6) For Resident #5, the facility failed to implement their abuse policy and procedure to investigate and report a bruise when multiple staff members observed bruising to Resident #5's face. Resident #5 was admitted to the facility in July 2022 with diagnoses including dementia, diabetes and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/12/23, indicated Resident #5 had a Brief Interview of Mental Status (BIMS) score of 7 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #5 wanders and required supervision with walking. Review of the skin check, dated 12/8/23, indicated: -No skin issues. On 12/12/23 at 7:59 A.M., Resident #5 was observed in bed with purple discoloration to his/her right side of face. On 12/13/23 at 6:41 A.M., and 12/14/23 at 6:51 A.M., Resident #5 was in his/her bed and was observed with a purple discoloration to his/her right side of face. Review of the nursing progress note, dated 12/15/23, indicated: -Noted bruise on the bottom right chin. During an interview on 12/14/23 at 6:58 A.M., Nurse #2 said that Resident #5 sustained a bruise to his/her chin when he/she got into an altercation with Resident #13 on 12/11/23. During an interview on 12/15/23 at 11:00 A.M., Nurse #1 said that Resident #5 had a bruise on the bottom of his/her right chin. Nurse #1 said today (12/15/23) was the first time she saw the bruise. During an interview on 12/15/23 at 1:37 P.M., CNA #6 said that she found Resident #5 with a bruise on his/her face on 12/12/23 around 2:00 P.M., CNA #6 said that she did not witness Resident #6 hit his/her face, but CNA #6 said Nurse #1 was aware of the new bruising. During an interview on 12/15/23 at 11:02 A.M., the Activities Assistant said that she saw the bruise on Resident #5's right chin on 12/12/23. The Activities Assistant said that she did not report the bruise. During an interview on 12/15/23 at 11:04 A.M., CNA #5 said he saw the bruise on 12/12/23. CNA #5 said he did not report the bruise. During an interview on 12/15/23 at 11:03 A.M., CNA #3 said he saw the bruise on 12/14/23. CNA #3 said he did not report the bruise. During an interview on 12/15/23 at 11:07 A.M., CNA #2 said Resident #5 got the bruise from a resident-to-resident altercation, but he did not know the date. During an interview on 12/15/23 at 11:10 A.M., Nurse Supervisor #1 said she was not aware of Resident #5's bruise on his/her right side of the face until 12/15/23. Nurse Supervisor #1 said new bruises should be reported to management and investigated. During an interview on 12/15/23 at 8:51 A.M., the Nursing Home Administrator said that bruising of unknown origin needs to be reported within 2 hours. 7) For Resident #13, the facility failed to ensure nursing implemented the facility abuse policy and reported an injury of unknown source to the Department of Public Health, as required. Resident #13 was admitted to the facility in April 2023 with diagnoses including dementia with severe psychotic disturbance, bipolar disorder and major depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/12/23, indicated Resident #13 had a Brief Interview of Mental Status (BIMS) score of 99 out of a possible 15 which indicated he/she was rarely understood. The MDS indicated Resident #13 experienced hallucinations and delusions. Resident #13 experienced wandering 4 to 6 days a week and physical and verbal behaviors 1 to 3 days a week. The MDS indicated Resident #13 was dependent on staff for bathing, toileting and personal hygiene. The MDS indicated Resident #13 required supervision or touching assistance with ambulation. On 12/12/23 at 7:58 A.M., Resident #13 was observed sitting on the edge of his/her bed. There was a purple discoloration under his/her right eye. Resident #13 was unable to say what happened to him/her. Review of the incident note, dated 12/11/23, indicated Resident #13 appeared agitated during meals throwing food on the walls and at staff CNA (Certified Nurse Assistant) during breakfast. The incident note indicated a CNA and this LPN (Licensed Practical Nurse) encouraged and redirected Resident #13 with no success. The note indicated Resident #13 then ambulated with assistance with a CNA to his/her room to rest. Staff observed Resident #13 hitting the walls and tables with his/her hands and fists. The note indicated Resident #13 threw sheets and a bed spread on the floor. The note indicated staff redirected Resident #13 to the dining room to participate in activities. The note indicated Resident #13's aggressive behavior continued and he/she was resistive to ADL care. The note indicated the nurse then observed that Resident #13 had a discoloration on his/her right cheek. Review of the facility incident report dated 12/11/23 at 14:00, indicated: Nursing Description: Resident seen with discoloration on the right cheek. Resident Description: Resident unable to give a description. Review of the plan of care related to bruise, dated 12/11/23, indicated: - Resident has a new bruise to the right cheek. From unknown source. Review of the written witness statements, dated 12/11/23, indicated CNA #2, CNA #3, CNA #4, CNA #5, CNA #6 and CNA #7, did not witness how Resident #13 obtained a bruise. Review of the incident report notes, dated 12/14/23, indicated: - Follow up assessment done by Director of Nursing bluish discoloration on left cheek below eye [injury is below right eye]. - Bruise on left cheek may have been self inflicted. During an interview on 12/12/23 at 8:50 A.M., Nurse #1 said she was assigned to Resident #13 on 12/11/23. Nurse #1 said she did not witness Resident #13 hit him/herself in the face and did not witness Resident #13 obtain the bruise under his/her right eye. Nurse #1 said the injury was of unknown source. During an interview on 12/15/23 at 1:37 P.M., CNA #6 said she found Resident #13 with a bruise on his/her face. CNA #6 said that she did not witness Resident #13 hit his/her face and did not know how the bruise happened. During an interview on 12/14/23 at 2:28 P.M., Nurse Supervisor #1 said she was made aware of Resident #13's bruising when she read the incident report on 12/12/23 in the morning during report (approximately 19 hours after the injury was discovered by Nurse #1 and CNA #6). Nurse Supervisor #1 said Resident #13's bruise was an injury of unknown source. During an interview on 12/15/23 at 9:27 A.M., the Director of Nursing said she was made aware of the bruise on 12/12/23. The DON said the bruising was of unknown origin. During an interview on 12/15/23 at 8:51 A.M., the Nursing Home Administrator said bruising of unknown source needs to be reported to the Department of Public Health within 2 hours. Based on observations, interviews and record reviews the facility failed to implement their Abuse policy for 7 Residents (#62, #44, #16, #28, #11, #5 and #13) out of a total sample of 29 residents. Specifically 1. For Resident #62, the facility failed to implement the abuse policy following three incidents of Resident #62 being struck by peers in the 1 [NAME] Unit dining room on 12/12/23, 12/13/23 and 12/18/23. 2. For Resident #44, the facility failed to implement the abuse policy when he/she struck a peer in the 1 [NAME] Unit dining room on 12/12/23. 3. For Resident #16 the facility failed to implement the abuse policy after he/she struck a peer, on 12/13/23 and 12/18/23, in the I [NAME] Unit dining room. 4. For Resident #28, the facility failed to implement a timely investigation when he/she reported to staff that a man had come into his/her room the previous night and spit on him/her. 5. For Resident #11 the facility failed to implement a timely investigation into a bruise of unknown origin. 6. For Resident #5 the facility failed to implement their abuse policy and procedure when multiple staff members observed new bruising to Resident #5's face. 7. For Resident #13 the facility failed to ensure nursing implemented the facility abuse policy and reported an injury of unknown source, as required. Findings include: Review of the facility policy, titled Abuse, dated 10/23/22, indicated the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. -Investigation 1. All alleged violations involving abuse, neglect, exploitation, and/or misappropriation of resident property will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. 2. The facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown source to determine if abuse or neglect was involved. 3. The Shift Supervisor/Charge Nurse is identified as responsible for immediate initiation of the reporting process upon receipt of the allegation. 4. An injury will be classified as an injury of unknown source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury or location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. 5. Facility will initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interviewable and have information regarding the allegation. -Reporting 1. Staff should notify the Shift Supervisor/Charge Nurse/Manager immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing immediately and initiate gathering requested information. And investigation MUST be directed by the Administrator or designee immediately. 4. Notify the local law enforcement and appropriate State Agency(s) immediately (no late than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident. 8. Report results of investigation to the proper authorities as required by state law. Review of the facility policy, titled Investigations, revised 10/2022, indicated the facility has designed and implemented processes to enable it to come to a resolution, after thoroughly investigating grievances, accidents, incidents, losses, thefts, allegations or other means in order to determine appropriate actions that can be taken to correct the situation and prevent further reoccurrences. -Procedure 1. Notify the Supervising Nurse or Charge Nurse as soon as a complaint is received, or an incident is reported. a. If the complaint is a verbal report of an accident or incident the incident/accident report shall be written by the person receiving the complaint with time and date of complaint. d. The Director of Nursing (DON) or Administrator must notify the state within 2 hours of an incident that is alleged or determined to be abuse, neglect, mistreatment or exploitation, as per your state guidelines. i. NOTE: Employees and licensed professionals are required by law to report any witnessed abuse, mistreatment or neglect to facility leadership. 3. The supervising nurse or nurse in charge, begins the investigation immediately. 4. The supervising nurse completes the Resident Incident Report. 5. The supervising nurse ensures the implementation of immediate intervention as indicated. i. If the incident involves an allegation of abuse, neglect, or mistreatment against an employee, the registered nurse (RN) supervisor or designee interviews the employee, gets a written statement an (sic) immediately suspends employee prior to investigation. The employee is removed from duty for the protection of residents during investigation. -Conducting the Investigation 1. The RN Supervisor or designee starts the investigation immediately. i) The investigator must remain objective. 3. The investigator conducts interviews in the following order: i) The resident(s) involved. Obtain a statement (if possible) about what occurred from the resident and complete appropriate nursing assessments (i.e. pain, skin integrity). ii) Locate and arrange interviews with the people involved in, or may have witnessed, the incident (i.e. the person who found the resident/patient or to whom the incident was first reported, people who were near the incident scene, the staff member responsible for the care of the resident or patient, the nurse responsible for the unit). This may involve going back 24 hours and interviewing staff on previous shifts (or greater than 24 hours if alleged incident occurred earlier). 11. Interview all potential witnesses. Request only information about what they actually observed. i) Employees ii) Roommates iii) Family member(s) 12. Document a brief, concise, objective description, in the medical record of what was actually observed. Do not speculate; record only factual information noted at the scene. 1. For Resident #62 the facility neglected to keep him/her safe and Resident #62 was struck three times by 2 peers, in the unit dining room, on 3 different days during the Survey and failed to immediately implement an abuse investigation following 2 of the 3 incidents. The facility policy titled Abuse, dated as revised 10/23/22, indicates the following: -Neglect is the failure to provide good or services to avoid physical harm, mental anguish or mental illness. -Under the policy's section titled Protection the policy indicates the following: 1. The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in process. 3. Provide for the immediate safety of the resident/patient upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Which may include but not limited to: a. Move resident/patient to another room or unit b. Provide 1:1 monitoring as appropriate Resident #62 was admitted to the facility in March 2023 and has diagnoses that include dementia, anxiety and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/07/23, indicated that Resident #62 was assessed by staff to have had severely impaired cognition. The MDS further indicated Resident #62 had behavior or wandering in 4 to 6 of the last 7 days of the assessment period. Review of the most recent Licensed Nursing Summary, dated 11/26/23, indicated that Resident #62 had behavior of intrusive wandering for 30 of the last 30 days. Review of the behavior care plan, most recently updated 6/19/23, failed to indicate interventions to keep Resident #62 safe by addressing intrusive behavior in the unit dining room. On 12/12/23 at 8:31 A.M., the surveyor observed Resident #62 seated in the 1 [NAME] Unit dining room. Resident #62 was seated beside Resident #44 and multiple times Resident #44 told Resident #62 to go away and to shut up. Staff were across the room, out of eye sight of the two Residents. Resident #44 punched Resident #62 in the right upper arm and said get out of here. At 8:33 A.M., the surveyor notified Nurse #4 what had been observed. Nurse #4 said they don't sit together and, walked across the room to redirect Resident #62, while at the same time saying to Resident #44 you shouldn't punch him/her. Resident #62 was easily redirected away from Resident #44. During an interview on 12/13/23 at 12:14 P.M., with Nurse #4 she said that she notified Nurse Supervisor #1 of the incident on 12/12/23 and that the incident should have been investigated, statements obtained from staff, and skin check done of Resident #62. In this case she said she is not sure that any of that happened. Nurse #4 said that she did not conduct a skin check of Resident #62 and had not asked any staff for witness statements. On 12/13/23 at 12:58 P.M., Resident #62 stood directly beside Resident #16 at a table in the 1 [NAME] Unit dining room for several minutes. At 1:01 P.M., Resident #16 open handed slapped Resident #62. A staff person was near to Resident #62, observed the incident and immediately instructed Resident #62 to walk with her. Resident #62 complied and was easily redirected away. During an interview on 12/13/23 at 2:25 P.M., Certified Nursing Assistant (CNA) #3 said that he was not aware that Resident #62 had been struck by a peer at lunch that day. CNA #3 said that the nurse should have let me know. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that she was notified on 12/12/23 that Resident #62 had been struck by a peer but hasn't had a chance to look into it yet, nor could she state a plan to protect Resident #62 from further abuse. During an interview on 12/13/23 at 3:58 P.M., with the Director of Nursing (DON) and Nursing Home Administrator (NHA) the surveyor discussed concerns that had been identified and observations that had been made during the survey process regarding the handling of resident to resident altercations and the implementation of the facility's abuse policy. The DON said that she was aware that Resident #62 had been struck twice by peers, on 2 days of survey, in the 1 [NAME] Unit dining room but had not yet a chance to look into it. Nor could she state a plan to protect Resident #62 from further abuse and said that behavior of striking others is expected on a dementia unit. During a follow-up interview on 12/15/23 at 11:51 A.M., with the DON she said that she has not yet spoken with staff, obtained statements regarding what occurred or was observed in the dining room on 12/12/23 or 12/13/23. The DON could not state a plan to protect Resident #62 from further abuse. On 12/18/23 at 10:50 A.M., the surveyor observed Resident #16 strike Resident #62 with an open hand in the 1 [NAME] Unit dining room. The Activity Assistant #1 was the only staff person in the room and did not observe the incident. The surveyor immediately notified her of what had occurred. During an interview on 12/18/23 at 12:35 P.M., the DON she said staff is unable to stop Resident #62 from getting into others personal space, adding that Resident #62 does this all the time. The DON was unable to state a plan to protect Resident #62 from further abuse. During a follow-up interview on 12/19/23 at 11:27 A.M., with the DON and NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 2. Resident #44 was admitted to the facility in March 2022 and had diagnoses that included vascular dementia with agitation and obsessive compulsive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/23/23, indicated that Resident #44 scored a 2 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated that for the 1-3 of the previous 7 days Resident #44 had episodes of Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). Review of the most recent Licensed Monthly Summary, dated 11/26/23, indicated Resident #44 had no behaviors of being verbally abusive or physically abusive toward others in the month of November 2023. Review of the behavior care plan for Resident #44 indicated it was last updated on 10/13/22. The care plan focus area indicated Resident #44 exhibits nonverbal signs of communication when annoyed or space invaded . Review of the care plan interventions, last updated on 02/08/23, failed to indicate any interventions for when Resident #44 began to exhibit annoyance toward others. On 12/12/23 at 8:31 A.M., the surveyor observed Resident #62 seated in the 1 [NAME] Unit dining room. Resident #62 was seated beside Resident #44 and multiple times Resident #44 told Resident #62 to go away and to shut up. Staff were across the room, out of eye sight of the two Residents. Resident #44 punched Resident #62 in the right upper arm and said get out of here. The surveyor immediately notified the Nurse #4. At 8:33 A.M., the surveyor notified Nurse #4 what had been observed. Nurse #4 said they don't sit together and, walked across the room to redirect Resident #62 while at the same time saying to Resident #44 you shouldn't punch him/her Review of the clinical progress notes indicated a note dated 12/12/23 at 21:05 P.M., and written by Nurse #4: Reported to this writer that Res hit another Res while they were sitting in the dining room. This writer redirected Res with good effect and separated the Residents to different dining rooms. Safety Maintained. During an interview on 12/13/23 at 12:14 P.M., Nurse #4 said that Resident #44 is not nice to residents sitting nearby to him/her. Nurse #4 said that Resident #44 is regularly verbally abusive, but accepts redirection, and she said that that Resident #44 had never struck anyone before. Nurse #4 said that she notified Nurse Supervisor #1 of the incident on 12/12/23 and that the incident should have been investigated and statements obtained from staff. In this case she said she is not sure that any of that happened. During an interview on 12/13/23 at 3:13 P.M., the Nurse Supervisor #1 said that she was notified on 12/12/23 that Resident #44 had struck a peer but hasn't had a chance to look into it yet. Nurse Supervisor #1 said that Resident #44 hits other residents all the time, especially when someone is in his/her personal space. She added everybody has been slapped by Resident #44. During an interview on 12/15/23 at 11:51 A.M., the DON said that she had not yet spoken with staff and obtained statements regarding what occurred or was observed in the dining room on 12/12/23. During a follow-up interview on 12/19/23 at 11:27 A.M., with the DON and NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 3. Resident #16 was admitted to the facility in January 2021 and had diagnoses that included Alzheimer's disease and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/02/23, indicated that Resident #16 scored an 8 out of a possible 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. Review of the current behavior care plan indicated that Resident #16 exhibits nonverbal signs of communication when annoyed or space invaded. An intervention on the care plan included Intervene as necessary. Approach/speak in a calm manner. Divert attention. remove from situation and take to alternate location as needed On 12/12/23 at 8:58 A.M., the surveyor observed Resident #16 throw a cup at a peer. The surveyor immediately informed the Nurse #4 who went over to Resident #16 and took his/her tray away and said you cannot throw cups at people. Nurse #4 failed to implement the plan of care and Approach/speak in a calm manner. Divert attention. remove from situation and take to alternate location as needed. On 12/12/23 at 9:00 A.M., Nurse #4 gave Resident #16 a cup of juice, said do not throw it at anyone, and walked away On 12/13/23 at 1:01 P.M., Resident #16 open hand slapped Resident #62, who had been standing beside his/her chair in the 1 [NAME] Unit dining room for approximately 3 minutes. The staff redirected the peer that had been slapped, however, they failed to implement the plan of care and Approach/speak in a calm manner. Divert attention. remove from situation and take to alternate location as needed. During an interview on 12/13/23 at 2:25 P.M., CNA #3 said that he was not aware that Resident #16 had thrown a cup at a peer the day prior or that he/she had struck Resident #62 at lunch that day. CNA #3 said that the nurse should have let me know. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that she was notified at lunch about Resident #16 striking Resident #62 but hasn't had a chance to look into it yet. During an interview on 12/15/23 at 11:52 A.M., with the DON she said that she has not yet spoken with staff and obtained statements regarding what occurred in either incident of Resident #16 aggressing at peers on 12/12/23 or 12/13/23. During a follow-up interview on 12/19/23 at 11:27 A.M., with the DON and NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 4. Resident #28 was admitted to the facility in July 2023 and had diagnoses that include severe dementia with anxiety and insomnia. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/19/23, indicated Resident #28 was assessed by staff to have had severely impaired cognition. The MDS further indicated Resident #28 had hallucinations, delusions or behaviors. Review of the most recent Licensed Monthly Summary, dated 10/25/23, indicated Resident #28 had no behaviors. Review of the most recent Psychiatric Evaluation, dated 11/10/23, indicated the following Assessment/Plan: * Dementia with behaviors-behaviors have been stable since admission, adjusting to facility, is calm and cooperative, accepts meds, participates in activities, stable appetite, and sleeping well. Has not exhibited any new or worsening signs of psychosis, mania, delusions, A/VH, or voiced any suicidal, self injurious, other injurious ideas, intentions, plans or action at this time. * Insomnia-well managed on Trazadone at bedtime, no signs of worsening insomnia or NOC restlessness. During an interview on 12/12/23 at 8:08 A.M., Resident #28 told the surveyor I had a terrible night last night, a man came in my room, I was in bed, and he sat at the end of my bed and wouldn't leave. Resident #28 said that finally they removed the man but that he/she let them know that he spit at me, and that they wiped Resident #28 down and got the spit off of him/her. On 12/12/23 at 8:36 A.M., the surveyor overheard Resident #28 tell Nurse (#4) that the guy came to my room last night and spit on me. Nurse #4 told Resident #28 that she would keep an eye on it and make sure he doesn't come back. On 12/12/23 at 9:13 A.M., the surveyor overheard Resident #28 tell the Activity Staff #1 about the man that came in his/her room the previous night and spit on him/her. The Activity Assistant #1 told Resident #28 we will make sure it doesn't happen again and walked away. During an interview on 12/13/23 at 12:18 P.M., with Nurse #4 she acknowledged that the previous morning Resident #28 had told her that a man came in his/her room and spit on him/her. Nurse #4 said to the surveyor that was a delusion and that Resident #28 has a history of abuse and having a man break into his/her home. Nurse #4 said that this is the first time Resident #28 said that someone spit on him/her, but that she attributes it to the abuse history and that when Resident #28 makes allegations she will redirect him/her like she did yesterday. During an interview on 12/13/23 at 3:06 P.M., with Nurse Supervisor #1 she said that she had not been made aware of Resident #28's allegation, so no investigation had been started. Nurse Supervisor #1 added that if it was not witnessed we cannot 100% believe that happened. During an interview on 12/13/23 at 3:58 P.M., with the DON and NHA the surveyor discussed concerns that had been identified and observations that had been made during the survey process regarding the implementation of the facility's abuse policy. The DON said that Resident #28's allegations of abuse should be looked into. During an interview on 12/19/23 at 11:27 A.M., with the DON and the NHA, the NHA said I would say that there is a problem with reporting and abuse in the facility. 5. Resident #11 was admitted to the facility in September 2022 and had diagnoses that include dementia with agitation. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/14/23, indicated Resident #11 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #11 was totally dependent on staff for care. On 12/12/23 at 12:13 P.M., the surveyor observed a fading purple and yellow, quarter sized bruise on the left side of Resident #11's forehead. Resident #11 said that he/she did not know how he/she sustained the bruise. During an interview on 12/15/23 at 11:01 A.M., with Resident #11's Certified Nursing Assistant (CNA) #3 he said that he noticed that Resident #11 had a bruise on his/her forehead on Wednesday, 12/13/23. CNA #3 said that he did not tell Nurse (#4) because he figured she was aware. The surveyor and CNA #3 observed the bruise on Resident #11's head together and he asked Resident #11 how he/she got the bruise. Resident #11 said he/she didn't know. During an interview on 12/15/23 at 11:07 A.M., with Resident #11's Nurse #4 she said she observed the bruise for the first time the afternoon prior when observing Resident #11 with another surveyor and has no idea how Resident #11 got it. Nurse #4 could not explain why she had not noticed the bruise sooner as she had been Resident #11's nurse on 12/12/23 and 12/13/23. Nurse #4 said that she had not yet notified Nurse Supervisor #1 or the Director of Nursing about the bruise, and had not initiated an investigation into this bruise of unknown origin. She said that a full skin assessment should have been done when the bruise had been identified but she had not done one yet. During an interview on 12/15/23 at 11:18 A.M., Nurse Supervisor #1 said that staff should have reported the bruise to her immediately and began an investigation, including starting an incident report, getting statements from staff, and a full skin check. She said that she would then have notified the Director of Nursing because a bruise of unknown origin should be reported. During an interview on 12/15/23 at 11:53 A.M., the Director of Nursing said that she does not recall if she was aware that Resident #11 had a bruise of unknown origin and that she had not started an investigation. During a interview on 12/19/23 at 11:27 A.M., with the DON and Nursing Home Administrator (NHA), the NHA said I would say that there is a problem with reporting and abuse in the facility.

Based on observation, interviews, record and policy reviewed for one Resident (#13) out of a total sample of 29 residents, the facility failed to ensure residents with a history of trauma received trauma informed care in accordance with professional standards. Specifically, the facility failed to implement Resident #13's trauma-informed plan of care which indicated he/she should have female care givers for personal care. Findings included: Review of the facility policy titled, Trauma Informed Care, revised 10/22/22, indicated to ensure residents, who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice which are culturally-competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -Care Planning: 1. The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions. 3. Care plans should have interventions that minimize or eliminate the effect of known triggers. a. If triggers are unknown/unreported facility should multiple [sic] ways to identify resident triggers. 4. Trigger-specific interventions should identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Resident #13 was admitted to the facility in April 2023 with diagnoses including dementia with severe psychotic disturbance, bipolar disorder and major depression. Review of the Minimum Data Set (MDS) assessment, dated 10/12/23, indicated Resident #13 was unable to complete the Brief Interview of Mental Status (BIMS) exam and was assessed by staff to have severely impaired cognition. Resident #13 experienced hallucinations and delusions. Resident #13 experienced wandering 4 to 6 days and physical and verbal behaviors 1 to 3 days. The MDS also indicated Resident #13 was dependent on staff for bathing, toileting and personal hygiene. The MDS indicated Resident #13 required supervision or touching assistance with ambulation. Review of the physician's order, dated 4/7/23, indicated: -Activate Heath Care Proxy Review of the plan of care related to related to care, dated 4/17/23, indicated: Focus: -History of being a victim of a traumatic event related to sexual assault when he/she was in his/her early 20's. Son reports no known triggers but he/she should have female staff providing all personal care. Intervention: -Female staff for all personal care Review of the 7:00 A.M. to 3:00 P.M. First Floor Assignment, dated 12/13/23, indicated five of five Certified Nurse Assistants (CNA) assigned to work were male. Review of the Documentation Survey Report v2 (Activities of Daily Living flow sheets), dated November 2023 and December 2023, indicated Resident #13 had a male caregiver for bathing and toileting hygiene on the following days: 11/2/23 3:00 P.M. to 11:00 P.M., 11/3/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/4/23 3:00 P.M. to 11:00 P.M., 11/6/23 7:00 A.M. to 3:00 P.M., 11/7/23 3:00 P.M. to 11:00 P.M., 11/8/23 7:00 A.M. to 3:00 P.M., 11/9/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/12/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/13/23 7:00 A.M. to 3:00 P.M., 11/14/23 7:00 A.M. to 3:00 P.M., 11/17/23 3:00 P.M. to 11:00 P.M., 11/18/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/19/23 7:00 A.M. to 3:00 P.M., 11/20/23 7:00 A.M. to 3:00 P.M., 11/23/23 3:00 P.M. to 11:00 P.M., 11/24/23 3:00 P.M. to 11:00 P.M., 11/25/23 3:00 P.M. to 11:00 P.M., 11/26/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/27/23 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M., 11/28/23 3:00 P.M. to 11:00 P.M., 11/29/23 7:00 A.M. to 3:00 P.M., 11/30/23 3:00 P.M. to 11:00 P.M., 12/1/23 3:00 P.M. to 11:00 P.M., 12/2/23 3:00 P.M. to 11:00 P.M., 12/3/23 3:00 P.M. to 11:00 P.M., 12/4/23 7:00 A.M. to 3:00 P.M, and 3:00 P.M. to 11:00 P.M., 12/5/23 3:00 P.M. to 11:00 P.M., 12/6/23 3:00 P.M. to 11:00 P.M., 12/7/23 7:00 A.M. to 3:00 P.M, 12/8/23 7:00 A.M. to 3:00 P.M, 12/10/23 7:00 A.M. to 3:00 P.M, 12/12/23 7:00 A.M. to 3:00 P.M, and 3:00 P.M. to 11:00 P.M., Review of the incident note, dated 12/11/23 at 16:41, indicated Resident #13 appeared agitated during meals throwing food on the walls and at staff CNA during breakfast, Staff CNA and this LPN encouraged and redirected with no success. Resident then ambulated with assistance with staff CNA to his/her room to rest. Resident seen hitting the walls and tables with his/her hands and fists. Resident throwing sheets and bed spread on the floor. Resident then redirected to the dining room to participate in activities. Aggressive behavior continued and was resistive to ADL care. Resident then seen by this Nurse with discoloration on the right cheek. Review of the behavior note, dated 12/12/23 at 8:43, indicated Resident #13 is alert, responsive with confusion at baseline. Denies pain or discomfort. Resident continues with extreme behaviors, getting up in the middle of the night going to other residents room, sitting on their beds, waking them up. Staff continue to provide frequent rounds, assist resident to use the bathroom and redirect resident back to his/her room with fair effect. Review of the incident note, dated 12/12/23 at 13:59, indicated Resident #13 ambulated by staff CNA to the dining room for breakfast. Resident began hitting his/her hand on the table and displaying aggressive behavior. Staff then redirected resident back into his/her room to administer 1:1 feed with good effect. Review of the psychiatric consult note, dated 12/14/23, indicated, asked to see Resident #13 with history of bipolar disorder, dementia with behaviors, depression, and delirium due to worsening aggression, agitation, combativeness, and other behaviors. Has had multiple med adjustments as result of labile behaviors. Review of the order note, dated 12/14/23, indicated new psych recommendation to increase Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg) twice daily to Seroquel oral tablet 37.5 mg twice daily. On 12/13/23 at 8:15 A.M., Certified Nurse Assistant (CNA) #1, a male, was observed bringing Resident #13 into the bathroom. Two minutes later, CNA #1 and Resident #13 left the bathroom. CNA #1 said that Resident #13 requires toileting before meals and is resistive to care. During an interview on 12/13/23 at 8:00 A.M., Nurse #3 said Resident #13 has lots of behaviors and he/she shakes and can be combative and resist care. Nurse #3 said that Resident #13 will make fists like he/she is going to hit someone and recently required an increase in his/her antipsychotic medication for behavior management. Nurse #3 said that Resident #3 can have both male and female care givers. During an interview on 12/13/23 at 8:19 A.M., CNA #3 said there were only males assigned to work on the 7:00 A.M. to 3:00 P.M. shift on 12/13/23. CNA #3 said there are no residents who require female only care givers. During an interview on 12/14/23 at 6:58 A.M., Nurse #2 said there are no residents who require female care givers only on the first floor unit. During an interview on 12/14/23 at 2:29 P.M., Nurse Supervisor #1 said she is not aware of any residents on the first floor who require female care givers only. During an interview on 12/15/23 at 9:35 A.M., the Director of Nursing (DON) and Administrator said that Resident #13's trauma informed care plan should be followed. The Administrator continued to say that he was not sure if this was still an active problem and wasn't sure if female caregivers was still Resident #13's preference. During an interview on 12/15/23 at 11:55 A.M., Resident #13's activated Health Care Agent said that Resident #13 was a sexual assault victim. Additionally, the Health Care Agent said Resident #13 was sexually assaulted in his/her previous nursing home by a male. The Health Care Agent said that Resident #13 should only have female caregivers and the Health Care Agent is concerned that Resident #13 would strike a male if he got too close. During an interview on 12/15/23 at 12:27 P.M., the Social Worker reviewed Resident #13's care plan with the surveyor and said that Resident #13 should only have female CNAs. Using the reasonable person concept, an individual with a known history of sexual assault by a male, and who is unable to articulate or verbalize his/her concerns and trauma, would experience emotional distress when being cared for by men.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that the facility does not have enough staff to supervise the dining rooms. She said that this is a dementia facility, and we need more staffing than a traditional nursing facility. Nurse Supervisor #1 said weekends are particularly low staffing and that I tell the staff if there aren't enough staff on, then feed resident's 50%, then move onto the next person because at least they got something in them. During an interview on 12/13/23 at 3:58 P.M., with the Director of Nursing (DON) and Nursing Home Administrator (NHA) the surveyors inquired, based on what had been observed thus far in the survey process, if the staff to resident ratio was sufficient given the volume of resident-to-resident altercations and lack of required supervision at meals. The NHA said that he was not sure, and the DON said that they often are not able to meet the safe level they have determined through their facility assessment. During a follow-up interview on 12/15/23 at 1:15 P.M., the surveyors again addressed concerns regarding staffing as it relates to resident safety, supervision and assistance with meals with the DON and NHA. They said that part of the problem was that the facility's ownership had not paid one of their staffing agencies and that the agency therefore wouldn't send staff to the facility. The NHA said that ownership was cutting the agency a check that day and that the agency would assist to staff the facility adequately that coming weekend. On Monday 12/18/23, review of the weekend staffing indicated that despite reassurance from the NHA that the staffing would be sufficient over the weekend, it still remained considerably less than directed by the facility assessment. The facility assessment indicates staffing for CNA's each day, based on the census should be 85.68 hours on the 7-3 and 3-11 shift: * On Saturday 12/16/23, there were 72 hours of CNAs on the 7-3 shift and 64 hours on the 3-11 shift. * On Sunday 12/17/23, there were 80 hours of CNAs on the 7-3 shift and 72 hours on the 3-11 shift. SEE F600, F607, F689, F699 Based on observations, record review and interview, the facility failed to 1.) ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs and to timely assist residents with dining needs on 4 of 4 units and 2.) failed to ensure 2 Residents (#54 and #64) were provided with assistance, as needed, for meals. Findings included: During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for Fiscal Year (FY) Quarter 4 2023 (July 1- September 30th) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. During an interview on 12/18/23 at 9:02 A.M., the Director of Nursing said that the facility does not accept clinically complex residents and all residents must have a diagnosis of dementia to be admitted . 1. The facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs and to timely assist residents with dining needs on 4 of 4 units Review of the facility assessment, dated as reviewed 1/16/23, indicated the following during a typical month: An average daily resident census of 93 with a facility capacity for 110 residents. Further review indicated that the daily number of Certified Nurse's Aides (CNA) required to care for residents in the facility is 27 full time equivalents (FTE's); 1.02 hours per resident per shift on the 7 A.M.- 3 P.M. and 3 P.M.-11 P.M. shifts and .407 hours per resident per shift on the 11 P.M.-7 A.M. shift. Further review failed to indicate if staffing levels change based on the acuity level of the residents and failed to indicate what the current acuity level of the residents is. Review of the staffing schedules dated 11/25/23, through 12/12/23, indicated the facility failed to ensure staffing levels for CNA's were maintained at the level their facility assessment indicated was needed to safely and adequately meet each resident's personal and cognitive care needs. Further review indicated the following: - On 7 A.M.-3 P.M. 11 out of the 18 shifts did not meet the required number of hours. - On 3 P.M.-11 P.M. 17 out of the 18 shifts did not meet the required number of hours. - On 11 P.M.-7 A.M. 14 out of the 18 shifts did not meet the required number of hours. 2. The facility failed to ensure 2 Residents (#54 and #64) were provided with assistance, as needed, for meals. a.) Resident #54 was admitted to the facility in October 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and Alzheimer's. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/20/23, indicated that Resident #54 scored 0 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS indicated that Resident #54 requires verbal cues or touching assistance with eating. Review of the care plan, dated as revised 10/17/23, indicated that Resident #54 requires assistance/ potential to restore function to maximum self-sufficiency for eating related to: cognitive deficits related to dementia, easily distracted. On 12/15/23 at 12:25 P.M., the surveyor observed Resident #54 in her/his room, sitting in a chair eating her/his meal. The surveyor also observed that no staff member was in the room assisting the Resident. b.) Resident #64 was admitted to the facility in November 2022 with diagnoses including dysphagia, dementia and hallucinations. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #64 scored 2 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Further review indicated that Resident #64 requires verbal cues or touching assistance with eating. Review of the care plan, dated as revised 11/11/22, indicated that Resident #64 requires limited assistance from staff to eat. On 12/15/23, at 12:25 P.M., the surveyor observed Resident #64 in her/his room, sitting in a chair eating her/his meal. The surveyor also observed that no staff member was in the room. During an interview on 12/13/23, at 2:18 P.M., CNA #9 said that continual supervision means that someone has to watch the resident at all times. CNA #9 then said that it is everyone's responsibility, but there is not enough staff because almost everyone requires cues and supervision and there is just not enough staff. CNA #9 then said that we leave some of the heavier care residents in bed when we don't have enough staff, we can't do it all. CNA #9 said that there are not enough activities for the residents which makes it much harder to care for everyone because the residents wander around and it's not safe. During an interview on 12/13/23 at 2:31 P.M., CNA #8 said it is really difficult to supervise everyone in the dining room because we are so short staffed. She continued to say that especially on the weekends we are very short staffed, sometimes there are only two CNA's on the second floor, we have to leave dependent residents in bed because we don't have the staff to feed everyone so they have to eat late. Ever since the new company took the building over it seems like they are not hiring. During a follow-up interview on 12/19/23 at 10:49 A.M., CNA #8 said there are not enough staff in the building and the residents are suffering from it. CNA #8 said we cannot provide as many showers to the residents as we should be. She continued to say that residents are always waiting to be fed because they need to wait for us to finish assisting other residents with meals, dependent residents are unable to be fed at the same time. During an interview on 12/13/23 at 2:15 P.M., Nurse #6 said we are short staffed, so it is hard to always supervise residents during meal time. During an interview on 12/14/23 at 6:59 A.M. Nurse #2 said that staffing is short on the weekends. He said they typically run on the evening shift with 3 or 4 CNAs and need at least 5. Nurse #2 said when staffing is bad they leave non ambulatory residents in bed for meals. He said nurses are taken away from their medication pass and nursing duties to assist with feeding.

Based on interview and record review, including review of the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring the facility was sufficiently staffed per the Facility Assessment; 2. ensuring quality of care related to abuse was maintained for one Resident (#62); and 3. ensuring quality of care related to safety & hazards in the facility was maintained for two Residents (#30 and 35) out of a total sample of 29 residents. Findings include: Review of the Facility Assessment, dated as reviewed with the QAPI committee, 06/01/23, indicated that the Governing Body included, but was not limited to, the Administrator, Director of Nursing (DON), Assistant Director of Nursing, the Chief Operating Officer and the Medical Director. 1. During an interview on 12/12/23 at 9:37 A.M., with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the DON said that the facility had not had most key staff positions in place since she started in February of 2023. The DON said that this included lack of a staff educator or Infection Preventionist nurse until this past month. On day 2 of the survey the Staff Educator/Infection Preventionist nurse quit. During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for Fiscal Year (FY) Quarter 4 2023 (July 1- September 30th) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. During an interview on 12/13/23 at 12:21 P.M., the Staff Development Coordinator (SDC) said that she was unable to locate any documentation that the staff had received any dementia training for the year 2023. During an interview on 12/13/23 at 2:31 P.M., Certified Nursing Assistant (CNA) #8 she said that ever since the new company took over last year (December 2023) we don't have any support and it feels like they are not hiring anyone. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor (#1) she said that the facility does not have enough staff to supervise the dining rooms. She said that this is a dementia facility and we need more staffing than a traditional nursing facility. Nurse Supervisor #1 said weekends are particularly low staffing and that I tell the staff if there aren't enough staff on, then feed resident's 50% then move onto the next person because at least they got something in them. During an interview on 12/13/23 at 3:58 P.M., with the Director of Nursing (DON) and Nursing Home Administrator (NHA) the surveyors inquired, based on what had been observed thus far in the survey process, if the staff to resident ratio was sufficient given the volume of resident to resident altercations and lack of required supervision at meals. The NHA said that he was not sure and the DON said that they often are not able to meet the safe level they have determined through their facility assessment. During an interview on 12/14/23 at 11:45 A.M., with the Director of Nursing (DON) she said Corporate was not assisting her with getting support for the vacant positions, they just say there are no applications coming in. The DON said that she had only seen the Corporate Nurse once since she started in February 2023 and that she cannot get her DON duties done because there's no help. During a follow-up interview on 12/15/23 at 1:15 P.M., the surveyors again addressed concerns regarding staffing as it relates to resident safety, supervision and assistance with meals with the DON and NHA. They said that part of the problem was that the facility's ownership had not paid one of their staffing agencies and that the agency therefore wouldn't send staff to the facility. The NHA said that ownership was cutting the agency a check that day and that the agency would assist to staff the facility adequately that coming weekend. During the Recertification survey, newly hired employees and their education records were requested. A total of 20 new employees, including the Director of Nurses and Nursing Home Administrator, had been identified as being hired since January of 2023. The facility was unable to provide documentation that 10 of the 20 new hires had the required dementia training. During an interview on 12/18/23, at 9:20 A.M., the Human Resource Director (HR) said that no annual reviews have been completed since the change of ownership on 12/15/22, and she was not able to locate any annual reviews for the eight employee records the surveyor requested. The HR Director also said that she could locate only one of the 8 yearly staff competencies requested and that it was completed the day before on 12/17/23. Review of the staffing schedules dated 11/25/23, through 12/12/23, indicated the facility failed to ensure staffing levels for CNA's were maintained at the level their facility assessment indicated was needed to safely and adequately meet each resident's personal and cognitive care needs. Further review indicated the following: 1. 7 A.M.-3 P.M. 11 out of the 18 shifts did not meet the required number of hours. 2, 3 P.M.-11 P.M. 17 out of the 18 shifts did not meet the required number of hours. 3. 11 P.M.-7 A.M. 14 out of the 18 shifts did not meet the required number of hours. 2. Resident #62 was admitted to the facility in March 2023 and has diagnoses that include dementia, anxiety and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/07/23, indicated that Resident #62 was assessed by staff to have had severely impaired cognition. The MDS further indicated Resident #62 had behavior of wandering in 4 to 6 of the last 7 days of the assessment period. During survey Resident #62 was involved in the following resident to resident altercations in the 1 [NAME] Unit dining room: * On 12/12/23 at 8:31 A.M., Resident #44 punched Resident #62 in the arm. The surveyor witnessed the incident and immediately notified facility staff. * On 12/13/23 at 1:01 P.M., Resident #16 open handed slapped #62 on the hand. The surveyor and a facility staff member witnessed the incident. * On 12/18/23 at 12:18 P.M., Resident #16 open handed slapped #62 on the shoulder. The surveyor witnessed the incident and immediately notified facility staff. The facility neglected to investigate each incident timely, resulting in continued episodes of abuse to Resident #62. 3. For Resident #30, with a diagnosis of dysphagia (difficulty chewing and swallowing), the staff failed to provide continual supervision during breakfast in the 1 [NAME] Unit dining room on 12/12/23, and Resident #30 ate pieces of his/her paper meal ticket. Following the staff becoming aware of this behavior, and the facility stating that all paper would be removed from Resident #30's tray at meals, Resident #30 continued to be served paper products for three additional meals and the continual supervision was not provided at that time. For Resident #35, during lunch in the 1 [NAME] Unit dining room on 12/13/23, the staff failed to provide the required assistance with meals and Resident #35 ate part of a napkin and continued to accidentally push a napkin into his/her mouth and chew on it while attempting to self feed him/herself food. During an interview on 12/13/23 at 3:13 P.M., with the Nurse Supervisor #1 she said that the facility does not have enough staff to supervise the dining rooms. During an interview on 12/13/23 at 2:15 P.M., Nurse (#6) said we are short staffed, so it is hard to always supervise residents during mealtime. During an interview on 12/13/23 at 2:31 P.M., Certified Nursing Assistant (CNA) #8 said it is really difficult to supervise everyone in the dining room because we are so short staffed. See F725, F600, F689