**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility policy review, and review of Self-Reported Incident (SRI) #223561, the facility failed to ensure Resident #43 was free from verbal abuse. This affected one Resident (#43) of one resident reviewed for abuse. The facility census was 87. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including panic disorder, schizophrenia, major depressive disorder, and generalized anxiety. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/04/22, revealed Resident #43 had mild cognitive impairment and required extensive assist of one staff for bed mobility, locomotion off unit, dressing, and toilet use. For transfers, Resident #43 required extensive assist of two staff. Review of the care plan, initiated on 08/06/18, revealed Resident #43 had alteration in mood or behavior by feeling bad or upset with self because of medical issues. Review of the nursing progress note dated 07/02/22 at 6:45 P.M. revealed Resident #43 yelled and used profanity toward State Tested Nursing Assistant (STNA) #294 during smoke break. Review of SRI #223561 dated 07/02/22 revealed an allegation of emotional/verbal abuse with Alleged Perpetrator (STNA #294) and victim (Resident #43) which occurred on 07/02/22. The summary indicated on 07/02/22 staff witnessed Resident #43 and STNA #294 speaking to each other with raised tone of voice during smoke pass. Staff separated STNA #43 and Resident #43. STNA #294 reported during smoke pass Resident #43 used profane language towards her and attempted to run into her with his wheelchair. The facility unsubstantiated the allegation due to lack of evidence and STNA #294 was provided with education on resident rights and customer service. STNA #294 left facility, and Resident #43 did not request police involvement. Review of SRI #223561 witness statement for Resident #43 dated 07/02/22 revealed Resident #43 and STNA #294 were discussing their personal relationship and STNA #294 stated she left him because he preferred dirty girls. Resident #43 responded stating STNA #294 was a cheater and STNA #294's family were cheaters. STNA #294 yelled out I have been waiting to get this off my chest for 12 years. Resident #43 admitted to using profanity but stated it was mutual. STNA #294 told Resident #43 to put out his cigarette, he was done with his smoke break, and would not be smoking at the next smoke break. Resident #43 refused to leave, continued to smoke, and Resident #43 and STNA #294 continued to swear at each other until Resident #43 returned into the facility and went back to his room. Review of SRI #223561 witness statement for STNA #294 dated 07/02/22 revealed STNA #294 assisted residents out for smoke break at 6:30 P.M. STNA #294 stated Resident #43 was in a foul mood and tried to hurt her feelings by calling her and her sister names. STNA # 294 stated she had many domestic disputes with Resident #43 and had told all the nurses on night shift. STNA #294 stated she still took Resident #43 on smoke breaks but was just waiting because Resident #43 was going to do this. Review of SRI #223561 witness statement for Resident #12 dated 07/02/22 revealed STNA #294 started insulting Resident #43 and he responded by swearing and calling STNA #294 names. Resident #12 was unable to recall the exact phrases used but indicated STNA #294 made references to Resident #43's condition by saying Well look where you are now. Resident #12 also reported STNA #294 told Resident #43 that she had been holding this in for 12 years and now was going to get it off her chest. Resident #12 stated in her own opinion, STNA #294 could have ended the discussion but kept it going. Review of SRI #223561 witness statement for STNA #258 dated 07/02/22 revealed STNA #258 was in the pantry during the time of the incident and heard the arguing outside but could not make out the words. Upon going to check it out, Resident #43 and STNA #294 had separated. Review of SRI #223561 witness statement for Licensed Practical Nurse (LPN) #234 dated 07/02/22 revealed STNA #294 came to her and indicated Resident #43 and her had argued. STNA #294 stated Resident #43 was not a person, he is a monster. STNA #294 then continued to state Resident #43 should not receive a 9:00 P.M. smoke break. LPN #234 explained to STNA #294 that staff members should treat all residents the same and cannot punish or yell at residents. Interview on 07/19/22 at 11:40 A.M. with Resident #43 verified an incident occurred with STNA #294 on 07/02/22, who was once a girlfriend several years ago. Resident #43 stated STNA #294 stated he was a loser, talked in a loud voice first, and then started to yell. Resident #43 confirmed several residents who were smoking in the area witnessed the incident. STNA #294 reported the incident and then staff came and talked with him. Resident #43 indicated not wanting to contact police since STNA #294 left and went home. Resident #43 stated STNA #294 argued with him in the past when they dated. Further interview on 07/22/22 at 10:37 A.M. with Resident #43 revealed the incident which occurred on 07/02/22 embarrassed him and made him feel bad. Resident #43 stated STNA #294 had insulted and yelled at him in front of four to five residents who were smoking at that time. Resident #43 indicated being glad STNA #294 was no longer working at the facility and stated if she was it would happen again. Review of Alleged Perpetrator (STNA #294) personnel file revealed a hire date of 03/31/22. STNA #294 was educated on abuse, neglect, exploitation and misappropriation, customer service and professionalism upon hire. A criminal background check was completed on 03/21/22, and a review of the nurse aide registry was completed on 03/22/22. Review of disciplinary action form for Alleged Perpetrator (STNA #294) dated 07/08/22 revealed a violation of resident rights which resulted in suspension from 07/02/22 through 07/08/22, a written warning, and education on customer service and resident rights with employee signing the document on 07/08/22. Interview on 07/20/22 at 12:56 P.M. with Director of Nursing (DON) and Administrator stated STNA #294 had an emotional response from the previous relationship and therefore was in violation by not listening, discussing personal issues, not using an indoor voice, and that she chose to not reveal the past relationship to the facility. They confirmed STNA #294 did not reveal the past relationship with Resident #43 and was unprofessional. They also verified STNA #294 acknowledged what she did was wrong. Interview with Administrator on 07/19/22 at 2:34 P.M. verified STNA #294 was suspended 7/02/22 through 07/08/22 pending investigation, and it was decided for STNA #294 to return with the plan for STNA #294 not to work on the hallway where Resident #43 resided. STNA #294 asked for a transfer to a sister facility but did not return and did not go to a sister facility. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed all alleged violations involving abuse, neglect, exploitation, and mistreatment of a resident would be thoroughly investigated; the facility would prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process; and if an alleged violation was verified appropriate corrective action would be taken.

Based on observation and interview, the facility failed to ensure a homelike environment free of gouges and unpainted patched areas on the walls in resident rooms and common hallways. This affected 13 Residents (#10, #16, #26, #35, #37, #49, #54, #56, #60, #84, #87, #289, #290). The facility census was 87. Findings include: Observation during an environmental tour on 07/22/22 from 8:40 A.M. to 8:51 A.M. with Maintenance Director #207 revealed the following findings: • Resident #10 and #16's room had one large gouge on the bottom portion of the wall by the window with paint peeling away from the area. • Resident #26 and #84's room had one patched non-painted area on the bottom right side of the wall by the window and two large gouges behind the headboard. • Resident #35's room had 11 large gouges in the wall with drywall exposed behind the headboard of the bed. • Resident #56's room had two large gouges in the drywall, one on the bottom right-hand side of the wall with the window and one gouge halfway up on the left-hand side on the wall closest to the hallway. • Resident #60's room had five large gouges in the wall by the window. • Resident #87's room had one large hole in the drywall with a corner bead showing on the right bottom side of the wall by the bathroom door, and multiple chipped areas with drywall showing on bottom portion of the wall with the window. • Resident #289's room had 20 large gouges in the wall with drywall exposed behind the headboard of the bed. • Resident #290's room had five large gouges in the drywall between the bed and the chair. • Arbor Avenue common hallway had one large white patched strip from the ceiling to the handrail located on the left wall next to the double doors. • Buckeye Boulevard common hallway had a large square shaped area free of paint with drywall showing on the area to the right of the wall with the mounted hand sanitizer container near the hallway entrance. Interview at the time of the observation with Maintenance Director #207 verified the above findings.

Based on observation, interview, and the review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to maintain infection control practices for the spread of infectious diseases by not ensuring staff properly donned and maintained the wearing of facemasks while in resident care areas and hand hygiene was not performed after removing gloves. This affected two (Residents #295 and #413) and had the potential to affect all 87 residents residing in the facility. Findings include: 1. Observation on 07/18/22 at 10:04 A.M. of D wing hallway revealed State Tested Nursing Assistant (STNA) #252 was observed exiting Resident #413's room, which required droplet precautions, while wearing the upper strap of the N95 respirator on back of head and the lower strap dangling under chin. STNA #252 also did not perform hand hygiene after removing her soiled gloves as she exited Resident #413's room. STNA #252 stated she normally wears both straps to the N95 but this time she did not and confirmed she did not wash her hands with soap or water or sanitize her hands with an alcohol-based sanitizer after removing gloves. At the time of confirmation, STNA #252 sanitized hands with an alcohol-based sanitizer. 2. Observation on 07/18/22 at 2:56 P.M. of D wing revealed Medical Records #205 entering Resident #295's room, which required droplet precautions, with a surgical mask underneath the N95 respirator. The upper strap of the N95 was secured on the back of the head and the lower strap was dangling under her chin. Medical Records #205 confirmed upon exit of Resident #295's room the N95 respirator was not worn properly. Review of facility policy titled Infection Control-Standard Precautions, dated 05/05/17, revealed after removing gloves, hand hygiene needs to be performed to avoid transfer of microorganisms to other residents or environments. Review of Personal Protective Equipment (PPE), reviewed 10/21/21, from the Centers for Disease Control and Prevention Healthcare-Associated Infections (HAIs), located at https://www.cdc.gov/hai/prevent/ppe.html, revealed to put on a mask or respirator, secure ties or elastic bands at the middle of the head and neck; fit the flexible band to the nose bridge; fit it snug to the face and below the chin; and place goggles or a face shield over the face and eyes and adjust to fit and to wash hands or use an alcohol based sanitizer immediately after removing PPE. 3. Observation on 07/21/22 at 4:30 A.M. of STNA #262 on B wing hallway was not wearing a facemask or eyewear. Interview at the time of the observation with STNA #262 verified a facemask or eyewear was not donned while in a resident care area. STNA #262 walked to the nurse's station where a facemask and goggles were setting on the countertop and donned the items. STNA #262 stated the facemask was removed because it was easier to breathe. Review of Personal Protective Equipment (PPE), reviewed 10/21/21, from the Centers for Disease Control and Prevention Healthcare-Associated Infections (HAIs), located at https://www.cdc.gov/hai/prevent/ppe.html, revealed to put on a mask or respirator, secure ties or elastic bands at the middle of the head and neck; fit the flexible band to the nose bridge; fit it snug to the face and below the chin; and place goggles or a face shield over the face and eyes and adjust to fit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sufficient staff to meet the needs the residents. This affected Resident's #43, #69 and #78 and had the potential to affect all 87 residents residing in the facility. Findings include: Interview on 07/18/22 at 1:50 P.M. with Resident #78 stated there was not enough staff because there was only one State Tested Nursing Assistant (STNA) for every resident on the hallway and could take up to 30 minutes for staff to respond to the call light. Interview on 07/18/22 at 2:44 P.M. with Resident #43 revealed there was not enough staff since there was only one STNA all the time available on the hallway. Interview on 07/20/22 at 12:26 P.M. with family of Resident #69 revealed it was necessary to visit daily before lunch until after dinner to assist Resident #69 with meals because there was not sufficient staff, especially on the weekends, to ensure Resident #69 received adequate meal intake. Resident #69's family stated it took longer for staff to answer call lights on the weekends, staff were more hurried, and Resident #69 was pressured to finish meals quicker. Interview on 07/21/22 at 4:30 A.M. with STNA #262 verified there was one STNA to each hallway but there was occasionally a float. STNA #262 stated it was more difficult without a float because the nurse had to be relied upon for the residents who required two staff assistance, so it took longer to complete work. STNA #262 verified without a float STNA residents did not receive showers but a bed bath instead. Interview on 07/21/22 at 4:54 A.M. with Licensed Practical Nurse (LPN) #230 confirmed there was only one STNA on each hallway but usually there was a float. LPN #230 stated when there was not a float, it was harder to get residents up in the morning or lay them down for bed, and showers were completed when there was a float but if there was not, the showers were delayed or rescheduled for the next shift. Observation on 07/21/22 at 6:00 A.M. with STNA #253 of the memory care secured unit, of which resided 22 residents, revealed the STNA was alone on the unit an alarm sounded for Resident #45 who attempted to self-transfer to bed. STNA #253 entered Resident #45's room, closed the door, provided personal care, and assisted Resident #45 to bed. Interview at the time of the observation with STNA #253 verified there was no other staff on the unit to monitor the other residents while she was providing personal care to Resident #45 behind the closed door because the nurse had floated to another hallway to pass medications, and there was not a float aide. STNA #253 indicated although tasks were completed with only one aide, it took longer and would stay if necessary to get things done. Review of Facility assessment dated [DATE] through 07/28/22 revealed there was no information on the number of staff needed to meet the needs for each resident. Review of Resident Council minutes from 01/31/22 through 06/30/22 revealed on 01/31/22 snacks were not always passed; on 02/25/22 a complaint of more staff was needed on 300 hallway; on 05/31/22 there was a staff delay returning a resident from dialysis; and on 06/30/22 a resident complained of a bed not being made. Review of staffing tool from 06/24/22 through 06/26/22, 07/03/22 through 07/09/22, and 07/15/22 through 07/17/22 revealed the facility was below the daily direct care requirement of 2.50 hours per resident on 06/25/22, 06/26/22, 07/03/22, 07/09/22, 07/15/22, 07/16/22, and on 07/17/22. Interview at the completion of the staffing tool on 07/20/22 at 10:27 A.M. with Human Resources #215 verified the staffing tool was accurate and the facility was under the staff requirements due to call offs, which the facility was unable to cover. Human Resources #215 stated the facility had a contract with an agency for temporary staff but did not used them.

Based on record review and interview, the facility failed to ensure staff needs were identified on the facility assessment as required. This had the potential to affect all 87 residents. Findings include: Review of the facility assessment, dated 07/07/22 to 07/28/22, revealed it did not contain an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet the needs of each resident. Interview on 07/22/22 at 9:39 A.M. with Director of Nursing, Administrator, and Corporate Nurse #296 verified the facility assessment did not contain facility staffing needs as required.

Based on interview, observation, and record review the facility failed to ensure a resident was supervised while smoking and that he did not have smoking material including cigarettes and lighter on his person per his smoking assessment and care plan. This affected one resident (Resident #5) of twelve residents identified as smoking residents residing at the facility. Findings include: Record review for Resident #5 revealed an admission date of 07/28/18 and diagnoses included alcohol abuse, cannabis abuse, abuse of non-psychoactive substances, and schizophrenia. Review of care plan dated 07/30/18 for Resident #5 revealed he had health risks related to smoking. Interventions included staff were always to provide supervision for smoking and smoking items were to be kept at the nursing station. Review of quarterly Minimum Data Set (MDS) for Resident #5 dated 04/08/19 revealed he had cognitive impairments as his Brief Interview for Mental Status (BIMS) score was a ten. Review of smoking assessment labeled, Smoking Data dated 07/09/19 for Resident #5 revealed staff were to observe the resident while smoking as all residents would be supervised while smoking regardless of their capabilities. He required no appliances or assistance while smoking. Interview on 07/09/19 at 2:16 P.M. with State Tested Nursing Assistant (STNA) #601 revealed all residents were to be supervised to smoke and no residents, per policy, can have cigarettes or lighters on them as they had to be stored in the nursing station. She revealed staff had to light all cigarettes for the residents when they are smoking. She revealed Resident #5 had to sign out in the leave of absence book and go to the new patio the facility recently built off the path if he wanted to smoke unsupervised outside of smoking times. Interview on 07/09/19 at 4:10 P.M. with Licensed Practical Nurse (LPN) #603 revealed all residents were to be supervised when smoking and were not to keep cigarettes or lighters on them as smoking materials were stored at the nursing station. She revealed if Resident #5 wanted to smoke in between smoking times he had to sign out on leave of absence and go to a patio off the path to smoke. She revealed he then was not supervised. Interview on 07/09/19 at 4:20 P.M. with Resident #5 revealed he goes a few times a day to the new outside patio the facility just built to smoke which was located down the path. Resident #5 revealed he does not need to be supervised while smoking and can go anytime throughout the day. Interview on 07/09/19 at 4:28 P.M. with the Maintenance Director #600 revealed he recently built the new patio located next to the paved path going around the facility. He revealed the patio was considered off facility property as technically the owner owns the property but was not part of the facility's property where the new patio was built. He revealed the residents use this area for smoking, but the residents had to sign out by leave of absence to be able to use the area unsupervised. Interview on 07/09/19 at 5:55 P.M. with the Administrator and Director of Nursing revealed in the past when the residents wanted to smoke outside of smoking times they signed out by leave of absence and went across the street off facility property to smoke. They revealed they felt this was a safety concern and recently the facility decided to have a cemented area with a picnic area built next to the path. They revealed this area was off facility property. They revealed all residents including Resident #5 was to be supervised while in the facility and no residents were to have smoking material on their person. Observation on 07/10/19 at 8:35 A.M. of Resident #5 revealed he opened the gait to the gazebo area and propelled in his wheelchair down the path to the newly cemented area. He then lit a cigarette that he pulled from a cigarettes case out of his pocket. No staff were in the area while he was smoking. Interview on 07/10/19 at 8:37 A.M. with STNA #602 verified Resident #5 was smoking unsupervised on the patio next to the paved path by the facility. She verified he had a lighter and four remaining cigarettes in a case on his person. Interview on 07/10/19 at 8:39 A.M. with LPN #603 verified she was Resident #5's nurse and he did not sign out in the leave of absence book and she verified he was to be supervised when he smokes at the facility. She verified that residents were not to have cigarettes or lighters on them per their facility policy. Review of undated form labeled, Release of Responsibility for Leave of Absence, for Resident #5 revealed he did not sign out on 07/10/19 at 8:35 A.M. when he went to smoke. Review of facility policy dated 07/17/18 labeled, Resident Smoking, revealed all residents would be supervised while smoking, and staff would light all smoking products. The policy revealed all smoking materials would be kept in a secured area and distributed by the facility staff and a resident would not be permitted to carry or have in their possession smoking material including cigarettes or lighters. The policy did not include residents signing out on leave of absence to smoke.