**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to honor a resident's rights to make her own healthcare decisions for end-of-life care for one (1) of 24 residents reviewed for advanced directives. Resident #3 Findings include: Record review of the facility policy titled, Advance Directives with a revision date of 9/2022 revealed The resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Facility will inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment at the resident's option and to formulate an Advanced Directive. Record review of the Physician Statement of Status of Mental Capacity of Resident dated 1/23/24 revealed that the physician checked Competent, revealing that the resident was able to make her own decisions. Record review of the DNR (Do Not Resuscitate)/Full Code Request and Consent form dated 1/23/24 revealed Resident #3 had not signed her consent form and that it was signed by a family member. In an interview on 2/04/25 at 3:00 PM, Resident #3 revealed she could make her own decisions, and when she was admitted to the facility, no one talked with her about her end-of-life wishes. She revealed her niece had already signed all the paperwork and she did not sign her own Advance Directive. She stated, I had my legs cut off, not my brain, and revealed no one had gone over the paperwork with her. An interview on 2/04/25 at 3:31 PM, with the admission Nurse revealed that she met with the family and had the paperwork signed prior to the resident's admission. She revealed that their physician also sees the resident prior to admission and deems the resident competent or non-competent in determining whether they can sign their own paperwork. She revealed Resident #3 was deemed competent; however, the niece signed the Advance Directive instead of the resident. She revealed that Resident #3 was able to make her own decisions and should have been given the opportunity to make her own decisions regarding her Advance Directive. An interview on 2/05/25 at 9:40 AM, the Administrator revealed that if a resident is able and competent to sign their own advance directive, the facility should go over the paperwork with the resident and allow them to sign. Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease with Heart Failure, Cerebral Infarction, Acquired absence of right leg below the knee, and Acquired absence of left leg above the knee. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/6/25, revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #3 was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to accurately complete Section A of the Minimum Data Set (MDS) for a resident with a serious mental illness (SMI) for one (1) of 21 MDS reviewed. Resident #23 Findings Include: Review of the facility policy titled Accuracy of Assessments unrevised revealed, The facility must ensure the assessment represents accurately the resident's status during the observation/look back period. The assessment must be reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Record review of the Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 11/02/16 revealed under, Mental Health: The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary a diagnosis of Schizophrenia, paranoid type and under, Axis I secondary a diagnosis of Psychotic disorder. Record review of the Annual MDS with an Assessment Reference Date (ARD) of 4/18/24, revealed under, section A1500, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? No was marked. An interview with the MDS Nurse on 2/04/25 at 3:10 PM confirmed, Resident #23 had a SMI and revealed the MDS was not coded correctly. She explained that she kept a list of the residents that had a Level II but must have overlooked it. The MDS Nurse revealed the purpose of having an accurate assessment was for the staff to provide the best possible care for the residents. An interview with the Administrator on 2/5/25 at 11:36 AM, revealed her expectations were for the MDS to be checked and submitted accurately, so the residents get the best quality of care for mental health. Record review of the admission Record revealed the facility admitted Resident #23 on 10/12/16 with medical diagnoses that included Paranoid Schizophrenia, Unspecified Psychosis and Hallucinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review and facility policy review the facility failed to report an allegation of abuse when a resident reported that a Certified Nursing Assistant (CNA) balled up her fist, placed her knuckles into the resident's thigh and twisted for one (1) of eight (8) residents reviewed for abuse. Resident #1. Findings include: Record review of the facility policy, titled Freedom from Abuse, Neglect and Exploitation revealed, It is the policy of the facility to provide services based on the following requirement .Reporting of Alleged Violations .The facility will ensure that all alleged violations involving abuse .are reported immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the Administrator of the facility and State Survey Agency, Adult Protective Services and local law enforcement in accordance with state law . A record review of the facility Resident Incident Report for Resident #1, dated 5/26/24 and completed by Licensed Practical Nurse (LPN) #1, revealed that on 5/26/24, Resident #1 reported that CNA #2, who changed her on the previous shift balled up her fist and placed her knuckles into her thigh and twisted, and pointed at her left thigh. A record review of a witness statement from CNA #1, dated and timed 5/26/24 at 1:10 AM, revealed that Resident #1 told her that on 5/26/24 at 10:30 PM, the CNA took her knuckle and pushed it into the back of her left thigh. In an interview with Resident #1 on 6/3/24 at 2:06 PM, stated that she could not remember the day but when CNA #2 was turning her to clean her up it felt like she was pushing her in the thigh with her fist. During a telephone interview with LPN #1 on 6/3/24 at 2:45 PM, she confirmed that on 5/26/25 around 1:15 AM, CNA #1 informed her that Resident #1 stated that on the previous shift CNA #2 balled up her fist and placed her knuckles into her thigh and twisted. LPN #1 stated that she followed-up with Resident #1 and the resident verified that CNA #2 balled up her fist, placed her knuckles into her thigh and twisted. She stated that she was concerned about the report from the resident and notified the on-call Registered Nurse (RN) because it was an allegation of abuse. In an interview with RN #1 on 6/3/24 at 3:15 PM, she verified that she was the on-call RN on 5/26/24. She stated she received notification from LPN #1 on 5/26/24, of Resident #1's allegation of CNA #2 balling up her fist, placing her knuckles into her thigh and twisting. She stated that on 5/26/24 at 6:00 AM, Resident #1 told her that CNA #2 had come into the room to clean her up and asked her to grab the rail and hold herself. Resident #1 then told RN #1 that she felt CNA #2's fist smash into her left thigh. RN #1 stated that she notified the Administrator and Director of Nursing (DON) immediately because Resident #1's statement was an allegation of abuse. On 6/3/24 at 3:25 PM, during an interview with the DON, she verified that she received a report of Resident #1's allegation from RN #1 on 5/26/24. She stated that the facility did not report Resident #1's complaint of CNA #2 balling up her fist, placing her knuckles into her thigh and twisting because the resident has a history of making false accusations and on completion of their investigation, they could not validate the incident occurred. The DON agreed that Resident #1's complaint should have been considered an allegation of abuse and should have been reported as such. In an interview with the Administrator on 6/3/24 at 4:30 PM, she stated that Resident #1's complaint was not reported because they did not feel it was an allegation of abuse. A record review of the Face Sheet for Resident #1 revealed that the facility admitted the resident on 1/23/2017 with a diagnosis of Flaccid Hemiplegia affecting left non-dominant side. A record review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of Resident #62's Care Plans revealed a care plan was not developed for the PICC line maintenance. An interview with Registered Nurse (RN) #2 on 7/20/23 at 8:35 AM, confirmed that Resident #62 did not have a care plan for PICC line care. She stated, No ma'am, it's not in there; That's what I'm working on now. She revealed the purpose of developing and implementing a care plan was to make sure that the care was done and individualized to that resident. Record review of Resident #62's Electronic Medication Administration Record (eMAR) revealed an order dated 6/21/23 to flush the PICC line in the left arm with 10 cubic centimeters (CC) of normal saline (NS) before and after each antibiotic. Record review of the Face Sheet revealed Resident #62 was admitted to the facility on [DATE] with medical diagnoses that included Benign Prostatic Hyperplasia, Unspecified Systolic Congestive Heart Failure and Unspecified Atrial Fibrillation. Resident #69 Record review of Resident #69's care plan dated 7/13/23 revealed under intervention, 1200 cc (cubic centimeters) fluid restriction. Dietary to provide 720 cc. Nursing to provide 480 cc with med pass. On 7/18/23 at 4:45 PM, an interview with the DON confirmed that the facility did not monitor or document Resident #69's fluid intake on the Medication Administration Record (MAR) or Activities of Daily Living (ADL's) record. An interview with RN #2 on 7/19/23 at 2:10 PM, revealed the purpose of the care plan was to tell staff what the problem was with the resident and how to address it. She confirmed that staff did not follow the fluid restriction care plan for Resident #69. She stated, They wouldn't know the resident was on a fluid restriction. An interview with the DON on 7/19/23 at 2:30 PM confirmed that Resident #69's care plan was not followed for the fluid restriction and acknowledged that it should have been. An interview with the Assistant Director of Nursing (ADON) on 7/20/23 at 8:40 AM, revealed the purpose of the care plan was to determine what kind of care the resident was to receive. She confirmed that by not developing or implementing the care plan, the facility may fail to provide the care that was needed. Record review of the Face Sheet for Resident #69 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Systolic Congestive Heart Failure, Hypokalemia, and Major Depressive Disorder. Based on observations, staff interview, record review and facility policy review the facility failed to implement a care plan for shaving for Resident #26, failed to develop a care plan for maintaining a PICC (peripherally inserted central catheter) line for Resident #62, and failed to implement a care plan for fluid restriction for Resident #69. This was for three (3) of 19 care plans reviewed. Findings include: Review of the facility policy titled Develop/Implement Comprehensive Care Plan with a revision date of September 2022 revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights and that includes measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required . 4. The resident's goals for admission and desired outcomes Resident #26 Record review revealed the resident had a care plan with problem onset date of 9/24/2015, Requires assistance with ADL's (Activities of Daily Living) due to DX (diagnoses) of Parkinson, Decreased Muscle Strength, Impaired Mobility, and Decreased Bed Mobility .Approaches .Assist with ADL's as needed . An observation of Resident #26 on 07/17/23 at 11:39 AM revealed she was sitting up in her wheelchair in the day room with a patch of white hair on both sides of her chin that is approximately 1/4 inch wide and approximately 1/4 inch long. An interview on 7/20/23 at 8:30 AM, with the Administrator and the Corporate Administrator confirmed that the residents Activities of Daily Living (ADL) care plan was not being implemented since the resident had hair on her chin and needed to be shaved. Record review of Resident #26's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia without Behavioral Disturbance. Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 5/29/23 revealed in Section G that the resident required total dependence with bathing and in Section C a Brief Interview for Mental Status (BIMS) score of three (3), which indicates the resident is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, record review and facility policy review the facility failed to flush a residents PICC (peripherally inserted central catheter) line for (1) one of (7) seven residents reviewed during medication observations. Resident #62. Findings include: Review of the facility policy titled Central Venous Catheter Procedures PICC/Central Venous Line Dressing and Caps (needleless connector) Change and Care policy revealed under, Policies and Guidelines . Flush PICC line every 12 hours or as ordered by physician . An observation and interview on 7/19/23 at 10:56 AM, with Resident #62 revealed a PICC line to his left upper arm with a dressing intact. Resident #62 revealed he went to the doctor recently and the device was flushed, but they do not flush it here at the facility. Record review of the July 2023 Medication Administration Record (MAR) for Resident #62 revealed an order dated 6/21/23, Normal Saline Flush 1 ML (milliliter) SYR (syringe) flush PICC (peripherally inserted central catheter) line left arm with 10 cc (cubic centimeters) normal saline before and after each antibiotic with a stop date of 7/04/23. Record review of the Physician Orders for the month of July 2023 revealed an order dated 6/22/23, PICC (peripherally inserted central catheter) line left arm sterile dressing change every 7 days: Sterile gloves clean gloves; mask; 4×4's; alcohol swabs occlusive dressing; Barrier for sterile field; An interview with the Assistant Director of Nursing (ADON) on 7/19/23 at 11:00 AM, revealed the resident was recently sent to the hospital for a blood transfusion. She revealed the Nurse Practitioner (NP) was waiting to see if the resident would require any further blood work or transfusions before removing the PICC line and she revealed that the resident had a follow-up appointment with the urologist on 7/17/23 and the NP wanted to leave the PICC line in place until that appointment. An interview with the ADON on 7/19/23 at 1:15 PM, revealed she was not aware that Resident #62's PICC line was not being flushed. She stated, We were flushing it. She revealed that the resident was receiving antibiotics for a UTI (urinary tract infection) and the PICC line flush order must have stopped when the antibiotic was completed on 7/04/23. She confirmed that they should be flushing it every day to maintain patency and prevent occlusion. An interview with the Director of Nursing (DON) on 7/19/23 at 1:30 PM, revealed she was not aware that Resident #62's PICC line was not being flushed every day. She stated, The order was entered with a stop date for when the IV antibiotic was completed. She revealed the NP wanted the line left in until he followed up with the Urologist. An interview with the NP on 7/19/23 at 1:45 PM, revealed the PICC line should still be flushed, and she stated, Yes, I didn't know that it wasn't, I can re-order that. She confirmed that flushing the PICC line could prevent the line from occluding. An interview with the DON on 7/19/23 at 2:00 PM, confirmed that Resident #62 should have an order to flush his PICC line and confirmed that by not doing this, the line could clot off. Record review of the Face Sheet revealed Resident #62 was admitted to the facility on [DATE] with medical diagnoses that included Benign Prostatic Hyperplasia, Unspecified Systolic Congestive Heart Failure and Unspecified Atrial Fibrillation. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 12, indicating resident #62 is moderately cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, resident interview, record review and facility policy review the facility failed to shave a resident that was dependent on staff for bathing and personal hygiene for one (1) of 74 residents reviewed during initial tour. Resident #26 Findings Include: Review of the facility policy titled Mississippi Care Center-ADL (Activities of Daily Living) Care Provided for Dependent Residents with a review date of 09/22 revealed, Residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . An observation on 07/17/23 at 11:39 AM, revealed Resident #26 sitting up in her wheelchair in the day room with a patch of white hair on both sides of her chin that is approximately 1/4 inch wide and approximately 1/4 inch long. An interview and observation on 7/18/23 at 12:45 PM, with Certified Nurse Assistant (CNA) #2 revealed that Resident #26 is in an A bed and those baths are performed on Monday-Wednesday and Friday's. She stated that all personal hygiene care goes along with the resident's baths to include shaving. During an observation of Resident #26, CNA #2 confirmed that Resident #26 had hair on her chin and when the CNA asked the resident if she wanted it shaved off , the resident stated, If it's there then it needs to be off, I did not even know it was there CNA #2 confirmed that she should have been shaved and she would take care of it. An interview on 7/18/23 at 1:10 PM, with the Director of Nurses (DON) confirmed that female residents need to be shaved of facial hair when they have their baths unless the resident refuses. Record review of Resident #26's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia without Behavioral Disturbance. Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/29/23 revealed in Section G that the resident required total dependence with bathing and in Section C a Brief Interview for Mental Status (BIMS) score of 3, which indicates the resident is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review and facility policy review the facility failed to provide appropriate incontinent care treatment to prevent the potential for infection for one (1) of four (4) residents observed for care observations. Resident #21. Findings include: A review of the facility policy titled Incontinence, revised September 2022, revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. The Policy Explanation and Compliance Guidelines revealed: Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. An interview on 07/17/23 at 11:13 AM, with Resident #21 revealed she doesn't feel like they clean her good. On 7/19/23 at 8:02 AM, an observation of Resident #21's incontinent care with Certified Nursing Assistant (CNA) #1 revealed that she did not change gloves after setting up the wash basin. CNA #1 wet a bath cloth, wiped across the resident's lower abdomen and groin areas. She then placed the contaminated bath cloth back in the clean water basin and wiped more than one area with the same area of the bath cloth. An interview on 07/19/23 at 09:45 AM, with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 regarding the incontinent care process, LPN #1 stated that the staff should clean with a different area of the bath cloth from top to bottom with one swipe with each different location. RN #1 stated that CNA #1 should have used two basins. An interview on 07/19/23 at 10:00 AM, with CNA #1 regarding incontinent care confirmed that she put the dirty bath cloth back into clean water and contaminated the clean water and she should not wipe more than once with the same area of the bath cloth. An interview on 7/20/23 at 9:50 AM, with the Director of Nursing (DON) confirmed staff does annual competency check offs but the staff does get nervous. A review of facility in-service records revealed that CNA #1 attended an in-service on incontinent care on 01/30/23 and successfully performed skills check off for incontinent care on 07/20/22. A review of the facility Face Sheet for Resident #21 revealed she was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Intracerebral Hemorrhage, and Needs assistance with personal care. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview, record review and facility policy review the facility failed to follow a physician prescribed fluid restriction for (1) one of (4) four residents on dialysis. Resident #69 Findings include: Review of the facility policy titled Fluid Restriction policy dated 12/13/2018 revealed, Fluid restriction orders will be carried out as ordered by the physician by the nursing and dietary departments 2. Fluids ordered for the resident will be divided between the Nursing and Dietary departments. 3. Fluids determined to be used by Dietary will be sent out on the meal tray. 4. All fluids given by the aides will be recorded in the resident's room on a fluid intake form. 5. Fluids determined to be used by nursing will be divided between their medication passes. 6. Fluids given by the nurses on medication passes are to be recorded on the eMAR (electronic medication administration record). 7. Fluid intake sheet will be totaled, and a 24-hour total entered on the eTAR (electronic treatment administration record). An observation and interview with Resident #69 on 7/18/23 3:15 PM, revealed that he did not have a water pitcher in his room. The resident revealed that he goes by his fluid restriction. He stated, Pretty much, I drink only what they bring me. Record review of the July 2023 Physician Orders revealed an order dated 6/06/23, 1200 cc (cubic centimeter) fluid restriction R/T (related to) ESRD (End Stage Renal Disease) Record review of the July 2023 Medication Administration Record (MAR) revealed Resident #69 did not have an order listed for fluid restriction or a monitoring tool to track fluid intake within a 24-hour period. An interview with the Director of Nursing (DON) on 7/18/23 at 4:15 PM, revealed that the aides would know not to give Resident #69 any fluids because he doesn't have a water pitcher in his room. An interview on 7/18/23 at 4:30 PM with Medical Records revealed that Resident #69's fluid restriction was not added on the Activities of Daily Living (ADL) task for the aides to document. An interview with the DON on 7/18/23 at 4:45 PM, confirmed that the facility did not monitor or document Resident #69's fluid intake on the MAR or ADL's. She confirmed that this should have been done, and that this could cause the resident to be in fluid volume overload. She also confirmed that they did not provide a breakdown of the total number of fluids that the resident should receive between nursing and the dietary department in a 24 -hour period. She stated, No, we didn't do it. An interview with Certified Nurse Aide (CNA) #3 on 7/19/23 at 8:00 AM, revealed she was able to identify if a resident was on a fluid restriction because the resident will not have a water pitcher in their room. She stated, The fluid restriction will be on their meal slip. She revealed that Resident #69 does go by his ordered fluid restriction. She stated, He may ask for 1/2 (one-half) cup of coffee in the mornings, and we have to check with the nurse before getting it. An interview with Registered Nurse (RN) #2 on 7/19/23 at 2:10 PM, revealed Resident #69 did not have an order for a fluid restriction on the MAR or ADL. She stated, They (the staff) wouldn't know the resident was on a fluid restriction because it's not on there (the ADL or MAR). An observation of Resident #69's Medical Record with the Minimum Data Set (MDS) on 7/20/23 at 9:15 AM, confirmed that the resident did not have a fluid restriction task on the ADL's. Record review of the Face Sheet for Resident #69 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Systolic Congestive Heart Failure, Hypokalemia, Gastro-Esophageal Reflux Disease Without Esophagitis, and ESRD. Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 7/07/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident #69 was unable to complete the BIMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to post an oxygen in use sign outside the door and to label oxygen tubing and a humidifier bottle for one (1) of four (4) residents reviewed that were receiving oxygen. Resident #21. Findings include: Record review of a procedure Nursing Department Infection Control undated, revealed .Respiratory Equipment: .Oxygen tubing .When not in use, store the mask/cannula in a plastic bag labeled with the resident's name and date . An observation on 07/17/23 at 11:11 AM, revealed, Resident #21's oxygen tubing and humidifier bottle were not labeled and dated. The cannula was laying on the floor underneath the overbed table. No oxygen in use signage was on the door. An observation and interview on 07/19/23 at 8:16 AM, with the Director of Nursing (DON) confirmed, Resident #21's oxygen tubing was laying on the floor and the oxygen tubing and humidifier water bottle was not labeled. The DON stated that the procedure should be to change tubing every seven days and that tubing should be labeled with time, date and initials. The DON stated that the water bottle on the concentrator should be changed every thirty days and should be labeled with time, date, and initials. The DON stated that the tubing should be stored in a plastic bag when not in use and should not be laying on the floor to prevent infection. The DON confirmed that there was not an oxygen sign on the door. A record review of the Physician Orders dated 07/17/23 revealed Oxygen at two (2) liters per minute by nasal cannula as needed. An observation and interview with Resident #21 on 07/19/23 at 04:30 PM, revealed the oxygen tubing and humidifier bottle remained unlabeled and the tubing was laying on the floor. Resident #21 stated she doesn't use it all the time, just when she thinks she needs it. A review of the facility Face Sheet revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Human Immunodeficiency Virus, Essential Hypertension and Cough. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and facility policy review the facility failed to prevent the possibility of infection as evidenced by failing to perform hand hygiene, provide a clean workspace, change gloves and keep oxygen tubing off the floor and in a plastic bag for one (1) of four (4) resident care observations. Resident #21 Findings include: A review of the facility policy titled Infection Control, revised September 2022, revealed: Staff involved in direct resident contact will perform hand hygiene (even if gloves are used). Hand hygiene is performed: After removing personal protective equipment (e.g., gloves, gown, facemask). Gloves changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. Oxygen tubing, when not in use, store the mask/cannula in a plastic bag labeled with the resident's name and date. An observation, on 07/17/23 at 11:11 AM, revealed Resident #21's oxygen tubing and humidifier bottle were not labeled and dated. The cannula was laying on the floor underneath the overbed table. , An observation and interview on 07/19/23 at 8:16 AM, with the Director of Nursing (DON) confirmed, Resident #21's oxygen tubing was laying on the floor. The DON stated that the tubing should be stored in a plastic bag when not in use and should not be laying on the floor to prevent infection. An observation on 07/19/23 at 08:24 AM, of incontinent care with Certified Nursing Assistant (CNA) #1 revealed, she set up a wash basin on the overbed table of Resident #21. There was an open container of juice, toothpaste, a comb, jewelry, and a contact case on the same table with the wash basin. CNA #1 did not change gloves after setting up the wash basin. CNA #1 wet a bath cloth and wiped across the resident's lower abdomen and groin areas and placed the contaminated bath cloth back in clean water basin and reused it. CNA #1 wiped more than once with the same area of the bath cloth and left the dirty bath cloth on the bed. CNA #1 positioned Resident #21 on her right side. CNA #1 then got a new bath cloth and did not change gloves. CNA #1 looked over resident #21's room for briefs touching items in drawers, touching furniture, the bed and the privacy curtain. CNA #1 then put on clean gloves without performing hand hygiene. CNA #1 then applied skin protectant, did not change gloves and then applied a clean brief to Resident #21. An interview on 07/19/23 at 09:45 AM, with Registered Nurse (RN)#1 and Licensed Practical Nurse (LPN) #1 regarding incontinent care process revealed, LPN #1 stated that gloves should be changed frequently, and staff's hands should be washed each time gloves are changed. LPN #1 stated that the staff should clean with a different area of the bath cloth from top to bottom with one swipe with each different location. RN #1 stated that CNA #1 should have used two wash basins. An interview on 07/19/23 at 10:00 AM, with CNA #1 confirmed she put the dirty bath cloth back into the clean water and contaminated the clean water. CNA #1 stated that there should not have been anything on the table with the basin and confirmed there was open apple juice and other items on the table. She stated that having the items on the table was an infection control problem. An interview on 7/20/23 at 9:50 AM, with the DON confirmed staff does annual competency check offs, but the staff does get nervous. Record review of the Face Sheet for Resident #21 revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Human Immunodeficiency Virus, Essential Hypertension and Cough. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

Based on facility policy review, resident interview, staff interviews, and record reviews, the facility failed to respect a resident's rights, as evidenced by a staff member calling a resident boy for one (1) of six (6) residents reviewed. Resident #1 Findings include: Review of facility policy titled, Resident Rights Policy/F550 Resident Rights/Exercise of Rights, with a revised date of 9/2022, revealed Facility will ensure the resident has the right to a dignified existence . Facility will treat each resident with respect and dignity . The facility will protect and promote the rights of each resident . An interview with the Ombudsman on 3/28/23 at 08:30 AM, revealed she had been involved with Resident #1 regarding his complaint of being called a boy by the Registered Nurse (RN) Supervisor on 2/10/23 and she noted that Resident #1 was very upset by the incident. An observation and interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he was called a boy by the RN Supervisor on 2/10/23. Residents #1 revealed he was getting off the second (2nd) floor elevator when the RN Supervisor asked him Where you going boy? Resident #1 noted he heard the RN Supervisor but did not respond. Resident #1 then revealed the RN Supervisor expressed You're on the wrong floor aren't you boy? Resident #1 stated that he responded after being called a boy the second time and cursed the RN Supervisor. He informed the RN Supervisor that he was a grown man and should be called Mr. or Sir. Resident #1 revealed he was very upset from being called a boy and did not feel as he was being respected by the RN Supervisor. An interview on 3/28/23 at 07:45 PM, with Social Services revealed she spoke with Resident #1 on 2/10/23 regarding the incident where the RN Supervisor called him a boy. She noted Resident #1 was noticeably upset and cursed often in his description of the incident. Social Services revealed Resident #1 was still upset about the incident on 2/12/23, as he continually expressed his feelings about it, and how it bothered him. An interview on 3/28/23 at 07:52 PM, with the RN Supervisor, confirmed he did call Resident #1 a boy on 2/10/23. He noted he patted Resident #1 on the shoulder and he said, You are on the wrong floor boy. He confirmed that Resident #1 became furious with him but could not remember everything Resident #1 said. He stated he did remember him expressing that he was a grown man and should not be called a boy. He also revealed that when Resident #1 became as mad as he did, he realized what he had done by calling Resident #1 a boy. He expressed that he had addressed Resident #1 incorrectly and should have called him Mr. An interview on 3/29/23 at 05:40 PM, with the Director of Nursing (DON) revealed that the RN Supervisor did report that he called Resident #1 a boy on 2/10/23 and confirmed that the RN Supervisor should have treated Resident #1 with dignity and respect by addressing him as Mr. or Sir. An interview on 3/29/23 at 06:35 PM, with the Former Administrator in Training (AIT) ,that was working at the facility during the time of the incident revealed that she did not feel that Resident #1's Resident Rights were violated because the RN Supervisor did not mean anything by calling Resident #1 a boy. She revealed it was done in a playful manner and was not intended to violate Resident #1. A telephone interview on 3/30/23 at 11:41 AM, with the Former Interim Administrator, that was working at the facility during the time of the incident confirmed that Resident #1's Resident Rights were violated by the RN Supervisor by calling Resident #1 a boy and not Mr. or Sir on 2/10/23. Record review of the Face Sheet for Resident #1 revealed an admission date of 12/1/21 and diagnoses that included Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on facility policy review, record review, resident interview, and staff interviews the facility failed to include a resident in the development of his person-centered Trauma Informed care plan for one (1) of seven (7) residents reviewed for care plans. Resident #1. Findings include: Review of the facility policy titled F553 Right To Participate In Planning Care, with a revision date of 9/2022, revealed, The right to participate in the development and implementation of their person-centered plan of care including but not limited to: a. The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions of the person-centered plan of care. b. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. c. The right to be informed, in advance, of changes to the plan of care. Record review of the Care Plan for Resident #1 revealed Problem Onset: 2/10/2023 Resident stated he has a HX of trauma. Res. reported that he has encountered racism as a child and witnessed a Caucasian murder an African American which took an emotional effect on him. Certain words trigger flash backs. Example boy . Social to visit as needed. Engage in activities of choice. Speak with a Mental health Therapist to verbalize my feelings. Consult Psych as needed. An interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he had not been spoken to by Social Services about a Trauma Informed care plan to show how they were going to help him work this through the incident. An interview on 3/28/23 at 07:45 PM, with Social Services revealed she did develop a Trauma Informed care plan for Resident #1 confirmed that she did not give him the opportunity to participate in the development of the care plan and confirmed that she did not inform him in advance of changes to his care plan. An interview on 3/29/23 at 06:35 PM, with the Former Administrator in Training (AIT) that was working at the facility during the time of the incident did not confirm that Resident #1 should have been allowed to be involved in the development of his Trauma Informed care plan. She noted that Resident #1 agreed to his full care plan on 2/14/23, with no complaints, when reviewed with him by the Care Plan Nurse and Social Services even though he was noted by Social Services to not have been involved in the development of it on 2/10/23. A telephone interview on 3/30/23 at 11:00 AM, with Social Services revealed she did not go to Resident #1's room with the Care Plan Nurse to discuss and review the Trauma Informed care plan and had only signed the staff sheet attached to Resident #1's care plan after the Care Plan Nurse informed her she had a care plan meeting with Resident #1. She noted she was not aware of the level of explanation Resident #1 was given regarding his Trauma Informed care plan. A telephone interview on 3/30/23 at 11:41 AM, with Former Interim Administrator, that was working at the facility during the time of the incident, confirmed Resident #1 should have been allowed to participate in the development of his Trauma Informed care plan, to enable him to have an adequate person-centered plan of care. An interview on 3/30/23 at 01:20 PM, with the Care Plan Nurse revealed she was not aware of the development of the Trauma Informed Care Plan for Resident #1 until she was preparing to have her care plan meeting on 2/14/23 with Resident #1. Record review of the Face Sheet for Resident #1 revealed an admission date of 12/1/21 and diagnoses that included Benign Prostatic Hyperplasia Without Lower Urinary Tract, Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F699 Based on facility policy review, resident interview, facility staff interviews, and record review, the facility failed to resolve a grievance for a resident, for one (1) of six (6) residents reviewed for an unresolved grievance. Resident #1 Findings include: Review of the facility policy titled, F585 Grievances, with a revision date of 9/2022, revealed The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The facility will make information on how to file a grievance or complaint available to the resident. Record review of the Grievance/Complaint dated 2/13/2023, for Resident #1, revealed Date of Grievance/Complaint 2/10/23 . Explanation/Nature of Complaint: Res. approached SW stating he needed to talk. SW invited Res. into a private location. (SW office). Res. stated he was on the second floor, about to get off the elevator when (RN Supervisor's Name Removed) stated to him Boy you on the wrong floor. Boy where are you going? Res. expressed that he did not like being called a boy because he is a grown man; Summary of the pertinent finding of conclusions: SW spoke with DON (DON's Name Removed) who stated (RN Supervisor's Name Removed) was only joking and did not mean anything by calling Res. a boy. (RN Supervisor's Name Removed) apologized to Res. immediately. However, Res. stated he did not hear (RN Supervisor's Name Removed) apologizing; Corrective Action Taken: DON in serviced (RN Supervisor's Name Removed), informing him that he can not refer to Res. by anything other than their preferred name or Mr. or Mrs. ADMINISTRATOR along with AIT and resident had a meeting. Res. informed staff on why he didn't like the word boy. Resident stated he did not like being called a boy d/t racism and witnessing the murder of an African American. Res. stated the word boy makes him have flashbacks. Staff was unaware of the traumatic experience Res. stated he encountered. Res. agreed to have a conversation with (RN Supervisor's Name Removed). (RN Supervisor's Name Removed) apologized again to (Resident #1's Name Removed) and they were able to shake hands; Date and discussion with resident of the findings: 2/10/23; Is this matter resolved?: Yes; Was a copy of written findings requested? No; Was a copy of written findings provided? No; Is further action necessary? No . 2/12/23-Res. informed SW that he does not desire d/c and that he had another plan. SW asked Res. did he need any assistance Res. stated Its my personal business. Record review of the Departmental Notes/Social Notes, for Resident #1 revealed 2/13/23 . Grievance verbalized by this Res. on 2/10/23 is currently being investigated. SW reported Grievance to Local Ombudsman, who was present today and she went and spoke with Res. Res. came back to this SW and stated his advocate told him that this SW was suppose to file a Grievance and that he has to sign it. SW informed Res. that the Grievance had been initiated but it was not complete. Res. requested a copy. SW printed a copy for Res. Res. reviewed the Grievance and stated This shit ain't right, He called me a boy twice. SW changed Nature of Complaint. Res then stated, That's some bullshit he did not apologize to me. SW deleted that [NAME] had apologized. SW informed Res. that this information was given and put in by this SW and the details of the grievance came from the DON. SW also explained that the Grievance process is not complete until the DON has added how she plans to address issue. Res. then stated She ain't got shit to do with this. SW informed Res. that the DON is responsible for addressing grievances that are filed towards her staff. On 3/28/23 at 08:30 AM, during an interview with the Ombudsman revealed she had been involved with Resident #1 regarding his complaint of being called a boy by the Registered Nurse (RN) Supervisor on 2/10/23. She noted that Resident #1 was very upset by the incident, and that he had revealed he did not feel the nursing facility would do anything about it since the RN Supervisor's Supervisor, the Director of Nursing (DON), was his fiancé. She revealed Resident #1 told her being called a boy by a Caucasian male was very upsetting, she informed Resident #1 that he can be active in his grievance process. The Ombudsman told Resident #1 that he had the right to see what had been put in writing, by the nursing facility, regarding his grievance being resolved. She noted Resident #1 did meet with the Interim Administrator, and the RN Supervisor, but he informed the Ombudsman that he was still not satisfied with how the incident was being resolved. An interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he was called a boy by the RN Supervisor on 2/10/23. Resident #1 revealed he was getting off the second (2nd) floor elevator when the RN Supervisor ask him Where you going boy? Resident #1 revealed he went to Social Services to talk with her on that same day to get help regarding the incident, was told by Social Services that she would write it down for him but he did not feel anything would be done about it since the DON is the RN Supervisor's fiancé. Resident #1 expressed that he felt the DON should not be involved in the investigation, due to her relationship with the RN Supervisor. He noted he met with the two (2) lady bosses, the Interim Administrator and the Former Administrator in Training (AIT), and the RN Supervisor, on the Monday after the incident happened. Resident #1 discussed the conversation he had with the Ombudsman on 2/13/23, after meeting with the Interim Administrator and the RN Supervisor, about not being satisfied with the results of the meeting. He noted the Ombudsman informed him he could request a copy of his grievance form to see what was written on it. He revealed he went to Social Services, and she provided him with a copy of the grievance report and that Social Services had not discussed his grievance with him after he initially reported the incident with her. He shared that he was upset that the grievance report showed the DON was active in the investigation process and he was not satisfied with the information that had been recorded on the grievance report by Social Services. Resident #1 noted that none of the facility staff tried to tell him how the incident was going to be handled. An interview on 3/28/23 at 07:45 PM, with Social Services, revealed she spoke with Resident #1 on 2/10/23 regarding the incident where the RN Supervisor called him a boy and his wanting to be moved to another nursing facility. She revealed she started the grievance process and documented, on the grievance form, as she was provided information by the staff members involved in the investigation. She noted she was informed by the Interim Administrator of the meeting with Resident #1 on 2/13/23 and of the resolution between Resident #1 and the RN Supervisor. She confirmed she resolved the grievance and did not discuss it with Resident #1. An interview on 3/29/23 at 06:35 PM, with the Former AIT/Administrator confirmed that Resident #1 should have been talked to by Social Services before the grievance was resolved and Resident #1 should have been allowed to fully participate in the grievance process. A telephone interview on 3/30/23 at 11:41 AM, with Former Interim Administrator/Corporate Nurse, revealed she did not inform Social Services to resolve Resident #1's grievance on 2/13/23. She confirmed that Resident #1 should have been involved in his grievance process/resolution of his grievance, and has had an unresolved grievance since 2/10/23. Record review of the Face Sheet for Resident #1 revealed an admission date of 12/1/21 and diagnoses of Benign Prostatic Hyperplasia Without Lower Urinary Tract, Essential (primary) Hypertension, Elevated Blood-Pressure Reading, Without Diagnosis of Hypertension, Other Sleep Disorder Not Due to a Substance or Known Physiological Condition, Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on facility policy review, resident interview, staff interviews, and record review, the facility failed to implement a Trauma Informed Care Plan for a resident in need of trauma informed care for one (1) of six (6) residents reviewed for care plans. Resident #1 Findings include: Review of the facility policy titled, 656 Develop/Implement Comprehensive Care Plan, with a revised date of September 2022, revealed The facility will . implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet the resident's . mental and psychosocial need that are identified in the comprehensive assessment. Record review of the Care Plan for Resident #1 revealed Problem Onset: 2/10/2023 Resident stated he has a HX of trauma. Res. reported that he has encountered racism as a child and witnessed a Caucasian murder an African American which took an emotional effect on him. Certain words trigger flash backs. Example boy . Social to visit as needed. Engage in activities of choice. Speak with a Mental health Therapist to verbalize my feelings. Consult Psych as needed. An interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he had not spoken with anyone regarding a Trauma Informed care plan and wanted help to work through the trauma so he would not get upset again. Resident #1 stated that no staff had come to check on him to see how he was making it since the incident, nor had anyone spoken to him about options to deal with the bad feelings that were brought back to his memory. An interview on 3/28/23 at 07:45 PM, with Social Services confirmed she did not implement the Trauma Informed care plan and had not referred Resident #1 to any mental health services for him to work through his feelings about the trauma. She revealed she had not visited Resident #1 as indicated on the Trauma Informed Care Plan and had not worked with the nursing staff to get a physician's order for a referral to a psychiatrist for Resident #1. She revealed she did inform the Activities Director that the activities department will have responsibilities listed to implement in the Trauma Informed Care Plan on 2/10/23. An interview on 3/29/23 at 02:20 PM, with the Activities Director revealed she was not aware that Resident #1 had a Trauma Informed care plan and had not assessed Resident #1 for additional activities to implement the activities intervention of the Trauma Informed care plan. The Activities Director revealed she did not talk with Social Services regarding a Trauma Informed care plan, that she was not aware of the traumatic incident with Resident #1 being called a boy by the RN Supervisor on 2/10/23, and that Social Services could have possibly spoken with the Assistant Activities Director. An interview on 3/29/23 at 02:30 PM with the Assistant Activities Director revealed she had not been informed that Resident #1 had a Trauma Informed care plan but did come across it in record review in the electronic health record (EHR) last week when she updated other residents' Activities care plan. She revealed she did not assess Resident #1 for additional options for activities to assist to occupy him related to the incident of him being called a boy by the RN Supervisor on 2/10/23. An interview on 3/29/23 at 05:40 PM, with the Director of Nursing (DON), revealed she was aware that Social Services developed a Trauma Informed care plan for Resident #1 on 2/10/23 and had not attempted to obtain an order for a psychiatrist consult for Resident #1. The DON confirmed Resident #1 should have been referred to psychiatry services due to the level of how upset he was regarding his recent trauma from being called a boy by the RN Supervisor on 2/10/23. An interview on 3/29/23 at 06:35 PM, with the Former AIT/Administrator confirmed that the Trauma Informed care plan should have been implemented for Resident #1. A telephone interview on 3/30/23 at 11:41 AM, with the Former Interim Administrator confirmed that Resident #1's Trauma Informed care plan should have been implemented to assist him to work through his recent trauma and to avoid the possibility of psychosocial harm. Record review of the Physician Orders List revealed there was no physician's order for a referral to mental health services for Resident #1. Record review of the Face Sheet for Resident #1 revealed an admission date of 12/1/21 and diagnoses that included Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Cross reference F585 Based on facility policy review, observations, resident interviews, staff interviews, and record reviews, the facility failed to provide trauma-informed care and failed to complete a trauma-informed care assessment properly for a resident experiencing trauma, as evidenced by a resident's behaviors related to a nursing facility staff member calling him a boy for one (1) of six (6) residents reviewed for trauma. Resident #1. Findings include: Review of the facility policy titled, F699 Trauma Informed Care, with a revision date of September 2022, revealed, .1. The facility will ensure that residents who are trauma survivors receive culturally-competent, trauma care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Collaboration - There is an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clean and open communication between the staff and the resident. 4. Facility will use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences. This includes asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools . 8. Facility will provide cultural competencies to help staff communicate effectively with residents and their families and help provide care that is appropriate to the culture and the individual. Cultural competence refers to a person's ability to interact effectively with person of cultures different from his/her own. An interview on 3/28/23 at 08:30 AM, with the Ombudsman revealed she had been involved with Resident #1 regarding his complaint of being called a boy by the Registered Nurse (RN) Supervisor on 2/10/23. She noted that Resident #1 was very upset by the incident and that he had revealed he did not feel the nursing facility would do anything about it since the RN Supervisor's Supervisor was his fiancé, the Director of Nursing (DON). She revealed Resident #1 told her being called a boy by a Caucasian male caused him to have flashbacks of traumatic racial events from his youth and he had witnessed a racially motivated homicide as a child. She noted Resident #1 met with the Interim Administrator, the Former Administrator in Training (AIT)/Administrator (that was working at the facility at the time of the incident), and the RN Supervisor on 2/13/23, but he informed the Ombudsman that he was still not satisfied with how the incident was being resolved. The Ombudsman revealed she met with the Interim Administrator, AIT, who is now the nursing facility's Administrator, the DON, and Social Services (SS), on 2/13/23, immediately after Resident #1's meeting, and was informed, by the Interim Administrator, that the situation had been calmed down, and that Resident #1 was satisfied with the results of the meeting with the Interim Administrator and RN Supervisor. An observation and interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he was called a boy by the RN Supervisor on 2/10/23. Resident revealed he was getting off the second (2nd) floor elevator when the RN Supervisor asked him Where you going boy? Resident #1 noted he heard the RN Supervisor but did not respond. Resident #1 then revealed the RN Supervisor expressed You're on the wrong floor aren't you boy? Resident noted he responded after being called a boy the second (2nd) time, cursed the RN Supervisor as he informed him that he was a grown man, was old enough to be the RN Supervisor's father, and did not appreciate being called a boy. Resident #1 then revealed being called a boy was racist to him and it brought back horrible memories of racism from his childhood and when he was a younger adult. Resident #1 shared information of witnessing a racially motivated homicide when he was a child and was often called a boy by Caucasians in the 1960's to be degraded. Resident noted all those feelings came rushing back to him and made him feel that he was back in one of those degrading situations. State Agency (SA) observed Resident #1 became tearful and was angrily cursing when recounting the information of what he experienced when he was younger. Resident revealed he went to Social Services to talk with her on that same day to get help regarding the incident, was told by Social Services that she would write it down for him, but he did not feel anything would be done about it since the DON was the RN Supervisor's fiancé. Resident #1 expressed that he felt the DON should not be involved in the investigation, due to her relationship with the RN Supervisor. He noted he met with the two (2) lady bosses, the AIT/, and the RN Supervisor, on the Monday after the incident happened, and the RN Supervisor apologized to him. He shared that he did accept the RN Supervisor's apology, shook his hand, but told the RN Supervisor that he did not believe his apology was sincere. Resident #1 discussed the conversation he had with the Ombudsman on 2/13/23, after meeting with the Interim Administrator, the Former AIT/Administrator, and the RN Supervisor, about not being satisfied with the results of the meeting. He revealed he went to Social Services, and she provided him with a copy of the grievance report and that Social Services had not discussed his grievance with him after he initially reported the incident to her. He shared that he was upset that the grievance report that showed the DON was active in the investigation process, and he was not satisfied with the information that had been recorded on the grievance report by Social Services. Resident #1 also revealed the meeting with the AIT, and RN Supervisor called with him after he had gotten upset and strongly expressed himself verbally, again, in the Social Services office after reading the information on the grievance form. Resident noted there were only Caucasian staff members in the meeting on 2/13/23, and he felt they had gotten together to force him to accept the RN Supervisor's apology. Resident #1 shared that he felt he could no longer trust the lead Caucasian staff and Social Services at the nursing facility. Resident #1 noted that none of the nursing facility staff tried to tell him how the incident was going to be handled, or to talk with him to check and see how was managing since it made him very upset. Resident #1 also noted he did not to talk about it anymore with the lead staff in the nursing facility. Resident #1 revealed he was having a harder time sleeping and was stressed with all the thoughts of his past being on his mind, most of his day, and there were no activities offered to help keep his mind occupied. Resident #1 also shared that several employees saw him while he was upset and no one attempted to comfort him, nor appeared to care about him being upset, and he no longer felt he was being protected. An interview on 3/28/23 at 07:45 PM, with SS revealed she spoke with Resident #1 on 2/10/23 regarding the incident where the RN Supervisor called him a boy and his wanting to be moved to another nursing facility. SS revealed Resident #1 was still upset about the incident on 2/12/23, as he continually expressed his feelings about it, and how it bothered him. SS revealed she did not conduct follow up visits with Resident #1 to see how he was managing after the incident and was not aware he was having issues sleeping or was continually reliving traumatic moments from his past. She revealed she would ask him how he was doing when she saw him moving about the facility, and because he had a BIMS of 15, he could express to her if he had issues related to the incident. She noted she did not link him to any mental health services to assist him to work through the trauma. She revealed she had done a Trauma Informed Care Assessment for Resident #1 but did not review the questions with Resident #1 for the answers entered on the assessment. An interview on 3/28/23 at 07:52 PM with RN Supervisor confirmed he did call Resident #1 a boy on 2/10/23. He revealed he was on the 2nd floor and saw Resident #1 coming off the elevator and Resident #1 is not normally on the 2nd floor. He noted he was being playful with Resident #1, patted Resident #1 on the shoulder, and stated You are on the wrong floor boy. He confirmed that Resident #1 became furious with him, could not remember everything Resident #1 said, but did remember him expressing that he was a grown man with children older than the RN Supervisor and the RN Supervisor will not call him a boy. He also revealed when Resident #1 became as mad as he did, he realized what he had done by calling Resident #1 a boy, and knew it was wrong, but had said it without thinking about what it could mean to Resident #1. He noted could tell that Resident #1 was still not ready to talk with him by the way Resident #1 responded to each of the attempts by the RN Supervisor to talk to Resident #1. He revealed he was not aware that Resident #1 still had possible anxiety and loss of sleep due to the incident and had not talked to any other nursing staff to see if they had followed up on Resident #1. An interview on 3/29/23 at 02:20 PM, with the Activities Director revealed she had not assessed Resident #1 for additional activities to assist to occupy his mind and help him work through his trauma. The Activities Director revealed that she was not aware of the incident with Resident #1 being called a boy by the RN Supervisor on 2/10/23. An interview on 3/29/23 at 02:30 PM with the Assistant Activities Director, revealed she did not assess Resident #1 for additional options for activities to assist to occupy him related to trauma he experienced due to the incident from 2/10/23 of him being called a boy by the RN Supervisor. An interview on 3/29/23 at 05:40 PM, with the DON revealed Resident #1 did not have an order to be assessed by psychiatry to be evaluated for possible psychiatric interventions to assist him to work through the trauma. She noted she was not aware that Resident #1 was still upset regarding the incident. She revealed there was skilled monitoring and documentation being done by the nurses after the incident with Resident #1 that happened on 2/10/23 but confirmed there was no specification that the documentation was skilled monitoring related to the incident. An interview on 3/29/23 at 06:35 PM, with the Former AIT/Administrator revealed she did not agree that the incident should be related to Trauma Informed Care due to Resident #1 not initially expressing that his anger was related to a past trauma, and him only revealing he felt he should be respected by the RN Supervisor related to his age. She noted it was later that Resident #1 started to state that the incident caused him trauma and flashbacks of previous life events. An interview on 3/30/23 at 10:35 PM, with the Administrator and the DON revealed both noting Resident #1 did not tell them or any staff members that he was still having derogatory feelings related to the incident of being called a boy on 2/10/23. They both confirmed that they did not address Resident #1 specifically about the incident after 2/10/23. A telephone interview on 3/30/23 at 11:05 AM, with Licensed Practical Nurse (LPN) #1, revealed Resident #1 came to her several times on 2/12/23 to talk about being upset regarding being called a boy by the RN Supervisor on a previous day. A telephone interview on 3/30/23 at 11:41 AM, with Former Interim Administrator, revealed she had a meeting on 2/13/23 with Resident #1 and noted that he expressed why being called a boy by the RN Supervisor bothered him so badly. She revealed she did not follow up to ask Resident #1 how he was doing related to the incident. The Former Interim Administrator confirmed that Resident #1 should have received trauma informed care to avoid the possibility of psychosocial harm, and that the facility staff did not provide trauma informed care to Resident #1. An interview on 3/30/23 at 01:20 PM, with the Care Plan Nurse revealed she was aware that Resident #1 had been called a boy by the RN Supervisor, because Resident #1 had come into her office area two (2) times, on 2/10/23, tearful and talking about the incident. Record review of the Departmental Notes revealed there was no documentation that revealed Resident #1 received skilled monitoring from the nursing staff related to the incident of being called a boy on 2/10/23. The record review did reveal a nurse note from LPN #1, dated 2/12/2023, that revealed RESIDENT C/O RN SUPERVISOR CALLING HIM A BOY THE OTHER DAY. RESIDENT STATED, I CALLED MY FAMILY AND SHE TOLD ME NOT TO REQUEST TO MOVE, JUST REPORT IT. Record review of the Incident Log revealed there was no incident report completed for the incident of Resident #1 being called a boy by the RN Supervisor on 2/10/23. Record review of the nursing facility's in-services revealed an in-service for all nursing facility staff dated 10/19/22 titled Phase 3 training Number 1 and 2 Quality of Care (Trauma Informed Care and Cultural Diversity). Record review of the Physician Orders List revealed no physician's orders for a referral to mental health services for Resident #1. Record review of the Care Plan for Resident #1 revealed Problem Onset: 2/10/2023 Resident stated he has a HX of trauma. Res. reported that he has encountered racism as a child and witnessed a Caucasian murder an African American which took an emotional effect on him. Certain words trigger flash backs. Example boy . Social to visit as needed. Engage in activities of choice. Speak with a Mental health Therapist to verbalize my feelings. Consult Psych as needed. Record review of documentation from the DON, with a Date of Occurrence of 2/10/23, for Resident #1, revealed . Details of Incident: On 2/10/23 at approximately 1030 AM (RN Supervisor's Name Removed) RN came to this nurse and (Interim Administrator's Name Removed) Administrator and stated he saw (Resident #1's Name Removed) getting off the elevator and stated you're on the wrong floor boy. He stated he said this jokingly but could immediately see that (Resident #1's Name Removed) got upset. (RN Supervisor's Name Removed) states he apologized and came to the administrators office to report what happened. As soon as Administrator and DON met with (RN Supervisor's Name Removed), (Resident #1's Name Removed) was waiting to meet with this nurse. (Resident #1's Name Removed) was upset stating that nurse called me a boy, that the same thing as calling me the N word. Resident got irate and said he was calling state and wanted to go to another facility. We discussed it was his right to call state but not to make a decision about going to another facility while he was upset. Encouraged resident that it was not meant in a derogatory way and again apologized. Resident calmed down and left the office. Findings: Incident did occur and was investigated and was not found to be racial or derogatory and was just conversation. Record review of the Trauma Informed Care Assessments, dated 2/13/23 and 3/29/23, for Resident #1 revealed . For each event check one or more of the boxes to the right to indicate that: (a) it happened to you personally; (b) you witnessed it happen to someone else; (c) you learned about it happening to a close family member or close friend; (d) you were exposed to is as part of your job (for example, paramedic, police, military, or other first responder); (e) you're not sure if it fits; or (f) it doesn't apply to you. Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events. 2/13/23 . Event: 2. Fire and explosion . Doesn't Apply; . 3/29/23 . Event: Fire and explosion . Witnessed it; . 2/13/23 . Event: Life-threatening illness or injury . Doesn't apply; . 3/29/23 . Event: Life-threatening illness or injury . Happened to me (COVID); . 2/13/23 . Briefly describe the worst even (for example, what happened, who was involved, etc.) . (document revealed no response); . 3/29/23 . Briefly describe the worst event (for example, what happened, who was involved, etc.): Witnessed a homicide as a child-Res. stated he witnessed a white man murder a black woman; . 2/13/23 . How many times altogether have you experienced a similar event as stressful or nearly as stressful as the worst event?: Just once; . 3/29/23 . How many times altogether have you experienced a similar event as stressful or nearly as stressful as the worst event?: More than once (please specify or estimate the total number of times you have had this experience ___): lived on street, on drugs; . Keeping your worst event in mine, please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. 2/13/23 . 1. Repeated, disturbing, and unwanted memories of the stressful experience? . 1-A little bit; . 3/29/23 . 1. Repeated, disturbing, and unwanted memories of the stressful experience? . 3-Quite a bit; . 2/13/23 . 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? . 0-Not at all; . 3/29/23 . 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? . 1-A little bit; . 2/13/23 . 4. Feeling very upset when something reminded you of the stressful experience?: . 0-Not at all; . 3/29/23 . 4. Feeling very upset when something reminded you of the stressful experience? . 1-A little bit; . 2/13/23 . 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? . 0-Not at all; . 3/29/23 . 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? . 1-A little bit; . 2/13/23 . 6. Avoiding memories, thoughts, or feelings related to the stressful experience? . 0-Not at all; . 3/29/23 . 6. Avoiding memories, thoughts, or feelings related to the stressful experience? . 3-Quite a bit; . 2/13/23 . 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? . 0-Not at all; . 3/29/23 . 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? . 2-Moderately; . 2/13/23 . 11. Having strong negative feelings such as dear, horror, anger, guilt, or shame? . 0-Not at all; . 3/29/23 . 11. Having strong negative feelings such as dear, horror, anger, guilt, or shame? . 1-A little bit; . 2/13/23 . 12. Loss of interest in activities that you used to enjoy? . 0-Not at all; . 3/29/23 . 12. Loss of interest in activities that you used to enjoy. 1-A little bit; . 2/13/23 . 13. Feeling distant or cut off form other people? . 0-Not at all; . 3/29/23 . 13. Feeling distant or cut off from other people? . 1-A little bit; . 2/13/23 . 15. Irritable behavior, angry outbursts, or acting aggressively? . 0-Not at all; . 3/29/23 . 15. Irritable behavior, angry outbursts, or acting aggressively? . 3-Quite a bit; . 2/13/23 . 17. Being super alert or watchful or on guard? . Not at all; . 3/29/23 . 17. Being super alert or watchful or on guard? . 4-Extremely; . 2/13/23 . 18. Feeling jumpy or easily startled? . 0-Not at all; . 3/29/23 . 18. Feeling jumpy or easily startled? . 1-A little bit; . 2/13/23 . 19. Having difficulty concentrating? . 0-Not at all; . 3/29/23 . 19. Having difficulty concentrating? . 1-A little bit; . 20. Trouble falling or staying asleep? . 0-Not at all; . 3/29/23 . 20. Trouble falling or staying asleep? . 3-Quite a bit. Record review of the Life Experience Assessment, dated 12/1/21, for Resident #1, revealed If you have had a troubling event in your lifetime or if you witnessed something that is troubling to you, please complete the areas below. Disturbing memories, dreams, thoughts, or images of a stressful experience? 1-Not at all; . Do you struggle to find meaning, anger to God, giving up on your faith, or questioning lifetime beliefs? . 1-Not at all; . Suddenly acting or feeling as if the stressful situation were happening again? . 1-Not at all; . Feeling very upset when something reminds you of the stressful experience: . 1-Not at all; . do you fee fearfulness, anxiety, loneliness, helplessness but can't explain why? . 1-Not at all; . Do you feel apathy, isolation, have difficulty trusting, have thoughts of self-injury aggression because of a stressful situation? . 1-Not at all. Record review of documentation from the meeting for Resident #1, with no date and no staff signature, revealed On February 13, 2023 (Interim Administrator's Name Removed), Administrator, and (Former AIT/Administrator's Name removed), RN met with (Resident #1's Name Removed) on incident that occurred on February 10/ 2023. (Resident #1's Name Removed) expressed how he felt about the nurse calling him a boy. (Resident #1's Name Removed) stated this incident brought up old memories from his past where he witnessed a black lady being shot and how his whole hometown was prejudiced. The nurse was called down to meet with us with the permission from the resident. The resident stated his concerns with the statement of being called boy to the nurse. Record review of the Face Sheet for Resident #1 revealed an admission date of 12/1/21 and diagnoses that included Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on observation, staff interview, facility policy review, the facility failed to prevent the potential of injury to a resident, as evidenced by the absence of a wheelchair arm rest exposing a protruding screw for one (1) of 18 residents reviewed. Resident #1 Findings Include: Record review of the facility policy titled Equipment undated, revealed wheelchairs, walkers, crutches, and canes will be provided to the residents and are maintained as the property of the facility. An observation on 03/01/21, at 02:53 PM, revealed the left arm rest missing on Resident #1's wheelchair. Further observation revealed a screw that was sticking upward approximately 1/2 inch out of the metal piece where armrest should be. An interview on 03/01/21, at 02:54 PM, with Resident #1, confirmed that he does get up in the wheelchair at times. An observation on 03/03/21, at 11:14 AM, revealed Resident #1 up in his wheelchair with no arm rest on the left side. The screw was sticking upwards from metal bar. Resident #1 had on a long sleeve shirt. An observation and interview on 03/03/21, at 11:25 AM, with Licensed Practical Nurse (LPN) #1 confirmed the wheelchair did not have an arm rest on the left side. She confirmed the screw was sticking up and could cause a skin tear and possible infection. LPN #1 pulled Resident #1's sleeve up. There was no injury to his arm. An interview on 03/04/21, at 11:30 AM, with the Director of Nursing (DON) revealed that whoever notices equipment needs repair should report it. The DON stated the wheelchair arm should have been fixed, because getting the resident up in the wheelchair without the arm rest on and the screw sticking up could have caused an injury to the resident.

Based on observation, staff interview, facility policy review the facility failed to label and date left over food in the refrigerator for one (1) of two (2) tours. Findings Include: Review of the facility policy titled, Food Storage Labeling, revised 10/17, revealed that the facility will ensure the safety and quality of food by following good storage and labeling procedures. The procedure revealed suggested labeling include the common name and the date of preparation or the use by date. An observation of the standalone refrigerator on 3/2/21, at 11:30 AM, revealed metal containers of fortified sweet potatoes, vegetable soup, and chicken soup not labeled or dated. An interview, on 3/2/21 at 11:45 AM with the Dietary Manager (DM), confirmed the containers should be labeled and dated in order to know how long they had been in the refrigerator, so they could be discarded. The DM revealed she did not know what staff member placed the containers in the refrigerator unlabeled. The DM stated that bad food could cause sickness. An interview, on 03/04/21 at 12:45 PM, with the DM revealed that she and her staff were aware to date and label items in the refrigerator. She confirmed that they failed to date and label the fortified sweet potatoes, the vegetable soup, and the chicken soup. The DM stated that her staff had been in serviced on labeling and dating refrigerated items. Record review revealed an in-service dated 1/12/21, provided by the DM, addressed labeling, and dating of foods. Record review revealed four (4) staff members attended.

Based on observation, staff interview, facility policy review and record review, the facility failed to ensure staff wore masks appropriately covering the nose and mouth to prevent the possible spread of the COVID-19 virus for three (3) of five (5) survey days. Findings Include: The facility policy titled, Personal Protective Equipment, dated 4/1/20, revealed this facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. An observation of the dietary department on 3/2/21, at 11:00 AM, revealed the Dietary Manager (DM) wearing her mask below her nose. Dietary staff #1 and #3 had their masks below their nose while preparing food and setting up trays for the lunch meal. An observation, on 3/3/21, at 1:45 PM, revealed Dietary Staff #2 in the dietary department with his face mask below his nose. An interview, on 3/3/21, at 2:30 PM, with the Dietary Manager (DM), revealed that she and all workers should have their masks over their mouth and nose. On 3/4/21, at 2:14 PM, an interview with Dietary staff #2 revealed he stated that he did not realize his mask was not over his nose. He stated that his mask should be covering his nose because of the virus. Dietary staff #2 confirmed he has had in service education on proper wearing of Personal Protective Equipment (PPE). An interview, on 3/4/21, at 11:30 AM, with Dietary staff #1 revealed that when she talks her mask comes down. She stated that this was not good because when talking saliva could come in contact with others and the food and possibly spread the virus. Dietary staff #1 stated that she should get another mask that fits and does not slide down. Dietary staff #1 confirmed she has had in-service education regarding proper wearing of masks. On 3/3/21, at 2:32 PM, an observation revealed Licensed Practical Nurse (LPN) #2 sitting at the nurse's desk with her mask not covering her nose. She then walked down the hall and provided resident care with her mask not covering her nose. On 3/3/21, at 3:40 PM, an interview with LPN #2 revealed that she should wear her mask covering her mouth and nose. She stated that she guessed she was just not paying attention. LPN #2 stated that not properly wearing her mask could cause her or the resident to breathe in germs and COVID-19 is in the air. She stated that she has had several in-services on COVID-19, and they have been told to keep their masks on at all times. On 3/3/21, at 2:48 PM, an interview with the Director of Nursing (DON) revealed that all the staff know they are supposed to wear masks, goggles, or face shields properly when on the floor because they are trying to protect residents from getting COVID-19. On 3/2/21, at 4:00 PM, the Laundry Supervisor did not have a mask on during an interview with this surveyor. She did put a mask on during the interview. The Laundry Supervisor stated that she should wear a mask at all times in the laundry and a mask and goggles when she goes on the floor. She stated that she takes her mask off when she is in the laundry by herself. The Laundry Supervisor stated that according to facility policy and education, she should have a mask on all the time. Record review of a staff posting revealed all staff must wear facemasks at all times while at work. KN95 or N95 masks are to be worn on second and third floors at all times. Record review revealed that LPN #2, the Dietary Manager and Dietary Staff #1 and #3, and the Laundry Supervisor had attended in-service education classes related to face masks in November 2020. Dietary Staff #2's signature did not appear on any in-service sheets reviewed for proper PPE use.