of the facility's policy and procedure dated 10/2022 for abuse prevention revealed that the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff and other residents. d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking. Review of the medical record for resident #10 revealed an admission date of 02/24/2023 with diagnoses including schizophrenia, anxiety, hypothyroidism, anxiety and intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #10 had moderate cognitive skills for daily decision making. Review of the care plan revealed resident #10 was at risk for alterations in psychosocial wellbeing related to behaviors and diagnoses of schizophrenia, anxiety, and traumatic brain injury. Review of the medical record for resident #5 revealed an admission date of 09/23/2020 with diagnoses including paranoid schizophrenia, heart disease, dysphagia, mild intellectual disabilities, and depression. Review of the annual MDS dated [DATE] revealed resident #5 had moderate cognitive skills for daily decision making. Review of the care plan revealed resident #5 was at risk for alterations in psychosocial wellbeing related to behaviors due to diagnoses of schizophrenia, anxiety, traumatic brain injury, intellectual disabilities, anxious, and verbally abusive towards others. Review of the Resident Incident Report dated 07/20/2023 at 9:01 a.m. revealed resident #10 walked up to resident #5 to speak and to give him a fist bump when resident #5 started hitting resident #10. Resident #10 sustained a scratch on the right side of the neck, a scratch under the right side of the ear and a small bruise was noted on the right side of the forehead. Review of the nurse notes dated 07/20/2023 at 9:00 a.m., revealed resident #10 was in the television room with other residents when resident #10 walked up to resident #5 and attempted to give him a fist bump. Resident #5 started to punch resident #10 in the head. Resident #10 sustained a scratch on the right side of his neck and below the right ear, and also a bruise on the right side of his forehead was observed. An interview with S16Licensed Practical Nurse (LPN) on 08/16/2023 at 8:10 a.m. revealed she didn't actually witness the altercation. S16LPN revealed she entered the room to deescalate the issue and to assess the residents. S16LPN revealed she observed resident #10 to have a scratch on the right side of his neck and under the right ear and a small bruise on the right side of the forehead. An interview with S1Administrator on 08/16/2023 at 11:30 a.m. revealed resident #5 and #10 had an altercation and resident #5 hit resident #10. Further interview with S1Administrator revealed the day of the incident she observed a scratch on resident #10's neck and face area.

Based on record review and interviews, the facility failed to ensure all abuse investigation final results were reported to the state agency within 5 working days of the incident for 1 (#9) of 5 (#1, 4, 5, 3, 9) residents reviewed for a completed abuse investigations. Findings: Review of an abuse investigation revealed, on 08/04/2023, staff observed resident #9 hit resident #11 with an open hand. The blow was to the arm of resident #11. The facility investigation indicated the due date for completion and submission to the state agency of the final report was 08/11/2023. Review of the medical record revealed resident #9 had diagnoses which included Schizoaffective disorder, Bipolar disorder and Anxiety disorder. Review of the medial record revealed resident #11 had diagnoses which included Schizophrenia, depression and generalized anxiety. Review of the facility abuse investigation report revealed it had not been completed by 08/11/2023. On 08/16/2023 at 9:00am, Interview with #S1Administrator confirmed the final report was submitted on 08/15/2023. She confirmed the due date for the final report was 08/11/2023.

Based on interviews and record reviews the facility failed to ensure direct care staff had appropriate competencies and skills to assure resident safety and maintain the highest practicable physical, mental, and psychological well-being of each resident. According to the census list provided by the facility on 05/22/2023, 31 residents resided on the South hall locked unit (Behavioral unit). The facility failed to ensure 12 staff providing direct care (S3LPN (Licensed Practical Nurse), S4LPN, S5LPN, S6CNA (Certified Nursing Assistant), S7CNA, S8CNA, S9CNA, S10CNA, S11CNA, S12CNA, S13CNA, S14CNA) out of 12 (S3LPN, S4LPN, S5LPN, S6CNA, S7CNA, S8CNA, S9CNA, S10CNA, S11CNA, S12 CNA, S13CNA, 14CNA ) on the south hall locked unit had competency training in crisis prevention interventions for a resident (Resident #1) who displayed self-harmful behavior and was danger to self and others. Findings: Review of the record for resident #1 revealed an admission date to facility of 11/18/2022 with diagnoses of Schizophrenia, Bipolar Disorder, Major Depressive Disorder, Unspecified convulsions. Review of nurse's notes and incident reports from 03/13/2023 through 04/01/2023 revealed resident#1 displayed self-abusive behavior by striking self, throwing self on floor and against beds, which caused him to sustain multiple bruises on face, legs, arms and neck. Further review of record for resident#1 revealed he was unable to be redirected by staff when he displayed self-aggressive behavior. An interview conducted on 05/22/2023 at 11:34 a.m., with S6CNA revealed no crisis prevention training and no behavioral training was provided to her to assist residents on locked unit. She further reported that resident #1 was self-aggressive and was a harm to himself. S6CNA reported no specific approaches were provided for her and other staff to assist resident #1. An interview on 05/22/2023 at 11:50 a.m., with S7CNA revealed no crisis prevention training and no behavioral training was provided for her. An interview on 05/22/2023 at 1:45 p.m., with S8CNA revealed resident #1 exhibited a lot of self- abusive behavior. S8CNA reported that he was dangerous to himself and that she was not trained on how to assist him when he became abusive. An interview on 05/22/2023 at 2:05 p.m., with S9CNA revealed that she has worked on locked unit for about 2 months. She revealed she had not received any training regarding crisis prevention and reported that she was familiar with resident#1. S9CNA reported that the resident needed to have 1:1 staffing. An interview on 05/23/2023 at 5:40 a.m., with S3LPN revealed that he has worked on the locked unit since February 2023. S3LPN reported that he has not received any behavioral training to work on unit and no crisis prevention training was provided to him by the facility. He revealed resident#1 was self-abusive and self-injurious and was difficult to redirect. An interview on 05/23/2023 at 6:00 a.m. with S10CNA revealed that she has worked on the locked unit for over a year. S10CNA reported she had not received any behavioral training before she worked on the locked unit and no crisis prevention training was provided for her. She revealed resident#1 was a danger to himself and that she was not trained to intervene when he displayed self-aggressive behavior. An interview on 05/24/2023 at 11:53 a.m., with S12CNA revealed resident #1 should have never been on unit. S12 CNA reported resident#1 needed 1:1 staffing. S12CNA revealed nursing did not instruct the aides on how to care for resident#1 and no training was provided regarding how to handle self-abusive behavior. An interview on 05/24/2023 at 12:15 p.m., with S14CNA revealed resident#1 displayed many behaviors, which included self-injurious behaviors, jumping on the floor against the bed and walls. She further reported no training was provided regarding working with residents on the locked unit. S14CNA stated what can I do and not do to take care of them. She revealed she had not received crisis prevention type training. An interview on 05/24/2023 at 12:55 p.m., with S4LPN revealed she has worked on the locked unit since March 2023. S4LPN reported that she had not received any specific training regarding behavior/crisis prevention training. She revealed resident#1 displayed self-harmful behavior and was not easily redirected. Review of the training records revealed no crisis prevention training was provided for the following staff who work on behavioral unit: S3LPN, S4LPN, S5LPN, S6CNA, S7CNA, S8CNA, S9CNA, S10CNA, S11CNA, S12CNA, S13CNA, and S14CNA. An interview on 05/24/2023 at 1:56 p.m., with S2 RN Clinical Operations Consultant confirmed that the facility failed to ensure that behavioral unit staff had crisis prevention training to manage residents that are a harm to themselves and others.

Based on observation of medication administration, record review, and interview the facility failed to ensure that the medication error rates are not 5% or greater. The facility had a 6.4% medication error rate with 2 medication errors for 1 (#2) of 3 (#2, #13 and #14) residents observed for medication administration. The facility had 2 medication administration errors out of 31 opportunities. The facility's current census was 88 residents. Findings: On 04/22/2023 at 8:00 a.m., observation of medication administration with S8 LPN (Licensed Practical Nurse) revealed she did not administer resident #2's Carvedilol 6.25 milligrams tablet to be given every day at 8:00 a.m. and 8:00 p.m., and Miralax Powder 17 grams to be given every day at 8:00 a.m. Review of the April 2023 physician orders revealed an order dated 12/16/2022 for Carvedilol 6.25 milligrams by mouth two times a day, and Miralax Powder 17 grams by mouth every day. On 04/25/2023 at 2:30 p.m. S2 DON (Director of Nursing) was notified of the medication administration errors for resident #2 and the medication error rate of 6.4%. On 04/25/2023 at 2:45 p.m. S19 Clinical Operations Consultant was notified of the medication administration errors for resident #2 and the medication error rate of 6.4%.

Based on observation and interview, the facility failed to ensure the privacy and confidentiality of medical records for residents in the locked unit by having chart room unlocked and resident records accessible. 32 residents reside on the locked unit. Findings: Observation on 04/25/2023 at 2:50 p.m. of the locked unit chart room revealed that the door was closed and unlocked. Surveyor knocked and entered room and observed Resident #12 present with no staff. Resident #12 was observed opening drawers, cabinets and ice chest which was full of ice. Further observation revealed that all residents' records on the locked unit were identifiable and accessible to resident #12 at this time. Interview on 04/25/2023 at 3:03 p.m. with S25 RN confirmed that Resident #12 was in chart room alone and unattended. Further interview revealed that all resident records were identifiable and accessible at this time.

Based on observations, record reviews and interviews the facility failed to ensure residents have a safe, clean, comfortable and homelike environment for 5 (#2, #6, #9, #10, and #11) of 5 (#2, #6, #9, #10, and #11) sampled residents reviewed for environmental issues. The facility failed to ensure: 1. Resident #6's bed was not broken; 2. Resident #6's bedroom was without holes and a broken electrical receptacle 3. Resident #9's bathroom door was not missing. 4. Bathrooms d, c, a, b were stocked with toilet paper, soap, and paper towels. 5. Residents' #10, #11 floors were cleaned properly. 6. Resident #2's bathroom door did not close properly. Findings: Resident 6 Observation of resident #6's room on 04/23/2023 at 9:30a.m., revealed the following: broken head board on bed; broken electrical plug socket. Further observation revealed there were damaged base boards; holes and stains on walls and grime and dirt build up on the floor. Interview on 04-23-2023 at 10:43 a.m. with S1 Administrator confirmed that head board of resident #6 was broken as well of holes in wall and broken electrical plug socket. Further interview at this time confirmed damaged base boards along walls and dirt and grime build up on floor. Resident 9 Observation of Resident #9 bedroom on 04/25/2023 at 8:57 a.m. revealed a missing bathroom door. Further observation of Resident #9 room revealed a heavy build-up of grime and debris on floor and behind the bed. Interview with Resident #9 at this time revealed that his bed was in close proximity with bathroom and he has to watch and smell other residents use bathroom during the day time and when he eats meals. Interview with S24 RN Unit Manager on 04/25/2023 at 9:09 a.m. confirmed the missing bathroom door next to bed of resident #9 and dirty floors. Bathrooms a,b,c,d Observation on 04/23/2023 at 9:35a.m., revealed the following bathrooms on the locked unit were noted to have no toilet tissue, soap or paper towels. All residents in these rooms are capable to using these bathrooms. Further observation revealed that on each day of the survey the bathrooms were dirty and had strong odors. Interview on 04/23/2023 at 10:43a.m., with S1 Administrator confirmed that bathrooms a, b, c, and d did not have soap, paper towels or toilet tissue for residents to use. Resident #10, #11 Observation on 04/25/2023 at 8:50 a.m. of Resident #10 and Resident #11 room revealed dirty floors with trash and debris build up on floor and behind beds. Interview on 04/25/2023 at 8:50 a.m. with Resident #10 and #11, who were roommates, revealed that staff do no properly clean bathrooms and bedrooms and did not clean behind beds. Interview with S24 RN Unit Manager on 04/25/2023 at 9:09 a.m. confirmed the dirty floors in Residents #10 and #11 room. Resident 2 Observation on 04/23/2023 at 9:00 a.m. revealed that bathroom door which is in close proximity to his bed does not close properly. Further observation revealed strong urine odor noted in bedroom. Surveyor was unable to close door at this time. Interview with resident #2 on 04/23/2023 at 9:00 a.m. revealed the door did not close properly and odors were strong in bathroom at all times and that staff do not clean bathrooms properly. Interview on 04/23/2023 at 10:43a.m., with S1Administrator confirmed that bathrooms door of resident #2 did not close properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the residents right to be free of physical abuse by a staff member for 1 (#6) of 4 (#1, #2, #6, and #7) sampled residents reviewed for abuse. Findings: Review of the record for resident #6 revealed an admission date of 12/29/2020 and diagnoses of schizophrenia and bipolar disorder. Review of the Minimum Data Set, dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10 which indicates moderate cognitive impairment for daily decision making and he required extensive assistance with activities of daily living. Observation of Resident #6 on 04/23/2023 at 8:40 a.m. revealed the resident was assisted to the side of bed for breakfast. The resident appeared unkempt, with eyes matted. An interview was attempted with Resident #6 on 04/23/2023 at 8:40 a.m. but it revealed the resident was a poor historian. He was not oriented to time, place, person or situation. Review of a supervisor investigation summary form for abuse investigation regarding resident #6 dated 03/07/2023 revealed the following information: resident #6's name, Diagnoses: schizophrenia, bipolar disorder, type 2 diabetes, multiple fracture of ribs, fracture of skull and facial bones and hypertension, Date and time of the incident: room c (locked unit) on 03/07/2023 at 1:00 p.m., Where did event occur: hallway on locked unit. How and when was event discovered: On 03/07/2023 at approximately 1:00 p.m., S21 Director of Rehab (DOR) reported to S2 DON (director of nursing) that she heard hollering coming from specialty behavior unit and looked in through the window then opened the door to see who was hollering. Briefly describe event: On 03/07/2023 at approximately 1:00 p.m., S21 DOR reported to S2 DON that she heard hollering coming from specialty behavior unit and looked in through the window then opened the door to see who was hollering. S21DOR reports that she then saw S7 CNA (certified nursing assistant) roll white male resident to his room and as she got to his door she saw S7 CNA hand go up and come down slapping male resident on the right side of his head twice. Resident #6 was immediately assessed for injuries. S1Administrator was immediately notified and S7 CNA was removed from unit. Investigation was initiated immediately. Investigation initiated by S8 LPN (licensed practical nurse) on 03/07/2023 and the investigator was S2 DON (Director of Nursing). Employees interviewed revealed following date and time of interview: 1) S8 LPN- 03/07/2023 at 1:00PM; 2) S26 CNA- 03/07/2023 at 1:00PM; 3) S7 CNA- 03/07/2023 at 1:00PM; 4) S20 CNA, 03/07/2023 at 1:00PM and 5) S3 CNA- 03/07/2023 at 1:00PM. Residents interviewed: Resident #6: Other people interviewed: NONE. Records reviewed: resident #6. BIMS score as of 02/08/2023 10. Care plan: resident #6 is care planned for potential for injury/falls related to psychotropic drugs used for treatment of schizophrenia. Resident as history of throwing himself on the floor at times. Follow up action section: On 03/07/2023 at approximately 1:00 p.m., S21 DOR reported to S2 DON that she heard hollering coming from specialty unit and looked in through the window then opened the door to see who was hollering. S21 DOR then reports that she then stepped into the unit and was standing by the nurse's station and said S7CNA in question put her hand up and in a slapping manner, with open hand on right side of his head. S7 CNA in question stated that the resident rolled up the hallway screaming and yelling, and she turned him around, she then took him back to his room in an attempt to redirect and not escalate behaviors on the unit. S7 CNA was suspended immediately pending investigation and removed from residents care. Resident #6 was immediately assessed for injuries; no injuries noted. A complete head to toe skin assessment was completed, no findings. Resident was last seen in his room. S26 CNA was interviewed and stated that she had not witnessed S7 CNA in question hitting resident #6. Nurse on hall, S8 LPN, was interviewed by S2 DON and stated that she did not witness any physical abuse toward resident #6. Resident roommate was in the room as this took place in the hallway. Other residents were interviewed, who S7 CNA in question was also assigned to same S7 CNA and no reports of abuse was stated by them and they stated they felt safe. S20 CNA stated that resident #6 was cursing and throwing finger signs; he balled up his fist at S7 CNA as she turned him around and begin to try and hit her. S7 CNA was blocking his punches by holding his hand. Further review of the supervisor summary investigative form for Resident #6 revealed that he normally hollers, curses, screams, and cries randomly. Resident #6 has a BIMS of 10 and when questioned he denied any abuse at this time. Resident #6 able to make needs known. The findings of the abuse investigation summary for resident #6 revealed the following: Based on record review, staff interviews, resident and witness interview; the facility is unable to substantiate any neglect or abuse. In-service was initiated by S5 SDC (staff development coordinator) on de-escalating behaviors and abuse prevention. 100% audit skin audit of all residents taken care of by S7 CNA and no injuries were noted. S7 CNA was able to return to work on 03/11/2023 and was also re-educated on abuse prevention and de-escalation. S7CNA is also no longer assigned to resident #6 care. The resident's care plan was updated to include physical/verbal aggression towards staff. Pain medication was available upon request. Resident is own RP (responsible party), MD (Medical Doctor) was notified. Signature and title of primary investigator: S2 DON dated and signed on 03/07/2023 and S1 Administrator dated and signed also on 03/07/2023. Review of the facility's policy and procedure on abuse prevention (10/22) revealed that the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, and volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Definitions: Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident to resident, staff-to-resident, family to resident or visitor to resident. Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking. A phone Interview was conducted with S3 CNA on 04/23/2023 at 7:30 p.m. She witnessed abuse of resident #6 by S7 CNA. S3 CNA revealed on the day of the event she was working the middle hall and was finishing up care for resident in room with another CNA. She heard a loud noise with threatening tone coming from the locked unit which was across the hall. She reported that S21 DOR was at the locked unit door at was asking about the loud noise. S3 CNA reported that she and S21 DOR were looking into locked unit window immediately opened the door entered locked unit. S3 CNA revealed she saw S7 CNA and her sister S20 CNA laughing and sitting in chairs next to double doors in hall of nursing station close to residents' rooms. She stated that S7 CNA immediately got up and started pushing Resident #6 in his wheelchair in a fast motion down the hall. She reported at this time she witnessed S7 CNA slap resident #6 on right side of face two times. She stated that she could hear the slap and it sounded loud. Then reported that she witnessed S7 CNA push Resident #6 forcefully into his bedroom and shut the door. S3 CNA reported that she immediately told S8 LPN who was in nursing station about the incident. She said that S7 CNA did not see them and that S20 CNA was on her phone laughing and then looked up and saw her and S21 DOR looking at her. She reported that S5 Staff Development Coordinator (SDC) CNA supervisor, asked her to complete statement regarding abuse of Resident #6 that same day. She reported after she finished, she put it under S2 DON's office door. S3 CNA reported that S2 DON did not interview her at any time. About 1 week later after incident she again reported the abuse to S1 Administrator. She confirmed again that she witnessed clear physical abuse from S7 CNA directed at Resident #6. Interview conducted with S21 DOR on 04/24/2023 at 8:30 a.m. revealed that she witnessed physical abuse on 03/07/2023 regarding staff S7 CNA striking Resident #6. She reported around 1:17 p.m. on 03/07/2023, she left therapy department and was headed toward dining room. S21 DOR reported that as she was passing the closed doors of the locked unit she heard loud yelling of a male voice. She reported that yelling was common place on unit but this time it was more intense and aggressive in nature. She reported that the yelling got louder and she then saw S3 CNA who also commented on the loud noise and asked what was going on. She looked in the window of the locked unit but did not see anything. She reported that the yelling continued so she and S3 CNA entered the locked unit doors. She stated she saw S7 CNA pushing a white male, who S3 CNA said was Resident #6 in a wheel chair away from us down the hall and as approached resident #6's room she observed S7 CNA raised her right hand above her shoulder and slapped him on right side of his head two times forcefully. S21 DOR then stated that the slap was very audible. S21 DOR reported that staff S7 CNA pushed resident #6 into the room and did not come out by time they left unit several seconds later. She reported that S3 CNA identified another staff present as S7 CNA's sister, S20 CNA. She reported that she called S2 DON who was out of the building and told her what happened. She said S2 DON instructed her to talk to S5 SDC. S5 SDC gave her papers to fill out and asked her what happened. She stated that S3 CNA knocked on glass of nursing unit and told S8 LPN what happened. S21 DOR stated that the S1 Administrator was out of the building at the time but talked to him by phone that day. The next day S21 DOR spoke with S1 Administrator. She reported that she has not been interviewed anymore about the event after meeting with S1 Administrator on 03/08/2023. Interview with S8 LPN on 04/24/2023 at 11:35 a.m. revealed that she worked the day of the incident regarding resident #6 and was the nurse in charge of locked unit. She reported that she was in the nursing station and that S21 DOR got her out of the station and said S7 CNA hit Resident #6. She reported that she immediately went down and assessed him and noted no swelling. She reported that Resident #6 said to her that a man hit him. She reported that she asked S7 CNA what had happened and she stated she questioned Resident #9 and Resident #10 and they denied any incident. She reported that S7 CNA stated resident #6 was grabbing her arm and attempting to hit her and she was blocking him with her hand. S7 CNA told her she rolled resident #6 back into his room as so he could calm down. She further stated that S7 CNA was immediately removed from the unit. She reported that S21 DOR told her that she saw S7 CNA hit Resident #7 on the right side of face. She reported that she notified S22 RN (Registered Nurse) unit manager and S2 DON immediately regarding this event. Reported that she does not believe that resident #6 was abused/hit by S7 CNA and that she was just protecting herself because he was swinging at her. She confirmed that she heard loud noise and did not leave nursing station to check on incident. Also confirmed that she did not witness anything. She does not remember if she wrote a statement regarding this incident. Interview with S7 CNA on 04/23/2023 at 12:40 p.m., revealed she has been working as a CNA for 10 years and was currently working middle hall on day shift. She reported that she left the facility for another job and returned in 2021 and had primarily worked the locked unit. S7 CNA confirmed knowledge of incident involving resident #6. S7 CNA stated that resident #6 had just completed eating lunch and was hollering loudly that he was still hungry. S7 CNA reported that he rolled himself up toward nursing station in a wheel chair and began to scream and curse, 'No the f***k I did not eat and he continued to curse and threaten. S7 CNA reported that she then attempted to push resident #6 back to his room because he was agitated and threatening. She reported Resident #6 attempted to grab her arm and attempted to hit her but she blocked him with her left hand. She reported that she was initially leaning over the chair and then when he started swinging she stood erect and pushed him into his room so he could calm down. Resident #6 continued to be upset in room. She stated that S8 LPN came to the room and checked on resident #6. She reported that S8 LPN attempted to calm him down. She reported that she had to leave the unit immediately because it had been reported that she was accused of hitting him. She stated that she did not strike resident #6 but was just blocking him with her left hand when he tried to hit her. She confirmed that she did not get the nurse out of nursing station when he was agitated and pushed him back to his room without talking with S8 LPN. She also stated that only staff present that witnessed resident #6 agitated was her sister, S20 CNA, who was also working as a CNA on the locked unit that day. Interview with S22 Unit Manager on 04/24/2023 at 11:50 a.m. revealed that she was asked by S2 DON to assess and perform a skin audit on resident #6 regarding an incident on 03/07/2023. She reported that she asked resident #6 if he was hit and first he said no and then he said someone had hit him. She stated the next time she asked him that he said the boogie man hit me She then reported when she asked again he reports that he said a man pushing cart hit him. S22 Unit Manager reported that she did not write any progress notes regarding her assessment. Regarding the skin audit, S22 Unit Manager confirmed that she did not write the time on the form but only dated it. Further interview revealed that she only documented on the skin audit for resident #6: no bruising noted on following dates: 03/07/2023; 03/09/2023 and 03/13/2023. She reported that she notified S2 DON of her findings. Interview with S2 DON on 04/25/2023 at 9:30 a.m. revealed she has been DON for facility for 2 years. She reported S1 Administrator is the Abuse Prevention Coordinator. S2DON reported that she works with S1Administrator in the investigation of abuse and neglect. She reported that she was the investigator regarding investigation of abuse for Resident #6. The Abuse policy and procedure was reviewed with S2 DON at this time. S2 DON reported that she was not at the facility the day of the incident on 03/07/2023. She reported that she received a phone call from S21 DOR regarding abuse that was witnessed involving S7 CNA hitting resident #6. She also reported that she then immediately called S1 Administrator, who was also not in the facility that day. S2DON also reported that she did not come to the facility on the day of the incident. She stated she talked with S8 LPN, and told her to complete a statement. She also stated that she gave direction to aides on the hall to give statements. S2DON stated that she talked to S5 LPN, CNA supervisor and told her to remove S7 CNA from unit and send her home. She reported she sent S22 Unit Manager to go look at Resident #6 and do a body audit. S2 DON revealed she also asked the social worker to look at him. She stated that she opened up a reportable investigation that day. She reported that on 03/08/2023, she did not interview any staff but gathered information including statements. Reported that she gathered resident #6's information including his BIMS score, medication and face sheet. S2 DON confirmed that the only statements that she obtained were the following: S7 CNA, S20 CNA, S21 DOR and S26 CNA. S2 DON confirmed that she does not have a written statement from S8 LPN and no statement from S3 CNA. She also stated at this time that she did not interview staff but gave the staff statements and resident information to S1 Administrator. She confirmed that she never talked to S3 CNA. S2 DON was not able to produce any of her notes at this time regarding her investigation. S2 DON confirmed that the skin and wound evaluation performed on resident #6 on 03/07/2023 was not timed and that documentation by S22 Unit Manager was only noted to say no bruising noted. S2 DON further stated that in her opinion that she believed it was a thorough investigation and did not believe abuse occurred. She reported that she never interviewed and assessed resident #6. S2DON stated that she does not feel that abuse occurred because there are times resident #6 hits staff and she did not think that S7 CNA acted inappropriately. She confirmed that S21 DOR did tell her that S3 CNA entered the locked unit at the same time on the date of the event. S2 DON states at this time that she does not know how many eye witnesses are needed to determine abuse. Interview with S1 Administrator on 04/25/2023 at 10:00 a.m., S1 Administrator confirmed that he is the Abuse Prevention Coordinator of the facility. He reported that he worked on this investigation in conjunction with S2 DON, and he was not at the facility on day of the incident and that S2 DON called him. He reported that he notified S5 SDC to go and remove S7 CNA from the locked unit and to send her home. He then reported that he obtained the statements and brought staff in and interviewed them. When asked for his notes, he reported that he documented in SIMS (Statewide Incident Management System) and did not have any notes. He reported at this time that he did not save interviews he conducted at this time. S1 Administrator confirmed that everything he has was in the folder. He confirmed at this time he does not have a statement from S8 LPN or S3 CNA. When asked about S3 CNA interview he conducted he stated at this time that she threw her hands up and stated she did not see anything. He reported that he asked S3 CNA what transpired and he stated she said she did not hear anything. S1Administrator was then asked at this time to produce interview notes regarding S3 CNA and he was unable to do so. He reported that he talked with S21 DOR who wrote a statement and verified that it was accurate and true. Further interview with S1 Administrator at this time revealed that he unsubstantiated abuse based on following: resident #6 said he was not abused; 100 % skin audits; no bruising; and other residents interviewed denies any abuse. He confirmed that the cameras on the locked unit were not working. S1 Administrator confirmed that resident #6 comes in and out of awareness and has a BIMS of 10. He again concluded that he has no other notes regarding his investigation of abuse for resident #6.

Based on record review and interviews, the facility failed to report allegations of staff to resident physical abuse to the State Survey Agency no later than 2 hours after the allegation was made for 1 (#2) of 1 (#2) sampled residents reviewed for abuse incidents in a total of 6 (#1, 2, 3, 4, 5 6) sampled residents. Findings: Review of the facility policy and procedure regarding abuse revealed following components. (10/22) INVESTIGATION: The facility will initiate at the time of any findings of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The ED, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the SS act to the Dept. of Health as required. PROTECTION: Any allegations of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the SS act time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others) In addition to reporting to the state agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so the residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the residents care plan is followed. Review of the SIMS (Statewide Incident Management System) log for the facility on 04/23/2023 revealed no evidence that an allegation of physical abuse regarding Resident #2 was submitted to state agencies. Interview with resident #2 on 04/23/2023 at 10:20 a.m. revealed an incident occurred on 04/17/2023 between 1-2 p.m. that while using bathroom, he slipped and fell and could not get up. He reported that he called out for help and about 6-7 minutes passed when S3 CNA (Certified Nursing Assistant) entered room and exclaimed to resident to Get Up-You just like (Resident #11) - and he can get himself up in reference to his left- sided paralysis and supposedly comparing him to resident #11 on the unit. He reported that S3 CNA did not attempt to get him up and went and got maintenance staff S4 Maintenance Staff who he referred to as Hulk. He reported that S4 Maintenance Staff entered his room and loudly exclaimed Get Up and then reportedly dragged him from bathroom to side of his bed by his arm and then walked out. He further stated staff did not assist him to bed- he reported that he attempted to call S1 Administrator by using his cell phone but he did not respond. He reported that he told S21 DOR in therapy department the next day who in turn called S1 Administrator about being dragged from bathroom by staff. He stated at some point on evening of 04/18/2023 that S1 Administrator came to his room accompanied by S3 CNA and attempted to talk to him about incident. He stated to S1 Administrator that he wanted to talk to him in private in which he initially refused. He reported that S1 Administrator did speak with him alone and he told him that he slipped and fell in the bathroom and that staff refused to assist him up and that S4 Maintenance Staff dragged him from bathroom to side of the bed. He reported again that he told this to the administrator and he felt like he was abused regarding this incident. He reported that no other staff were available regarding this incident except for S3 CNA and S4 Maintenance Staff. He denies being hurt as result of this incident. He reported that he was able to lower his bed all way down and get himself into bed. Interview with S1Administrator on 04/23/2023 at 10:40 a.m. revealed that he was aware of the incident. He reported that he was told by S21 DOR (Director of Rehab), that it was reported to her by Resident #2 that he was dragged from bathroom to his bed on 04/17/2023 between 1-2 PM by staff named Hulk, S4 Maintenance Staff. He reported that he talked with S3 CNA about incident before talking to Resident #2. Reported that he went to resident #2 room and was accompanied by S3 CNA. He reported that resident #2 requested to talk with him alone so he asked S3CNA to step out of room. S1Administrator reported that resident #2 stated that he was using bathroom and became unsteady and was assisted to floor by S2CNA. Reported that S3 CNA and S10 CNA were unable to get resident #2 up and attempted to use lift but that resident #2 refused to have them use lift on him. He stated that S4 maintenance came in dragged him from bathroom to bedroom. He further stated that resident never mentioned that he fell in bathroom. Reported that he gathered all staff and obtained statements and nobody reported that Resident #2 was dragged or fell in bathroom. On 04/23/2023 at 12:15 p.m. surveyor went to resident #2 room accompanied by S1Administrator. Resident #2 verbalized to S1 Administrator that he told S1 Administrator on 04/18/2023 that he had fallen in the bathroom on 04/17/2023 and that Hulk S4 maintenance, dragged him from the bathroom to the side of his bed and that he felt he was abused. Interview conducted with S1 Administrator on 04/25/2023 at 10:00 a.m. confirmed that he did not complete a SIMS report because he ruled out abuse/neglect regarding investigation of Resident #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to thoroughly investigate an allegation of physical abuse for 1 (#2) of 4 (#1, #2, #6, and #7) sampled residents reviewed for abuse. Findings: Review of the facility policy and procedure regarding abuse (10/22) revealed following components. INVESTIGATION: The facility will initiate at the time of any findings of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The ED, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the SS act to the Dept. of Health as required. PROTECTION: Any allegations of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the SS act time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others) In addition to reporting to the state agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so the residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the residents care plan is followed. Review of the record for resident #2 revealed an admission date of 12/16/2022. Diagnoses include following: hemiplegia following cerebral infarct affecting left side, chronic kidney disease, type 2 diabetes mellitus, hypertension, presence of cardiac pacemaker. Review of MDS (Minimal Data Set) dated 03/15/2023 revealed BIMS (Brief Interview for Mental Status) score of 15 revealing that he is cognitively intact. Resident is continent of bowel and bladder. Requires stand by assistance with transfers, limited assistance x 1 for dressing, bathing and toileting, due to history of hemiplegia. Primary mode of locomotion is wheel chair, able to self -propel throughout the unit. Resident #2 able to make needs known to staff. Review of supervisor investigation summary form for abuse investigation for Resident #2 revealed the following information: Resident #2 diagnoses, room d, date of event: 04/18/2023 and time 4:00 p.m. (Event occurred on 04/17/2023 between 1-2 p.m.) How and when discovered: Resident #2 informed therapy that he was drug from one room to the next. Briefly describe event: Resident informed therapy he was drug from one room to the next by whom a CNA (Certified Nursing Assistant). (S21 DOR (Director of Rehab) stated that she reported S4 maintenance was accused to S1 Administrator). Investigation was initiated by S1Administrator: date and time started: immediately upon notification, and investigator was S1Administrator. Employees interviewed: S5 LPN, S10CNA and S3 CNA. He listed date of interview for these staff as 04/17/2023 but was not made aware of event until 04/18/2023. It is also noted that S21 DOR, and S4 Maintenance, were not listed as having been interviewed. In section of resident interviewed: Resident #2 is listed as having been interviewed in room d, on 04/17/2023 with no time listed. Review of the documentation regarding interview with resident #2 and administrator revealed following: S1Administrator notified by therapy that resident #2 wanted to talk to him. S1 Administrator interviewed Resident #2 and stated he was drug from one room to the next, resident #2 was asked if he was abused, resident just stated, they drug me S1Administrator documented following based on medical record, interview staff and residents, facility is unable to substantiate abuse/neglect, Facility suspects that resident #2 was on the toilet, was attempting to transfer without assistance and yelling for help, when S3 CNA entered the room, resident started saying I'm going to fall S3CNA attempted to assist resident to his chair, resident #2 started to resist, resident #2 was eased to the floor. Staff wanted to use the Hoyer lift to assist resident #2, however resident#2 refused, stated that he did not want to use the lift due to his arm and his hand. S10 CNA called for other staff to assist in helping resident #2, resident #2 then in turn started to scoot across the floor, he was educated to keep calm, other staff arrived, and resident #2 was assisted to his bed per staff. No injuries or skin issues are present at this time. Plan of care updated with 2 person assist with all ADL's (Activities of Daily Living) provided, Continue to follow resident current plan of care Interview with resident #2 on 04/23/2023 at 10:20 a.m. revealed an incident occurred on 04/17/2023 between 1-2 p.m. that while using bathroom, he slipped and fell and could not get up. He reported that he called out for help and about 6-7 minutes passed when S3 CNA entered room and exclaimed to resident to Get Up-You just like (Resident #11) - and he can get himself up in reference to his left- sided paralysis and supposedly comparing him to resident #11 on the unit. He reported that S3 CNA did not attempt to get him up and went and got maintenance staff S4 Maintenance who he referred to as Hulk. He reported that S4 Maintenance entered his room and loudly exclaimed Get Up and then reportedly dragged him from bathroom to side of his bed by his arm and then walked out. He further stated staff did not assist him to bed- he reported that he attempted to call S1 Administrator by using his cell phone but he did not respond. He reported that he told S21 DOR in therapy department the next day who in turn called S1 Administrator about being dragged from bathroom by staff. He stated at some point on evening of 04/18/2023 that S1 Administrator came to his room accompanied by S3 CNA and attempted to talk to him about incident. He stated to S1 Administrator that he wanted to talk to him in private in which he initially refused. He reported that S1 Administrator did speak with him alone and he told him that he slipped and fell in the bathroom and that staff refused to assist him up and that S4 Maintenance dragged him from bathroom to side of the bed. He reported again that he told this to the administrator and he felt like he was abused regarding this incident. He reported that no other staff were available regarding this incident except for S3 CNA and S4 Maintenance. He denies being hurt as result of this incident. He reported that he was able to lower his bed all way down and get himself into bed. Interview with S1Administrator on 04/23/2023 at 10:40 a.m. revealed that he was aware of the incident. He reported that he was told by S21 DOR, that it was reported to her by Resident #2 that he was dragged from bathroom to his bed on 04/17/2023 between 1-2 PM by staff named Hulk, S4 Maintenance Staff. He reported that he talked with S3 CNA about incident before talking to Resident #2. Reported that he went to resident #2 room and was accompanied by S3 CNA. He reported that resident #2 requested to talk with him alone so he asked S3CNA to step out of room. S1Administrator reported that resident #2 stated that he was using bathroom and became unsteady and was assisted to floor by S2CNA. Reported that S3 CNA and S10 CNA were unable to get resident #2 up and attempted to use lift but that resident #2 refused to have them use lift on him. He stated that S4 maintenance came in dragged him from bathroom to bedroom. He further stated that resident never mentioned that he fell in bathroom. Reported that he gathered all staff and obtained statements and nobody reported that he was dragged or fell in bathroom. On 04/23/2023 at 12:15 p.m. surveyor went to resident #2 room accompanied by S1Administrator. Resident #2 verbalized to S1 Administrator that he told S1 Administrator on 04/18/2023 that he had fallen in the bathroom on 04/17/2023 and that Hulk S4 maintenance, dragged him from the bathroom to the side of his bed and that he felt he was abused. Phone interview conducted with S3 CNA on 04/23/2023 at 7:30 p.m. S3 CNA reported that she was working on the locked unit on 04/17/2023. While entering meal data into the computer system that is in the wall in the hallway, she heard resident #2 holler out for help. She reported that she immediately entered into his room and reported that he was in the bathroom standing up over the toilet saying he was about to fall and felt uncertain that he could enter back to wheel chair. She reported that he did not fall but she assisted him to the floor in bathroom. She reported that she then got S10 CNA and they attempted to use the [NAME] Lift but resident refused to allow them to use the lift. S3 CNA then reported that S10 CNA contacted maintenance worker they call Hulk (S4 Maintenance staff) who came approximately 10 minutes later and they reported that they all assisted together and put resident #6 in bed. S3 CNA again stated that resident#6 was never dragged from bathroom to bedroom and that he did not fall. Further interview revealed that on 04/18/2023, resident #2 supposedly told people, S21 DOR, that he was dragged from bathroom to bedroom. S3 CNA then stated that she was working the middle hall and that S1Administrator asked her to go with him to talk with resident #2 about the incident. She reported that she went in and S1 Administrator told resident #2 he wanted to determine what happen. She stated that she was explaining what had happened when resident #2 asked to speak with S1 Administrator alone in which she was excused from the room. S3 CNA told S1Administrator in front of resident #2 prior to leaving that resident #2 did not fall to floor but was assisted; offered to lift with [NAME] lift but refused, and that he was assisted by S10CNA, S3CNA and S4 Maintenance Staff without incident. Interview with S21 DOR on 04/24/2023 at 8:30 a.m. revealed that resident #2 came into therapy department on Tuesday, 04/18/2023 around 12:00 noon and stated that he needed to talk to her. Resident #2 stated that he fell in the bathroom yesterday, 04/17/2023, and that S3 CNA could not get him up. Reported that S4 Maintenance staff came into his room, grabbed his arm and dragged him from bathroom to side of his bed. S21 DOR reported that she immediately contacted S1 Administrator, and reported what resident #2 stated. She reported that she gave verbal statement to administrator on 04/18/2028 at 12:15 p.m. Further interview revealed that resident #2 did not report any comments made by staff regarding incident at this time. S21 DOR reported that she was not ask to write a written statement regarding conversation with Resident #2. Interview with S4 Maintenance Staff on 04/24/2023 at 9:30 a.m. revealed that he works at facility as maintenance assistance. He has worked for 16 months at facility. Reviewed abuse and neglect policy and procedures with S4 Maintenance Staff and stated he received training and understands abuse and responsibilities. He stated that on 04/17/2023 sometimes after lunch that he was called by S10 CNA. He reported that S10 CNA stated she needed some help with assisting Resident #2 back in bed. He reported that he got there about 5 minutes after being called and immediately went into Resident #2 room and stated S3CNA and S10 CNA were present. Reported that resident #6 had scooted closer to bed. He reported that he got behind Resident #2 and lifted him up and the other staff assisted him by moving feet. Reports placed him in bed without incident. He then reported that resident #2 appeared angry and took a swing at him but did not hit him. Reported that he did tell anyone about resident #2 attempting to hit him. He stated that he did not drag resident #2 and has assisted him in the past and never had an issue in the past. He reported at this time that he was not ask to write a statement regarding this issue and has not been interviewed by anyone. Interview conducted with S1 Administrator on 04/25/2023 at 10:00 a.m. revealed that he was notified by S21 DOR on 04/18/2023 around 12:15 p.m. S21 DOR reported resident # 2 stated that he was physically dragged from the his bathroom and to placed next to his bed on 04/17/2023 by staff member S4 Maintenance Staff. He confirmed that he did not obtain a statement from S21 DOR and did not obtain a statement of the accused staff, S4 Maintenance Staff. He further stated that the information on the investigation summary form regarding date and time of the event, room number of the resident and location was incorrect. S1 Administrator also confirmed wrong dates and no time on staff interviews. He further confirmed no date and time of resident #2 interview and confirmed only comment documented during interview with resident #2 was he stated was drugged from one room to the next. S1 Administrator confirmed that investigation was not thoroughly and accurately investigated as per abuse policy. He also reports that he did not complete a SIMS (Statewide Incident Management System) report because he ruled out abuse/neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide assistance for residents who were unable to carry out activities of daily living by failing to maintain good grooming and personal hygiene for 2 (#2, #7) of 3 (#2, #6, and #7) residents investigated for ADL (activities of daily living) care. Findings: Resident #2 Review of the record for resident #2 revealed [AGE] year old male with an admit date of 12/16/2022. Diagnoses included: hemiplegia following cerebral infarct affecting left side, chronic kidney disease, type 2 diabetes mellitus, hypertension, and cardiac pacemaker. Review of MDS (Minimum Data Set) dated 03/15/2023 revealed BIMS (Brief Interview for Mental Status) score of 15. Resident was continent of bowel and bladder. The MDS also indicated the resident required stand by assistance with transfers, limited assistance x 1 for dressing, bathing and toileting. His primary mode of locomotion was a wheel chair which he was able to self -propel throughout the unit. Resident #2 was able to make his needs known to staff. Interview with resident #2 on 04/23/2023 at 9:05 a.m. revealed he has not had a shower in over a week and that staff refuse to assist him. He reported that he was supposed to get a shower every Tuesday, Thursday, and Saturday but staff have not helped him in a week even though he has asked for one. He was able to voice at this time that he has an odor and has been wearing same clothing for the past week. Observation revealed long, thick finger nails with grime in nail bed of both hands. Observation on 04/24/2023 at 9:00 AM revealed resident #2 lying was in bed watching TV. He was wearing the same clothing as he had on the previous day and he reported that staff did not bathe him even though he requested. Observation on 04/24/2023 at 1:30PM revealed the resident was sitting on the side of bed in same clothing with food and stains on the clothing. He reported that staff told him that he could not get a bath until tomorrow. A strong odor of urine was present. The resident's fingernails were long and dirt and grime was in the nail bed of both hands. He reported that no staff did not trim his nails and that he is unable to do so independently. Review of care plan for resident #2 revealed a deficit related to activities of daily living with an intervention in place that required nursing staff to assist with hygiene and grooming task. Interview on 04/24/2023 at 2:15 p.m. with S24 RN Unit Manager revealed that resident #2 was to receive showers when scheduled and his fingernails should be maintained by staff. Resident #7 Review of the medical record revealed an admission date of 09/20/2021 with diagnoses of chronic obstructive pulmonary disease, schizophrenia, anxiety, suicidal ideations, heart disease, diabetes mellitus, hyperlipidemia, and insomnia. Review of the care plan revealed the resident was independent with activities of daily living but needs supervision with bathing. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition for daily decision making and required supervision with one person assistance with transfers, eating toileting and bathing. On 04/24/2023 at 10:40 a.m. observation of the resident revealed his scalp had a heavy buildup of dandruff and he had body odor and was unkempt. On 04/24/2023 at 2:15 p.m. interview with S24 RN Unit Manager revealed that resident #7 should receive a shower as scheduled. On 04/25/2023 at 1:05 p.m. observation and interview with resident #7 revealed he was lying in the bed with a sling on his arm. He revealed he had not had a bath or shower since he broke his arm a couple of weeks ago and has been wearing the same shirt for several days. On 04/25/2023 at 1:15 p.m., S2 DON (Director of Nursing) was informed of resident #7 being unkempt and was in need of a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nurses administered a resident's medications, and failed to ensure blood sugar and blood pressure monitoring were performed for 1 (#1) of 4 (#1, #2, #7 and #8) records reviewed. Findings: Review of the medical record for resident #1 revealed an admission date of 03/10/2023 with diagnoses of hyperlipidemia, vitamin D deficiency, hypertension, fracture of the femur, depression, type 2 diabetes mellitus, heart disease, chronic obstructive pulmonary disease and reflux. Review of the Minimum Data Set, dated [DATE] revealed the resident had no cognitive impairment and required limited assistance with bed mobility, hygiene and bathing and required extensive assistance with transfers and toileting. Review of the nursing home admission physician's orders dated 03/10/2023 revealed orders for the following medications. Gabapentin 300 mg (milligrams) hs (hour of sleep), Ticagrelor 90 mg bid (two times a day), Eliquis 2.5 mg bid, Trelegy Ellipta 28 gr (grams) inhale 1 puff daily, Carvedilol 12.5 mg bid with meals, Fenofibrate 134 mg every day, Farxiga 10 mg every day, Lipitor 40 mg hs, Toujeo Solostar .17 ml (milliliters) subcutaneous daily, Albuterol Sulfate 90 mcg (micrograms) inhaler - one puff every 4 hours as needed while awake, Nystatin 30 gm topical to bilateral breasts three times a day, Ozempic 2 mg subcutaneous weekly, Vitamin D2 50,000 units weekly, Benadryl 25 mg every 6 hours as needed for itching, Triamcinolone cream 0.1% - apply to affected area as needed, Colace 100 mg bid, Escitalopram 10 mg every day, Lotrimin cream 90 grams topical - apply to affected area bid, and Fluconazole 100 mg every day for 10 days. Review of the March 2023 Medication Administration Record revealed the medications were not given until 03/12/2023. Review of the record revealed no documented evidence of resident #1's blood sugar level obtained until 03/13/2023 and she was admitted on [DATE] with a diagnosis of diabetes mellitus. Further review of the record revealed resident #1 had diagnoses of heart failure and hypertension and there was no documented evidence of blood pressure monitoring obtained unitl 03/12/2023. On 04/23/2023 at 10:30 a.m., an interview with S11 LPN (Licensed Practical Nurse) revealed the resident #1 did not receive medications until 03/12/2023 and she was admitted to the nursing facility on 03/10/2023. On 04/24/2023 at 11:45A a.m., an interview with S22 Unit Manager revealed the resident was admitted on Friday 03/10/2023 after the pharmacy stopped delivering medications for the day and she didn't realize the pharmacy did not deliver on the weekends. S22 Unit Manager revealed the resident did not receive her medications until 03/12/2023 for administration. S22 Unit Manager further confirmed the resident did not have her blood sugar obtained until 03/13/2023 and blood pressure checked unitl 03/12/2023. On 04/24/2023 at 2:25 p.m., an interview with S19 Clinical Operations Consultant revealed resident #1 didn't receive her medications until 03/12/2023 and she was admitted on [DATE].

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure to facility was free from insects and mice. The deficient practice had the potential to affect all residents in the facility. Findings: Interview with Resident #2 on 04/23/2023 at 9:00 a.m. revealed a pest problem existed at the facility. He reported that the staff does not clean resulting in the presence of rats, flies and roaches. Resident #2 reported that he recently saw a rat climbing on his oxygen concentrator about a week ago. He reported roaches and flies were throughout the unit. Observation at this time revealed the resident's room and floor to be filthy, with trash, food debris, grime, mouse droppings and dead insects behind the resident's bed. Multiple observations each day in the locked unit on 04/23/2023, 04/24/2025, and 04/25/2025 revealed flies were hall way and residents rooms. Observation on 04/25/2023 at 8:50 a.m. of Resident #10 and Resident #11 room revealed dirty floors with trash and debris on floor and behind their beds. Mouse droppings, dead roaches and other dead insects were behind both residents beds. Interview on 04/25/2023 at 8:50 a.m. with Resident #10 and #11 (roommates) revealed that staff do no properly clean bathrooms and bedrooms and do not clean behind the beds. Further interview confirmed that they have problems with insects, flies, roaches and mice. Observation of Resident #9's bedroom on 04/25/2023 at 8:57 a.m. revealed dead insects and mouse droppings in closet and on the floor and behind the bed. Interview with Resident #9 confirmed there were ongoing problems with mice, roaches, and flies. Interview with S24 RN Unit Manager on 04/25/2023 at 9:09 a.m. confirmed that in the rooms of resident #10 and 11, the floors were dirty and littered with dead insects and rat droppings.

Based on record review and interview, the facility failed to ensure each employee received training that educated staff on resident abuse prevention by failing to conduct annual abuse training for 1 (S7CNA) of 5 (S3CNA, S4Maintenance, S7CNS, S10CNA, S20CNA) sampled staff. Findings: Review of the personnel records revealed staff S7CNA (Certified Nurse Aid) was a certified nurse aid with a hire date of 09/29/2021. There was documentation in the personnel record of abuse training upon hire but there was no documentation that the staff had received annual abuse training. Review of the abuse in-service training records revealed she was not listed as being in attendance for the abuse training. On 04/25/2023 at 1:00p.m., interview with S5Staff Development Coordinator confirmed the staff did not receive abuse training at least annually.

Based on observation and interview the facility failed to ensure housekeeping services were provided to maintain a clean and sanitary environment for 1 of 1 (#66) residents with food left on the floor. Findings: On 01/24/2023 at 9:10 a.m. observation and interview with resident #66 revealed he spilled his supper tray on the floor last night (01/23/2023) and they brought him a new tray but no one came to clean the food up off the floor that he spilled. Observation revealed a piece of sausage and beans with a napkin were left on the floor next to the wall. On 1/24/2023 at 9:19 a.m. S2 DON (Director of Nurses) observed the food on the floor and said she would get it taken care of. On 1/24/2023 at 10:44 a.m. observation again revealed the food was still on the floor and had not been cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the assessment must accurately reflect the resident's status for 1 (#72) of 7 (#12, #18, #31, #40, #44, #60, #72) residents reviewed for accidents, by failing to reassess resident #72's smoking status. Findings: Review of the medical record revealed resident #72 was admitted to the facility on [DATE] with diagnoses including Schizophrenia. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a brief interview for mental status score of 07. A score of 00-07 indicates resident #72 had severe cognitive impairment in his daily decision making. On 01/23/2023 at 9:23 a.m., an observation revealed resident #72 sitting in his wheelchair in front of the nurses' station. Further observation revealed the resident was observed to have some small holes to his pant legs on both sides. On 01/24/2023 at 9:33 a.m., an observation revealed resident #72 outside in the designated smoking area, smoking a cigarette. During the observation, resident #72 was observed holding his cigarette close to his pants, but never touching his clothing. Further observation revealed the resident had smoked his cigarette nearly down to the butt of the cigarette. After the resident finished smoking, he placed the cigarette on the concrete and stomped the cigarette out. Review of the Smoking Evaluation Tool dated 11/15/2022 revealed documentation of resident #72 being evaluated as a safe smoker. On 01/25/2023 at 10:06 a.m., S5MDS Coordinator was notified of findings from the smoking observation and smoking evaluation tool assessment. S5MDS Coordinator reported that she had talked to resident #72 during her evaluation on 11/15/2022 and reported resident #72 had a brief interview for mental status score of 07 at the time of the interview. On 11/25/2022 at 11:13 a.m., S5MDS Coordinator reevaluated resident #72's cognitive status and identified the resident as having an MDS score of 05. S5MDS Coordinator confirmed she had not reassessed resident #72's smoking status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene for 1 (#8) of 3 (#1, #8, #86) residents observed for activities of daily living. The provider failed to ensure resident's fingernails were clean and trimmed. Findings: Record review revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included but not limited to the following: schizoaffective disorder, type 2 diabetes mellitus with diabetic neuropathy, unspecified dementia with other behavioral disturbance, paranoid schizophrenia, heart failure, metabolic encephalopathy, and need assistance with personal care. Review of the MDS (Minimum Data Set) dated 12/19/2022 revealed Resident #8 required extensive assistance by two person physical assist with bed mobility, transfers, and bathing. Resident #8 required extensive assistance by one person physical assist with dressing and personal hygiene. On 01/23/2023 at 2:35 p.m. an observation of Resident #8 revealed he was lying in hospital bed with head of bed elevated up 30 degrees. Resident #8's fingernails on both hands were long and jagged with a dark brown colored grime substance under his fingernails. On 01/24/2023 at 8:35 a.m. an observation of Resident #8 revealed he was lying in hospital eating breakfast. Resident #8's fingernails on both hands were long and jagged with a dark brown colored grime substance under his fingernails. On 01/24/2023 at 1:42 p.m. an interview conducted with S2 DON (Director of Nursing) in Resident #8's room revealed Resident #8's fingernails were long and jagged with dark colored grime substance under his fingernails. S2 DON reported that the treatment nurse does the nail care for diabetic residents and the CNA's (Certified Nurse Aide) do the nail care for residents who are not diabetic. S2 DON confirmed Resident #8's fingernails needed to be trimmed and cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide in room activities for 1 of 1 (#66) resident during COVID isolation. Findings: On 01/23/2023 at 3:14 p.m., interview with resident #66 revealed he just had COVID and he came off of isolation today. Resident #66 said it sure has been lonely with nothing to do in my room. He said I didn't even have a television. Resident #66 further said no one brought him anything to do while on isolation. Resident #66 said he was just in the room by himself with no interaction. Observation of room at that time revealed there was no television, radio or any other form of activity in the room. On 01/24/2023 review of the record for Resident #66 revealed he was diagnosed with COVID on 01/17/2023 and placed on isolation until 01/22/2023. On 01/24/2023 review of Resident #66 plan of care revealed he was at risk for alteration in psychosocial well-being related to restriction on visitation due to COVID. The plan of care further noted to encourage alternative communication with visitors, such as: computers, cell phones and tablets, monitor psychosocial changes, observe and report any changes in mental status and to provide in room activities such as books, radio, and television. On 01/24/2023 review of the activity assessment dated [DATE] revealed past likes were bingo, current likes were needlework TV sports, music, newspaper, mail, walking for relaxation, watching TV movies/videos, indoor gardening, talking conversing on phone, and attending resident council. Review of the only activity note revealed it was dated 12/27/2022. Resident located on the middle hall, resident does little activities will continue to encourage resident to participated in activities daily. On 01/25/2023 at 8:51 a.m., observed resident #66 in his room eating breakfast. Very pleasant, but again confirmed that he had nothing to do but look at the 4 walls during his 5 days of COVID isolation. Resident #66 said yesterday he went to the rec room which was actually the therapy department. He said he likes to lift weights so he enjoys going in there and he wasn't able to do that when on isolation. Resident #66 also said the activity person never brought him anything because she didn't want to be around COVID. On 01/25/2023 at 9:30 a.m., interview with S3 Activity Director revealed she has been here about 1 year. She said resident #66 likes movies, he likes to go to therapy, and likes party/socials. S3 Activity Director further said that the facility does not provide a television for the resident rooms but they do have some radios available for the resident rooms. S3 Activity Director also said that resident #66 will refuse activities at times but she only documents on a quarterly basis and did not document when resident #66 refused offered activities. S3 Activity Director agreed there were no activities provided in the room for resident #66 while he was on COVID isolation for 5 days. On 01/25/2023 at 9:30 a.m. interview with S4 Assistant Activity Director revealed she has been working at the facility for about 3 months. She said they have packets of coloring things for people who can't come out of their room but they did not provide any to resident #66 during his COVID isolation. S4 Assistant Activity Director also said that some days resident #66 will go to activities and he does like bingo. On 01/25/2023 at 10:07 a.m., interview with S1 Administrator revealed the facility will purchase a television for the resident if they have no family or any other means to obtain a television. S1 Administrator agreed there should have been some type of activity/socialization for resident #66 during his 5 days of COVID isolation.