**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, policy review, the facility failed to ensure home health services were arranged prior to resident discharge from the facility. This affected one resident (#139) of three resident records reviewed. The census was 136. Findings include: Review of Resident #139's medical record revealed he was admitted to the facility on [DATE] and discharged on 03/20/25. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, vascular dementia, dysphagia, impulse disorder, major depression, and intermittent explosive disorder. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required supervision or touching assistance with eating, oral hygiene, dependent on toileting, dressing, personal hygiene and turning and repositioning. He was frequently incontinent of urine and always incontinent of bowel. Review of the physician's orders revealed an order on 03/20/25 to discharge home. Review of the progress notes dated 03/18/25 at 10:54 A.M. by Social Service revealed Social Worker #256 faxed the resident's needed information to [NAME] Bridge Home Health. On 04/07/25 at 11:28 A.M. interview of Social Service Designee (SSD) #201 revealed on resident discharge they make the arrangements for home health, follow-up appointments, equipment and therapy prior to them going home. In regard to Resident #139, SSD #201 did not discharge Resident #139 but will check and see if therapy was ordered since therapy suggested it be ordered. On 04/07/25 at 1:08 P.M. during phone interview with [NAME] Bridge Home Health Staff #200 revealed they did not have a client by that name (Resident #139). On 04/07/25 at 9:52 A.M. and 1:10 P.M. phone interviews with Resident #139 revealed the resident has not had home health services since he was discharged from the facility and came home. The home health agency the facility contacted do not take care of residents under the age of 60. On 04/07/25 at 1:15 P.M. interview with the Administrator and Director of Nursing (DON) revealed they were not aware Resident #139 was not receiving Home Health services. They thought they had been arranged prior to the resident's discharge. Review of the Discharge Process for Planned Discharge policy and procedure dated 08/15/13 and revised 04/30/18 revealed Social Service or designated person will coordinate the resident's discharge planning process. The discharge process should include, but not limited to, an assessment of: 1. Resident/Primary Caregiver responsibilities, capabilities,and educational needs. 2. Transportation home. 3. Equipment needed at home and obtain the equipment. 4. Supplies needed at home and instruct residents home to obtain. 5. Housekeeping, laundry, grocery shopping, bill paying etc. 6. Psycho-social systems available at home. 7. Physical support systems available at home (accessible phone, utilities, access to bathroom, and bedroom access to entry of home etc.) 8. Referral for therapy after discharge. 9. Community referrals needed for support services at home (Home Health, Emergence Alarm Necklace, housekeeping etc.) 10. Follow-up appointments with physician/specialists, arrangements for labs and testing etc. 11. Make arrangements for medications. Discharge Follow-Up revealed a representative of the facility will place follow up calls to the resident or designated contact person in about 3 days and again in 3 weeks after discharge back to the community. Give the opportunity for the resident to ask questions and express concerns to seek direction. Follow up calls will be made on the Home Discharge Follow Up Log There was no documented evidence any follow up calls were made. This deficiency represents non-compliance investigated under Complaint Number OH00164217.

Based on observation and interview the facility failed to ensure residents were provided a dignified dining experience. This affected two residents (Resident #50 and #137) but had the potential to affect 16 residents (Resident #37, #46, #47, #52, #53, #55, #69, #80, #93, #94, #108, #109, #112, #120, #123 and #137) of 24 residents who ate meals in the 100 hall and 200 hall dining room and do not use adaptive cups. The census was 136. Findings include: Observation of dining room on the 100-Hall and 200-Hall on 09/18/24 at 5:00 P.M. revealed Resident #37, #46, #47, #52, #53, #55, #69, #80, #93, #94, #108, #109, #112, #120, #123 and #137) had styrofoam cups with water, coffee and/or hot chocolate. Interview on 09/18/24 at 5:10 P.M. with State Tested Nurses Assistant (STNA) #321 verified that styrofoam cups were being used for water, coffee and hot chocolate for residents that did not require adaptive cups. STNA #321 stated the silverware, and drinks are brought to the dining room prior to the delivery of the meal trays and there are not enough cups for coffee/hot chocolate, so they use styrofoam cups and the large water glasses are not on the beverage cart, so styrofoam cups are also used for water. Interview of 09/18/24 at 5:19 P.M. with Resident #52 stated staff use styrofoam cups every day and he does not like to use styrofoam cups for his beverages. Interview on 09/18/24 at 5:23 P.M. with Resident #137 stated he does not like to drink out of a styrofoam cup and prefers to drink out of real cups and glasses. Interview of 09/19/24 at 11:15 A.M. with Dietary Manager (DM) #308 stated more coffee cups need to be ordered due to not having enough cups for mealtimes. DM #308 stated the water glasses are to be put on the meal tray for ice water during the meal. The drink cart is sent out to the dining rooms and staff will use the styrofoam cups for water, hot coffee and hot chocolate. When they run out of cups the staff are not asking for more cups and will just use the styrofoam cups and not ask for more cups or glasses. This deficiency represents non-compliance investigated under Complaint Number OH00156585.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents. The census was 136. Findings Include: Observation of the kitchen on 09/19/24 from 11:00 A.M. through 11:30 A.M. revealed there was a five-pound bucket of pickle spears (half full), in the cooler, with no lid and the bucket was not dated when opened. The walk-in freezer floor had food and dirt buildup on the floor and the floor was sticky. The three sugar bins and one flour bin were not dated, and the outside of the bins were soiled with food and dirt buildup. Interview on 09/19/24 at 11:08 A.M. with [NAME] #307 verified the pickles were not dated or covered. [NAME] #307 verified the walk in-freezer was not clean and the floor was sticky. Interview on 09/19/24 at 11:15 A.M. with the Dietary Manager (DM) #308 verified all above findings. This deficiency is an incidental finding discovered during the investigation of Complaint Number OH00156585.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of staffing timecards, interviews, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure there were sufficient staff on the weekends. This had the potential to affect all 131 residents residing in the facility. Findings include: Review of the facility staffing schedule, timecards, and completion of the staffing tool for several weekends on 03/27/24 from 9:00 A.M. through 11:00 A.M. with Administrator and Director of Nursing (DON) revealed that the facility did not meet the required minimum direct care daily average of 2.50 hours on the following dates: • The staffing tool noted 2.25 hours of direct resident care hours on 04/08/23. • The staffing tool noted 1.75 hours of direct resident care hours on 04/09/23. • The staffing tool noted 1.85 hours of direct resident care hours on 05/27/23. • The staffing tool noted 2.28 hours of direct resident care hours on 05/28/23. • The staffing tool noted 2.36 hours of direct resident care hours on 06/17/23. • The staffing tool noted 2.29 hours of direct resident care hours on 06/18/23. • The staffing tool noted 2.45 hours of direct resident care hours on 02/17/24. • The staffing tool noted 2.45 hours of direct resident care hours on 03/09/24. • The staffing tool noted 2.40 hours of direct resident care hours on 03/10/24. Interview on 03/27/24 at 1:35 PM with Scheduler #368 revealed that she schedules enough staff, it's the call offs that occur. She stated the facility offers several incentives to maintain staff. Interview on 03/27/24 at 3:00 P.M. with Administrator and DON revealed the incentives that the facility put into place and the quality assurance project to obtain new staff. The administrator stated that due to the cliental, some newly hired staff are not comfortable with psych residents and quit shortly after hire. Scenic Pointe administration was made aware of low staffing measured for weekend for the third quarter of the fiscal year of 2023 per the PBJ staffing data report. In response to receipt of this data, Scenic has implemented additional staff recruitment techniques to assist in improving staff numbers. DON stated that pick up bonuses for weekends, nights, and days. Other incentives included wage increases, flexible scheduling to accommodate both eight- and twelve-hour shifts, as well as paid time off (PTO) accrual after 90 days of employment. For people that want to become state tested nursing assistants (STNA), the course is given at the facility and the potential STNAs are paid during the training and are hired upon graduation. Administrator stated that the new incentives that were introduced since the third quarter PBJ was weekend [NAME] pay, tuition reimbursement and differential for a seven-day schedule, sign on and referral bonuses, and do local job fairs at the local schools about working at the behavioral health facility. The Administrator stated that did experience a COVID outbreak during 02/17/24 through 03/15/24 where we had 26 positive COVID staff members, mostly direct care staff. The Administrator stated that there has been an improvement in staffing since the added incentives were implemented. Review of the PBJ Staffing Data Report form submitted from 04/01/23 to 06/30/23 for the third quarter, revealed the facility submitted weekend staffing data is excessively low.

Based on observation, interview, and review of staffing schedules the facility failed to ensure they had sufficient dietary staff to maintain a clean dining room and kitchen. This had the potential to affect all residents who consumed food from the kitchen. The facility indicated all residents consumed food from the kitchen. The facility census was 131. Findings include: Observation of the kitchen on 03/25/24 at 8:40 A.M. and on 03/27/24 from 9:40 A.M. to 10:00 A.M. revealed the kitchen floor had an overall muddy appearance, as if wet dirt had been pushed around. This appearance worsened the closer it got to the dish room. Additional observation revealed the floor underneath equipment and tables had a thicker buildup of dirt and food splatter. The corners and edges of the room had a buildup of dirt extending from the baseboard. Additionally, the floor under equipment and tables had several pieces of food, lids, and condiment containers. Interview on 03/27/24 between 9:40 A.M. and 10:00 A.M. with Head [NAME] #389 verified the observation. She reported they deep cleaned the floor and under the equipment once a month; however, they had been short staffed, so it was difficult to keep up with the cleaning. Observation of the kitchen on 03/25/24 at 8:40 A.M. and on 03/27/24 between 9:40 A.M. and 11:35 A.M. revealed the kitchen ceiling was covered in food splatters in almost all areas of the kitchen. In addition to what was suspected to be food splatters there were numerous unidentifiable stains. Interview on 03/27/24 at 11:35 A.M. with Dietary Manager #511 verified the stains on the ceiling. She reported she thought she had put in a maintenance request at some point to get it addressed. Interview on 03/27/24 at 2:59 P.M. with the Administrator revealed she thought it would be maintenance's responsibility to clean the ceiling. Observation on 03/27/24 at 7:20 A.M. of the main dining room revealed the floor was littered with debris including paper tickets, lids to cups, and paper from straws. Interview on 03/27/24 at 7:20 A.M. with Head [NAME] #389 verified the observation. She reported the dietary staff were supposed to clean the dining room after dinner the previous night; however, they had been short staffed and likely did not get the chance to complete it. She reported they only had two dietary aides the previous night which was insufficient to complete their jobs. Observation on 03/27/24 from 9:40 A.M. to 10:00 A.M. revealed a knife organizer attached to the wall. This organizer was clear, observation revealed the organizer was filled with food debris. Observation of the top of the container revealed slots for knives to slide into, at that time the container had one knife and a knife sharpener. The top of the container was covered in dust and food debris. Interview on 03/27/24 from 9:40 A.M. to 10:00 A.M. with Dietary Manager #511 verified the observation and indicated she would ensure it got cleaned. Observation on 03/27/24 at 11:10 A.M. revealed the lids for the six-quart steam table pans were in a large steel container. The container was filled with food crumbs and splatters. Interview on 03/27/24 at 11:35 A.M. with Head [NAME] #389 verified the observation. Interview on 03/27/24 at 12:30 P.M. with Dietitian #349 revealed they were having problems keeping staff in the kitchen. Interview on 03/27/24 at 12:49 P.M. with Dietary Manager #511 verified they had problems keeping staff in the kitchen and it was difficult for them to complete their cleaning tasks with the current staffing levels. Review of the kitchen staffing schedule from 03/17/24 to 03/26/24 revealed there were two second shift dietary aides scheduled on 03/17/24, 03/19/24, 03/20/24, 03/21/24, 03/22/24, 03/23/24, 03/24/24, 03/25/24, and 03/26/24. On 03/18/24 they only had one dietary aide.

Based on observation, interview, and review of cleaning schedules, the facility failed to ensure resident dining areas and the kitchen were maintained in a sanitary manner. Additionally, the facility failed to ensure 26 residents (#6, #10, #13, #14, #17, #33, #35, #41, #42, #45, #47, #51, #52, #71, #84, #88, #93, #95, #97, #102, #105, #120, #122, #123, #125, and #131) in the 300 and 400 hall dining rooms were served food in a sanitary manner. This had the potential to affect all residents who consumed food from the kitchen. The facility indicated all residents consumed food from the kitchen. The facility census was 131. Findings include: 1. Observation of the kitchen on 03/25/24 at 8:40 A.M. and on 03/27/24 from 9:40 A.M. to 10:00 A.M. revealed the kitchen floor had an overall muddy appearance, as if wet dirt had been pushed around. This appearance worsened the closer it got to the dish room. Additional observation revealed the floor underneath equipment and tables had a thicker buildup of dirt and food splatter. The corners and edges of the room had a buildup of dirt extending from the baseboard. Additionally, the floor under equipment and tables had several pieces of food, lids, and condiment containers. Interview on 03/27/24 between 9:40 A.M. and 10:00 A.M. with Head [NAME] #389 verified the observation. She reported they deep cleaned the floor and under the equipment once a month; however, they had been short staffed, so it was difficult to keep up with the cleaning. Observation of the kitchen on 03/25/24 at 8:40 A.M. and on 03/27/24 between 9:40 A.M. and 11:35 A.M. revealed the kitchen ceiling was covered in food splatters in almost all areas of the kitchen. In addition to what was suspected to be food splatters there were numerous unidentifiable stains. Interview on 03/27/24 at 11:35 A.M. with Dietary Manager #511 verified the stains on the ceiling. She reported she thought she had put in a maintenance request at some point to get it addressed. Interview on 03/27/24 at 2:59 P.M. with the Administrator revealed she thought it would be maintenances responsibility to clean the ceiling. Review of the maintenance requests from 01/01/24 to 03/25/24 revealed no requests related to the kitchen ceiling. Observation on 03/27/24 from 9:40 A.M. to 10:00 A.M. revealed a knife organizer attached to the wall. This organizer was clear, observation revealed the organizer was filled with food debris. Observation of the top of the container revealed slots for knives to slide into, at that time the container had one knife and a knife sharpener. The top of the container was covered in dust and food debris. Interview on 03/27/24 from 9:40 A.M. to 10:00 A.M. with Dietary Manager #511 verified the observation and indicated she would ensure it got cleaned. Observation on 03/27/24 at 11:10 A.M. revealed the lids for the six-quart steam table pans were in a large steel container. The container was filled with food crumbs and splatters. Interview on 03/27/24 at 11:35 A.M. with Head [NAME] #389 verified the observation. 2. Observation on 03/25/24 from 11:45 A.M. to 12:05 P.M. of the 300 and 400 hall dining room revealed staff including State Tested Nursing Aide (STNA) #338 and STNA #500, were observed serving residents their lunch trays. Staff were not sanitizing their hands between delivering trays to residents. Interview on 03/25/24 at 11:57 A.M. with STNA #338 and STNA #500 verified this observation, they reported there was no hand sanitizer in the dining room. The facility identified 26 residents in the 300 and 400 hall dining room, these included residents' #6, #10, #13, #14, #17, #33, #35, #41, #42, #45, #47, #51, #52, #71, #84, #88, #93, #95, #97, #102, #105, #120, #122, #123, #125, and #131. 3. Observation on 03/27/24 at 7:20 A.M. of the main dining room revealed the floor was littered with debris including paper tickets, lids to cups, and paper from straws. Interview on 03/27/24 at 7:20 A.M. with Head [NAME] #389 verified the observation. She reported the dietary staff were supposed to clean the dining room after dinner the previous night; however, they had been short staffed and likely did not get the chance to complete it. The facility reported they had no policies related to kitchen sanitation.

Based on observations, interviews, and review of the cleaning schedule, the facility failed to ensure all areas of the facility were clean and sanitary. This had the potential to affect 35 residents residing on the 100-hall (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30,#31, #32, #33, #34, #35) and 33 residents residing on the 400-hall ( #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, #131, #132, #133, #134, #135, #136, #137 and #138.) The census was 138. Findings included: Observation and interview on 06/29/23 at 7:44 A.M. of the 100-hall shower room with STNA #307 revealed there was black substance around the bottom perimeter of the shower floor. STNA #307 verified there was black substance around the bottom perimeter of the shower in the 100-hall shower room. Observation and interview on 06/29/23 at 8:00 A.M. of the 400-hall shower room with HK #313 revealed in both showers there was an approximate two-inch gap between the floor tile and shower walls and within this gap there was a dirty, black residue. The shower walls were also dirty. HK #313 verified the floor tile and shower walls were not clean and sanitary. Review of the daily cleaning schedule revealed shower rooms and showers were to be cleaned daily by the housekeepers. This deficiency resulted from non-compliance identified during the investigation of Complaint Number OH00143817.

Based on observations and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 138 residents in the facility who ate meals from the kitchen. No residents were identified by the facility as being nothing by mouth (NPO). Findings include: Tour of the kitchen on 06/29/23 from 7:05 A.M. through 7:30 A.M. with Licensed Social Worker (LSW) # 400 revealed the table top mixer had dried food splatter on the back splash of the bowl guard, pudding was splattered on the side of the reach-in refrigerator, the reach-in refrigerator had spilled milk and dry food residue on the bottom, dried chicken gravy and noodles on the floor located near the tilt skillet, food residue was on the clean side of the dish machine. Walls in the dish room, prep area and service area had liquid and food splatter. On the outside of bins containing flour and sugar there was food splatter and dirt on the bins. Interview on 06/29/23 at 11:30 A.M. with Dietary Manager (DM) #401 revealed dietary had been short staffed lately and there were no sanitation policies for the kitchen. DM #401 stated no residents were NPO. This deficiency represents non-compliance investigated under Complaint Number OH00143817.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the resident account information and interviews the facility purchased additional insurance for Resident #61 and Resident #138 without consent from the resident or their legal representative. This affected two residents of five residents reviewed for resident funds. Findings Included: 1. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, convulsions, diabetes, multiple sclerosis, hypertension, crushing injury of the skull, hemiplegia and tremors. Resident #61's sister was listed as his legal representative. Review of the Living Care Facility Resident Application for Insurance form dated 09/05/19 revealed Resident #61 was to pay $127.00 per month for dental coverage, $35.00 a month for vision coverage, $62.00 a month for audiology coverage and $66.00 a month for podiatry coverage, totaling $290.00 a month. The form was signed electronically by Business Office Manager (BOM) #197 with the facility as the legal representative. Review of the quarterly bank statements from 01/08/21 through 03/31/22 revealed Resident #61 had a monthly withdraw of $290.00 for the insurance premium. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #61 had intact cognition. Interview on 05/17/22 at 8:45 A.M. with Resident #61 indicated the facility was taking an extra $290.00 a month out of his monthly liability for an additional insurance he did not need. Resident #61 indicated he never agreed to have this premium paid from his account. Interview on 05/19/22 at 9:11 A.M. with BOM #197 indicated Resident #61's sister consented to the insurance premium. BOM #197 stated the Citizens Security Life Insurance was a 360 insurance offered by the state and the facility's corporate ownership had agreed to have it for some residents. She indicated it would reduce the amount of the resident's liability by $290.00 a month to pay for the insurance. BOM #197 verified Resident #61 had spoken to her a couple times indicating he did not want this extra insurance coverage and she said Resident #61 had never used any of their services. Review of an email dated 05/19/22 at 2:55 P.M. revealed the Administrator indicated she would investigate issues with the 360 insurance and why staff names were on the consents because the facility does not have anything to do with the consent. The Administrator stated 360 insurance was applying the staff names to the consents without talking to the residents and she would address this problem. 2. Record review Resident #138 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes, hypertension, anxiety disorder, major depressive disorder, bipolar disorder, affective mood disorder, paranoid schizophrenia, extrapyramidal and movement disorder, and dementia with behavioral disturbance. Further review of the medical record revealed Resident #138 had a guardian of person. Review of the Living Care Facility Resident Application for Insurance form dated 06/17/19 revealed Resident #138 was to pay $127.00 per month for dental coverage, $35.00 a month for vision coverage, $62.00 a month for audiology coverage and $66.00 a month for podiatry coverage, totaling $290.00 per month. The form as signed by the facility Administrator with the facility as the legal representative. Review of the quarterly statements from 01/08/21 through 03/31/22 revealed Resident #138 had a monthly withdraw of $290.00 for payment of the insurance premium. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #138 was severely cognitively impaired and exhibited disorganized thinking and inattention. Interview on 05/19/22 at 9:11 A.M. with BOM #197 stated the Citizens Security Life Insurance was a 360 insurance offered by the state and the facility's corporate ownership had agreed to have it for some residents. She indicated it would reduce the amount of the resident's liability by $290.00 a month to pay for the insurance. Review of an email dated 05/19/22 at 2:55 P.M. from the Administrator indicated she was going to look into the concern with the 360 insurance and how staff names were on the consents. The Administrator indicated she was not sure how it happened because the facility does not have anything to do with the consents and the 360 insurance was applying the names to the consents without talking to the residents. The Administrator verified it was a problem and it would be addressed.

Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for Resident #143. This affected one of one residents reviewed for pressure ulcers. The facility census was 153. Findings include: Review of Resident #143's medical record revealed and admission date of 06/04/19. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease, hypertension, osteoarthritis, and a pressure ulcer stage four to his coccyx. Stage four pressure ulcers involve a full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligaments, cartilage or bone and may have slough or eschar (dead or devitalized) tissue in the wound. Review of May 2022 physician order's for Resident #143 revealed orders for staff to use padded heel suspended boots to both of his feet while in bed and while in his wheelchair, and an order for a chair cushion in place on every shift. Review of Resident #143's care plan 05/02/22 revealed to maintain skin integrity, the facility staff would apply padded heel suspended boots to both feet/calves, and apply a pressure reducing chair cushion as tolerated/needed. Observations on 05/18/22 at 9:07 A.M. and 11:10 A.M. revealed Resident #143 sitting in his Broda chair, a specialized type of wheelchair. Resident #143 was not wearing the padded heel suspended boots. Observation on 05/18/22 at 1:36 P.M. revealed Resident #143 lying in his bed and he was not wearing his padded heel suspended boots. Interview and observation at the time of this observation with Registered Nurse #196 confirmed she was working as a State Tested Nursing Assistant that day and forgot to apply Resident #143's padded heel suspended boots. Observations on 05/19/22 at 8:17 A.M. and 9:32 A.M. of Resident #143 revealed he was sitting in his Broda chair and he was not wearing his padded heel suspended boots, his feet were not elevated, and he did not have a pressure relieving cushion on his chair. Interview and observation of Resident #143 on 05/19/22 at 9:32 A.M. with the Director of Nursing confirmed Resident #143 did not have his padded heel suspended boots in place and he was not sitting on a pressure relieving cushion in his Broda chair. Interview on 05/19/22 at 11:37 A.M. with Registered Nurse #251, the hospice nurse, confirmed Resident #143 should have the additional pressure reducing cushion in his Broda chair and not just the standard cushion on the chair.

Based on observation, interview, U.S. Department of Agriculture/U.S. Food and Drug Administration guidelines, and maintenance records the facility failed to ensure kitchen equipment was properly functioning and the facility did not properly store food. This had the potential to affect all 153 residents residing in the facility and consuming food/meals from the kitchen. Findings include: 1. Observation on 05/16/22 at 8:35 A.M. of the facility's kitchen revealed a pan covered with aluminum foil with writing on top of the foil identifying it as pork roast. The writing indicated the pork roast was made 05/11/22 and the use by date was 05/18/22. There was a pan covered with aluminum foil and labeled as country fried steak (poultry) with the date made as 05/11/22 and the use by date as 05/18/22. Interview on 05/16/22 at 8:35 A.M. with Dietary Aide #128 revealed all leftovers, including meats, are kept for seven days before they are discarded. Interview on 05/16/22 at 2:22 P.M. with Dietary Manager #218 revealed all leftovers are kept for seven days except for produce, which is kept for three days before discarding. She confirmed the leftovers can be served to the residents residing in the facility up to the discard date. Review of the U.S. Department of Agriculture/U.S. Food and Drug Administration Cold Storage Chart, dated July 2020, revealed that cooked meat leftovers should be kept for three to four days before discarding. 2. Review of the maintenance log dated 02/01/22 revealed State Tested Nursing Assistant #159 reported the bars needed welded on the food cart in the kitchen and indicated she had cut her arms several times. Observation on 05/16/22 at 8:35 A.M. of the facility's kitchen revealed a bucket collecting water underneath the drain of the three compartment sink, a leaky faucet sprayer, layers of tape holding a temperature knob in place on the warming oven, three other knobs missing from the warming oven, seven handles missing on the kitchen cabinets, and a metal food cart with a missing metal bar. Interview on 05/16/22 at 2:22 P.M. with Dietary Manager #218 confirmed the above finding and stated maintenance and the Administrator have been made aware of the conditions of the warming oven for awhile. She verified it is still in use at this time. Dietary Manager #218 reported maintenance was aware of the other issues as well but has yet to fix them.

Based on observations and interview, the facility failed to maintain a sanitary laundry room. This had the potential to affect all 153 residents residing in the facility at the time of survey. Findings included: Observation on 05/17/22 at 10:15 A.M. of the laundry room revealed four fans located on the clean side of the laundry room. The fans were visibly dirty with a heavy build-up of dirt and dust particles. Laundry staff were present in the laundry area folding residents' clothes and facility bed linens for all residents. Interview immediately after this observation with Laundry Staff #16 and Laundry Staff #101 verified the four fans on in the clean area of the laundry were covered in dirt/dust and needed cleaned.

Based on record review and interview the facility failed to inform Resident #145's guardian of changes in physician's orders in a timely manner. This affected one resident (#145) of one resident reviewed for notification of changes. Findings include: Review of Resident #145's medical record revealed diagnoses included dementia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, gastroesophageal reflux disease, high cholesterol level, anxiety disorder, schizoaffective disorder, borderline personality disorder, and psychosis. A psychiatrist's note, dated 12/29/18 indicated Resident #145 had behaviors and had delusional thoughts of being an airplane then a bird. The psychiatrist indicated he planned to target delusions by increasing Abilify (antipsychotic medication) to 25 milligrams (mg) every day. A nursing note, dated 12/29/18 at 12:11 P.M. indicated the psychiatrist visited and new orders were received. A nursing note dated 12/31/18 at 1:49 P.M. indicated the guardian was updated on medication changes. A progress note by a physician service with a date of service of 01/22/19 and signed 01/24/19 indicated Resident #145 had Barrett's esophagus (Barrett's esophagus is a condition in which tissue that is similar to the lining of your intestine replaces the tissue lining your esophagus.). The last EGD (Esophagogastroduodenoscopy, or EGD, is an endoscopic examination of the esophagus, stomach and duodenum (the uppermost part of the small intestine) for hiatal hernias, ulcers, bleeding sources, tumors or other problems.) was on 12/26/13 and a referral would be make for a follow up endoscopy. A nursing progress note dated 01/25/19 at 4:47 P.M. indicated the physician referred Resident #145 to a gastrointestinal specialist. The first indication of Resident #145's guardian being informed of the referral was a progress note dated 02/07/19 at 1:10 P.M. when the guardian was updated on the appointment for a gastroenterology specialist. A nursing note dated 05/01/19 at 11:27 A.M. revealed the physician assistant added aspirin. An order was written for Aspirin 81 mg every day. The note did not reveal the guardian was notified. A physician progress note dated 05/21/19 indicated Resident #145 complained of feeling nervous and his blood pressure was 95/55 and heart rate was 50. Resident #145 had difficulty with ambulation and required staff assistance. The physician assistant indicated blood pressures were reviewed and Lisinopril would be decreased to 2.5 mg every day and blood pressures would continue to be monitored. Nursing notes were silent to guardian notification of low blood pressures and changes to medication at that time. A nursing note dated 06/29/19 at 11:52 A.M. indicated the psychiatrist visited and gave order to increase Haldol (antipsychotic) to 5 mg twice a day. A nursing note dated 06/30/19 at 3:25 P.M. indicated the guardian was notified of the new order. A progress note dated 07/03/19 at 7:00 A.M. indicated staff reported Resident #145 was ambulating with an unsteady gait, leaning forward and stumbling/stutter step. A nursing note dated 07/03/19 at 8:56 A.M. indicated Resident #145 had an unsteady gait that morning, leaning forward and requiring two assists to ambulate. A nursing note dated 07/03/19 at 12:15 P.M. indicated the physician was notified of Resident #145's stumbling gait in the mornings. Haldol times were changed and the physician added Senna plus for constipation. A nursing note dated 07/03/19 at 5:00 P.M. indicated the psychiatrist was updated on resident behaviors, fall and medication regimen. New orders were received to decrease Haldol to 5 mg every day. A social service note dated 07/08/19 (Monday) at 3:11 P.M. indicated a care conference was held with Resident #145's guardian. Medications were discussed, along with recent lethargy in the mornings and possible causes. The guardian was updated that the physician visited Saturday and ordered laboratory tests. The note indicated the guardian would be updated on laboratory tests when completed. A nursing note dated 07/09/19 at 5:10 A.M. indicated a blood draw was completed by a laboratory technician for a complete blood count with differential, comprehensive metabolic panel, C-reactive protein (test used to help detect inflammation), hemoglobin A1c (test for mean blood glucose levels), and thyroid stimulating hormone. A urine specimen was also given to the laboratory technician. A nursing note dated 07/09/19 at 11:20 A.M. indicated the psychiatrist visited and was updated on laboratory and urinalysis results. The psychiatrist gave order to discontinue the Haldol. A nursing note dated 07/09/19 at 11:33 A.M. indicated the guardian was updated on new orders to discontinue the Haldol. There was no indication the guardian was notified of laboratory test results. Review of the facility's Change of Condition policy, revised April 2003, indicated a change in condition was defined as a deterioration in the health, mental, or psychosocial status of a resident related to a life-threatening condition, a significant alteration in treatment, or a significant change in the resident's clinical condition or status. Significant changes in resident's clinical condition or status included improvement or decline in sad/anxious mood uneasily altered, behavioral signs uneasily altered or the exhibition of new behaviors, ADL (activities of daily living) physical functioning, balance, safety awareness that resulted in a fall, and new physical or chemical restraint orders or changes to such orders. The Unit Supervisor or Charge Nurse were responsible for notifying the resident, physician and guardian/interested family member of all changes as stated above. The person doing the notification was responsible for documenting all notification in the medical record. On 08/08/19 at 12:57 P.M., the Director of Nursing (DON) was interviewed and stated staff were expected to notify guardians of changes in medications, even if just the dose changed. The DON stated the expectation was the notification would be made in a timely manner but could not state what would be considered timely. The DON stated the facility's policy did not address a time frame for notification. Discussions were made addressing changes in Abilify dosage on 12/29/18 with no notification until 12/31/18. The DON stated she believed the notification was made timely although it was two days after the order was given. Also addressed was the referral for a gastrointestinal (GI) appointment on 01/25/19 with no indication it was discussed with the guardian until 02/07/19. It was brought to the DON's attention that Aspirin was ordered 05/01/19 and changes were made in Lisinopril on 05/21/19 due to low blood pressures as well as a decrease in Haldol on 07/03/19 with no indication medications were addressed with the guardian until the care plan meeting on 07/08/19. The DON was also informed there was no indication the guardian was updated on laboratory results as referred to in the care plan meeting notes 07/08/19. On 08/08/19 at 3:10 P.M., the DON verified she could find no additional information regarding notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #133's eyeglasses were maintained in a functional and comfortable manner. This affected one resident (#133) of two residents reviewed for vision. Findings include: Review of Resident #133's medical record revealed diagnoses including age-related cataract and mild cognitive impairment. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #133 was usually able to make himself understood and he usually understood others. Vision was adequate with use of corrective lenses. During an interview on 08/05/19 at 11:32 A.M., Resident #133 stated the padding on the nose piece on the right side of his glasses was missing. This was confirmed through observation. Resident #133 stated he told one of the nursing assistants (could not recall name) and was told there was nothing staff could do. On 08/06/19 at 10:43 A.M., Resident #133 was observed to propel himself down the hall and stopped by the medication cart. Resident #133 stated he still had no nose pad on the right side of his glasses. Resident #133 removed his eyeglasses to show what he was talking about and the right side of his nose was red where the eyeglasses came into contact. Licensed Practical Nurse (LPN) #700 was present and stated she was made aware of the missing padding on Resident #133's eyeglasses on 08/05/19 and thought she had some padding she could provide. On 08/06/19 at 2:00 P.M., Resident #133's glasses were still missing the padding on the nasal area of the eyeglasses. On 08/06/19 at 2:26 P.M., LPN #700 verified Resident #133 made her aware of the eyeglasses needing repaired on 08/05/19. LPN #700 stated she phoned the nursing office and made them aware. LPN #700 would not identify who she spoke to in the nursing office. On 08/06/19 at 2:41 P.M., LPN #655 stated Resident #133 was a veteran and eyeglass repairs were done through the Veteran's Administration (VA). LPN #655 stated she was not sure what action had been taken to address Resident #133's eyeglasses needing repaired. On 08/06/19 at 3:30 P.M., LPN #655 stated Resident #133's eyeglasses were repaired. On 08/06/19 at 3:31 P.M., Social Service Designee (SSD) #520 stated the facility kept a kit for eye glass repairs which had nose pieces so they were able to repair Resident #133's eye glasses. SSD #520 stated she was not aware of eye glasses needing repaired until it was addressed by the surveyor.

Based on observation, record review and interview the facility failed to ensure Resident #87's respiratory mask used for aerosol treatments was stored in a manner to prevent the spread of infection. This affected one (#87) of 25 residents (#16, #17, #22, #23, #28, #37, #41, #45, #53, #54, #74, #76, #78, #81, #99, #104, #108, #114, #117, #120, #124, #132, #142, #147 and #452) identified by the facility as using aerosol masks for breathing treatments. Findings include: Review of Resident #87's medical record revealed the resident was admitted o the facility on 11/13/12. Resident #87 was under Hospice care with the diagnosis of end stage Parkinson's disease and had an additional diagnosis of chronic obstructive pulmonary disease requiring the use of aerosol or breathing treatments. Review of the physician's orders revealed Resident #87 had a physician order for Ipratropium-Albuterol or DuoNeb and received four breathing treatments each day. This order was written on 06/22/18. An additional order was present for the use of an Albuterol inhalation medication every four hours as needed for shortness of breath. The administration of the breathing treatment required the use of a nebulizer or clear plastic mask which would cover the nose and oral cavity and attached was a tube with a medication cup which would house the medication and provide a space for the medication to become a mist form and inhaled by the resident. Observation on 08/05/19 at 10:13 A.M., 08/06/19 at 6:00 P.M., 08/07/19 at 12:00 P.M. and 08/08/19 at 7:34 A.M. revealed the aerosol mask/nebulizer mask not bagged and on laying the resident's dresser. The clear plastic bag used for storage was empty and was on the floor at the base of the television stand. On 08/08/19 at 08:29 A.M. observation with Administrator #2 and the Director of Nursing (DON) revealed the aerosol mask/nebulizer mask was not being maintained in a bag. The plastic clear bag used for storage was laying under the storage space under the television. Administrator #2 and the DON verified the nebulizer mask should have been in the plastic bag when not in use to help decrease chance of infection. The facility identified 25 residents (#16, #17, #22, #23, #28, #37, #41, #45, #53, #54, #74, #76, #78, #81, #99, #104, #108, #114, #117, #120, #124, #132, #142, #147 and #452) who used aerosol masks for breathing treatments. Review of the facility policy titled Respiratory Equipment Cleaning/Disinfecting, last revised 09/14/18 revealed it was the policy of the facility to maintain respiratory equipment in a manner that prevents the spread of disease and infections. The procedure stated under #5, nebulizers revealed it was the policy to have the ensure the unit was stored clean and dry, and in a plastic bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self-reported incident (SRI) review and interview the facility failed to effectively implement their abuse abuse policy and procedure to prevent incidents of abuse and to ensure all allegations were thoroughly investigated. This affected five residents (#7, #52, #72, #106 and #145) of six residents reviewed for abuse. Findings include: 1. Review of Resident #72's medical record revealed an admission date of 03/15/19 with diagnoses including diabetes, hypertension, vitamin D deficiency, anxiety, chronic pain, depression and dementia with behavioral disturbance. Review of a quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively impaired and required limited assistance for ambulation and dressing. A care plan for Resident #72 revealed he wandered into peer's rooms to take things that did not belong to him. Listed interventions included the resident was sent to the emergency room for medical evaluation (03/23/19) and a colored sign was placed on the door with name identification. Review of nurses' notes from Resident #72's medical record dated 03/22/19 revealed the state tested nursing assistant (STNA) heard residents arguing in the hallway and upon coming into the hallway witnessed Resident #72 and Resident #151 striking at each other. Staff intervened and the residents were assessed. When asked, Resident #151 stated Resident #72 came into his room and grabbed his coffee so he struck him on the face. Resident #72 had red drainage coming from his nose. The doctor was notified, the family was attempted to be notified and Resident #72 was transferred to the emergency room. Resident #72 returned to the facility on [DATE]. Review of a nurse's note dated 03/23/19 revealed the family was reached and updated on Resident #72's condition which included a presumed nasal fracture; Augmentin (antibiotic) and follow up with an ear, nose, throat (ENT), physician specializing in care of the ears, nose and throat were ordered. Review of emergency department paperwork dated 03/23/19 revealed Resident #72 had been treated for a presumed nasal fracture and was to follow up with an ENT. Review of Resident #151's medical record revealed an admission date of 08/01/18 with diagnoses including prostate cancer, chronic obstructive pulmonary disease, hypertension, anxiety and insomnia. A discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #151 had moderate cognitive impairment. Resident #151 was sent to the emergency room on [DATE] for shortness of breath and did not return to the facility. Care plans for Resident #151 revealed a history of false statements and physical aggression towards peers. Review of a facility SRI dated 03/22/19 at 9:30 P.M. revealed an allegation of physical abuse between Resident #72 and Resident #151. Staff observed both residents arguing in the hallway and striking out at each other. The residents were separated and started on safety checks. Resident #151 stated Resident #72 came into his room and started drinking his coffee. Resident #72 did not provide any information. A brightly colored visual aid on Resident #72's doorway was placed as an intervention and Resident #151 was provided a room change. The facility found the allegation of physical abuse to be unsubstantiated. Review of the facility's investigation dated 03/22/19 consisted of a single statement from State Tested Nursing Assistant (STNA) #502. STNA #502 stated he observed Resident #72 and Resident #151 arguing in Resident #151's room. Resident #72 swung out and Resident #151 attempted to deflect by swinging his arms. STNA #502 alerted Licensed Practical Nurse (LPN) #503. Resident #151 stated Resident #72 came into his room and was drinking his coffee. He wanted Resident #72 to leave his room but he swung out at him. Resident #72 did not add information. Notifications were made and Resident #151 was offered a room change. A brightly colored visual aid was placed on Resident #72's doorway to help him identify his own room. There was no information contained in the SRI or facility investigation that indicated Resident #72 had sustained injuries from the altercation and no additional witness statements from staff or residents were available for review. Interview on 08/08/19 at 1:00 P.M. with the Director of Nursing (DON) revealed interviewing additional staff about residents' behavior prior to an incident was part of a thorough investigation and should have been completed. When asked about the incident dated 03/22/19, the DON verified the hitting between Resident #72 and Resident #151, as well as Resident #72's nosebleed and injuries should have been included in the SRI. A follow-up interview on 08/08/19 at 3:07 P.M. with the DON verified Resident #72 did have blood coming from his nose as a result of the resident to resident altercation but did not know if Resident #72 or Resident #151 caused the bleeding as both residents' arms had been swinging around. The DON confirmed Resident #72 had a presumed nasal fracture per the emergency room report. Review of additional information provided to the surveyor on 08/08/19 at 3:07 P.M. revealed communications with outside veteran services revealed Resident #72 was hit in the nose after taking a peer's coffee and his nose would not stop bleeding. He returned to the facility with an order to follow up with an ENT for possible nasal fracture and a computed tomography (CT- x-ray measurements from different angles which produce cross-sectional images of a specific area) scan was requested. Review of a CT scan completed for Resident #72 on 04/04/19 revealed comminuted fractures in the bilateral nasal bones with three millimeters of displacement and rightward angulation of the fracture fragments. Review of an outside provider consultation dated 04/03/19 revealed Resident #72 suffered nasal trauma on 03/23/19 during a peer to peer altercation at the facility. Resident #73 had a shifted nasal pyramid to the left. Surgery for closed reduction of Resident #72' s nose was scheduled for 04/08/19 and completed on that date. Review of a follow-up note dated 04/26/19 revealed Resident #72 was noncompliant with the nasal splints post surgery and pulled them out; more extensive surgical intervention would be required to correct the injury and Resident #72 was to be seen in four months for a follow-up. A follow-up interview was conducted with the DON on 08/08/19 at 4:50 P.M. The surveyor again asked for LPN #503's written statement. The DON stated the SRI report was LPN #503's written statement and verified no additional documentation regarding the resident to resident incident was available for surveyor review. A phone interview was conducted with LPN #503 on 08/08/19 at 6:46 P.M. LPN #503 verified her nurses' note from 03/22/19 and recalled Resident #72 and Resident #151 swinging their arms at each other. LPN #503 stated Resident #72's nose was swollen, didn't look right and had bloody drainage coming from it. LPN #503 shared she had documented in her nurses' note as well as completed a written statement regarding this resident to resident incident. Review of the facility policy on Abuse, Neglect and Misappropriation dated 11/21/16 revealed it was facility policy to investigate all alleged violations involving abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 2. Review of Resident #106's medical record revealed an admission date of 09/11/15 with diagnoses including hypertension (high blood pressure), spinal stenosis, anxiety disorder, recurrent depressive disorders, psychosis, bipolar disorder, dysphagia, dementia with behavioral disturbance, noncompliance and chronic viral hepatitis C. Review of a quarterly MDS 3.0 comprehensive assessment dated [DATE] revealed Resident #106 had moderate cognitive impairment, had inattention behaviors, and had other behavioral symptoms not directed towards others four to six days in the review period. Review of care plans for Resident #106 revealed a care plan for disturbing behavior, verbal and physical aggression and poor impulse control sometimes striking out at peers. Listed interventions included to attempt to identify what triggers behavior, discuss feelings of anger/guilt and options of appropriate channeling of these feelings with resident and educate resident on negative outcomes related to non-compliance. Review of Resident #1's medical record revealed an admission date of 04/11/19 and diagnoses including vitamin D deficiency, dementia with behavioral disturbance, depressive disorder, schizophrenia and diabetes. A MDS 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and had verbal behaviors one to three days in the review period. A care plan for Resident #1 revealed the resident had dementia and behavioral symptoms. Listed interventions included being patient with the resident, monitor for signs and symptoms of frustration and take measures to remove these and provide cues or reminders and address concerns promptly. Review of a facility SRI dated 06/10/19 at 5:30 P.M. revealed an allegation of physical abuse involving Resident #106 and Resident #1. Resident #106 was observed to be getting up the floor in the hallway and stated Resident #1 struck him, causing him to fall. Resident #1 alleged Resident #106 struck him then fell. Both residents were separated. The facility found the allegation to be unsubstantiated. Review of the facility investigation documentation revealed no witnesses were present, safety checks were started, notifications were made and aggression risk assessments were completed. Resident #1 and Resident #106 were examined and interviewed. A single statement was included with the investigation from Registered Nurse (RN) #500 revealed she noted Resident #106 getting up off the floor and that he stated Resident #1 struck him on the face and he fell. Resident #1 stated Resident #106 had been standing next to him, told him to sit down and called him names, hit him in the face then fell. The residents were separated, both residents were noted to be confused. No other staff or resident statements were included with the facility's investigation. Review of a nurses' note from Resident #106's medical record dated 06/10/19 at 5:30 P.M. revealed RN #500 noted Resident #106 getting up the floor of the hallway, agitated and arguing with his peer, Resident #1. When asked, Resident #106 stated Resident #1 struck him on the face and he fell. Resident #106 denied hitting Resident #1. Resident #106 was assessed, placed on 15-minute safety checks and the physician and family were notified. Review of a nurse's note in Resident #1's medical record dated 06/11/19 revealed Resident #1 was agitated about having neurological checks done, stating he didn't hit me and I didn't hit him, we were just swinging our hands in the air, missing each other. Interview on 08/08/19 at 1:00 P.M. with the Director of Nursing (DON) revealed interviewing staff about residents' behavior prior to an incident was part of a thorough investigation and acknowledged that should have been done with the investigation. When asked about the incident on 06/10/19, the DON stated Resident #1's comment about neither resident hitting each other could have been included with the facility investigation. The DON agreed as the incident occurred in the hallway, there could have been other witnesses to interview as part of a thorough investigation. A follow-up interview on 08/08/19 at 3:07 P.M. with the DON verified there was no additional information for review regarding the SRI investigation on 06/10/19. Review of the facility policy on Abuse, Neglect and Misappropriation dated 11/21/16 revealed it was facility policy to investigate all alleged violations involving abuse. The facility was to ensure all allegations were reported immediately to the Administrator and have evidence all alleged violations were thoroughly investigated. The policy did not clearly identify what constituted a thorough investigation and did not give extensive guidance on preventing and investigating resident to resident incidents. 3. Review of Resident #52' s medical record revealed an admission date of 01/30/18 with diagnoses including chronic obstructive pulmonary disease, dysphagia (difficulty swallowing), mild intellectual disabilities, noncompliance, unspecified mental disorder due to known physiological condition, bipolar disorder and paranoid schizophrenia. A quarterly MDS 3.0 comprehensive assessment dated [DATE] revealed Resident #52 had moderate cognitive impairment and wandered, had verbal and other behaviors not directed towards others on a daily basis. A care plan for Resident #52 revealed the resident had cognitive impairment and required oversight, cues and assistance daily with noted behaviors including yelling out daily, pacing and verbal aggression. Listed interventions included monitoring for changes in cognition and monitor for signs and symptoms of frustration and take measures to remove these. Review of Resident #108's medical record revealed an admission date of 04/23/13 and diagnoses including dysphagia (difficulty swallowing), impulse disorder, anxiety, diabetes and Parkinson's disease. A significant change MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Care plans revealed Resident #108 received Hospice services. Review of a facility SRI dated 03/29/19 at 6:45 P.M. revealed an allegation of physical abuse involving Resident #52 and Resident #108. When Resident #52 was attempted to be interviewed, he stated, I don't want to talk about it. Resident #108 was interviewed and revealed Resident #52 kept turning the light on and off so he struck out at Resident #52. The facility determined the allegation to be unsubstantiated. Review of the corresponding facility investigation revealed a single statement written by Licensed Practical Nurse (LPN) #501 dated 03/29/19. LPN #501 heard Resident #52 yelling, get him off of me as she turned from the medication cart and saw him in the doorway of his room and he left before she could enter the room. Resident #108 was sitting in his wheelchair next to Resident #52's bed. LPN #501 asked Resident #108 what happened and he stated Resident #52 wouldn't leave the light on and he said he punched his arm. LPN #501 attempted to interview Resident #52 and he stated, I don't want to talk about it, it's not worth it, and refused assessment. Both residents were started on 15-minute checks. No additional resident or staff statements were available for review as part of the facility's investigation. A nurses' note from Resident #52's medical record dated 03/29/19 and written by LPN #501 revealed she heard Resident #52 yell, get him off of me and saw the resident in the doorway of his room but he left before she could enter. Resident #52 told staff he did not want to talk about it and it's not worth it. Resident #52 denied injury and refused assessment; notifications were made and 15 minute checks were initiated. Interview on 08/08/19 at 1:00 P.M. with the Director of Nursing (DON) revealed interviewing staff about residents' behaviors prior to an incident was part of a thorough investigation and acknowledged that should have been done with the investigation. The DON agreed there could have been other witnesses to interview as part of a thorough investigation. A follow-up interview on 08/08/19 at 3:07 P.M. with the DON verified there was no additional information for review regarding the SRI investigation on 03/29/19. Review of the facility policy on Abuse, Neglect and Misappropriation dated 11/21/16 revealed it was facility policy to investigate all alleged violations involving abuse. The facility was to ensure all allegations were reported immediately to the Administrator and have evidence all alleged violations were thoroughly investigated. The policy did not clearly identify what constituted a thorough investigation and did not give extensive guidance on preventing and investigating resident to resident incidents. 4. Review of Resident #7's medical record revealed an initial admission date of 04/29/09. Diagnoses included end stage renal disease, anemia, anxiety disorder, history of a traumatic brain injury, bipolar disorder, paranoid schizophrenia, personality disorder, and mild cognitive impairment. A plan of care initiated 05/06/09 indicated Resident #7 had the potential for impaired social interaction related to impaired cognition, insight, and judgment. Resident #7 had a tendency to keep to himself and pace hallways. Resident #7 exhibited mood states that were not easily altered. Interventions included allowing Resident #7 to wander freely within the unit/facility and to encourage self-control and problem solving. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was able to make himself understood and was usually able to understand others. Resident #7 was assessed as having no short or long term memory problems and moderately impaired cognitive skills for daily decision making. Resident #7 had behavioral symptoms not directed toward others every day. Resident #7 walked in the corridor and in his room with supervision. Review of a facility SRI revealed on 07/06/18 Resident #7 reported to staff that Resident #455 had attempted to strike out at him while in front of the nursing station. The investigation indicated during the investigation Resident #7 was unwilling to give more details and Resident #455 was unable to provide details. Both residents were placed on safety checks. Review of the facility's investigation revealed Resident #146 was listed as a witness. The summary of the incident revealed Resident #146 reported Resident #455 was looking for a fight. There was no evidence Resident #146 was interviewed regarding what he meant when he stated Resident #455 was looking for a fight. There was no interview indicating Resident #146 was asked what he observed. On 08/07/19 at 5:12 P.M., the Director of Nursing (DON) was interviewed regarding the incident that occurred on 07/06/18. The DON stated she recalled when Resident #146 stated Resident #455 was looking for a fight all Resident #455 did was enter Resident #7's room. On 08/08/19 at 3:10 P.M., the DON was again interviewed regarding her statement that when Resident #146 reported Resident #455 was looking for fight it was because Resident #455 wandered into Resident #7's room. However, the investigation revealed the incident occurred in front of the nursing station. The DON verified the discrepancy. The DON verified she had not received clarification regarding what Resident #146 meant or what he observed. The DON verified with Resident #146 being the only witness, it would have been imperative to determine if something had precipitated the interaction in order to identify triggers and prevent possible further aggressive behaviors. When the DON was informed the investigation did not appear to be complete as was referred to in the abuse policy, she did not disagree. 5. Review of Resident #145's medical record revealed an initial admission date of 02/22/11. Diagnoses included dementia, unsteadiness on his feet, generalized muscle weakness, history of traumatic brain injury, anxiety disorder, schizoaffective disorder, borderline personality disorder, and psychosis. An annual MDS assessment dated [DATE] indicated Resident #145 had unclear speech. Resident #145 was usually able to make himself understood and usually understood others. Resident #145 was assessed with short and long term memory problems and had moderately impaired cognitive skills for daily decision making. Resident #145 exhibited behavioral symptoms not directed toward others daily. The assessment indicated Resident #145's behaviors did not place him or others at risk. Resident #145 wandered daily but not to potentially dangerous places and wandering did not significantly intrude on the privacy or activities of others. Resident #145 required supervision while walking in the room and corridor. A nursing note dated 03/18/19 at 6:15 P.M. indicated staff observed another resident holding onto Resident #145 at the waist on the floor. The other resident was striking out at Resident #145 and staff separated the residents. Review of a facility SRI revealed on 03/18/19 staff observed Resident #455 holding onto Resident #145's waist and they were on the floor. The SRI indicated Resident #455 attempted to strike Resident #145. After being separated, Resident #455 wandered over to Resident #550 and put his arms around her waist while she was seated in her wheelchair. Staff immediately separated and redirected both residents. The SRI revealed Resident #550 stated she was alright and said Resident #455 was a confused man. Review of the facility investigation of the incident did not include an interview from Resident #550 to determine what, if anything, she observed occur between Residents #145 and #455. On 08/08/19 at 3:10 P.M., the DON verified Resident #550 had not been interviewed regarding the altercation between Residents #145 and #455. The DON was informed the investigation did not appear to be thorough as addressed in the facility's abuse policy without the interview of the possible witness. The DON indicated she had no additional information. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16, revealed in the case of resident to resident abuse, the parties were separated from one another until the investigation was completed. The policy indicated all alleged violations involving abuse were to be thoroughly investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self-reported incident (SRI) review and interview the facility failed to ensure all abuse allegations were thoroughly investigated. This affected five residents (#7, #52, #72, #106 and #145) of six residents reviewed for abuse. Findings include: 1. Review of Resident #72's medical record revealed an admission date of 03/15/19 with diagnoses including diabetes, hypertension, vitamin D deficiency, anxiety, chronic pain, depression and dementia with behavioral disturbance. Review of a quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively impaired and required limited assistance for ambulation and dressing. A care plan for Resident #72 revealed he wandered into peer's rooms to take things that did not belong to him. Listed interventions included the resident was sent to the emergency room for medical evaluation (03/23/19) and a colored sign was placed on the door with name identification. Review of nurses' notes from Resident #72's medical record dated 03/22/19 revealed the state tested nursing assistant (STNA) heard residents arguing in the hallway and upon coming into the hallway witnessed Resident #72 and Resident #151 striking at each other. Staff intervened and the residents were assessed. When asked, Resident #151 stated Resident #72 came into his room and grabbed his coffee so he struck him on the face. Resident #72 had red drainage coming from his nose. The doctor was notified, the family was attempted to be notified and Resident #72 was transferred to the emergency room. Resident #72 returned to the facility on [DATE]. Review of a nurse's note dated 03/23/19 revealed the family was reached and updated on Resident #72's condition which included a presumed nasal fracture; Augmentin (antibiotic) and follow up with an ear, nose, throat (ENT), physician specializing in care of the ears, nose and throat were ordered. Review of emergency department paperwork dated 03/23/19 revealed Resident #72 had been treated for a presumed nasal fracture and was to follow up with an ENT. Review of Resident #151's medical record revealed an admission date of 08/01/18 with diagnoses including prostate cancer, chronic obstructive pulmonary disease, hypertension, anxiety and insomnia. A discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #151 had moderate cognitive impairment. Resident #151 was sent to the emergency room on [DATE] for shortness of breath and did not return to the facility. Care plans for Resident #151 revealed a history of false statements and physical aggression towards peers. Review of a facility SRI dated 03/22/19 at 9:30 P.M. revealed an allegation of physical abuse between Resident #72 and Resident #151. Staff observed both residents arguing in the hallway and striking out at each other. The residents were separated and started on safety checks. Resident #151 stated Resident #72 came into his room and started drinking his coffee. Resident #72 did not provide any information. A brightly colored visual aid on Resident #72's doorway was placed as an intervention and Resident #151 was provided a room change. The facility found the allegation of physical abuse to be unsubstantiated. Review of the facility's investigation dated 03/22/19 consisted of a single statement from State Tested Nursing Assistant (STNA) #502. STNA #502 stated he observed Resident #72 and Resident #151 arguing in Resident #151's room. Resident #72 swung out and Resident #151 attempted to deflect by swinging his arms. STNA #502 alerted Licensed Practical Nurse (LPN) #503. Resident #151 stated Resident #72 came into his room and was drinking his coffee. He wanted Resident #72 to leave his room but he swung out at him. Resident #72 did not add information. Notifications were made and Resident #151 was offered a room change. A brightly colored visual aid was placed on Resident #72's doorway to help him identify his own room. There was no information contained in the SRI or facility investigation that indicated Resident #72 had sustained injuries from the altercation and no additional witness statements from staff or residents were available for review. Interview on 08/08/19 at 1:00 P.M. with the Director of Nursing (DON) revealed interviewing additional staff about residents' behavior prior to an incident was part of a thorough investigation and should have been completed. When asked about the incident dated 03/22/19, the DON verified the hitting between Resident #72 and Resident #151, as well as Resident #72's nosebleed and injuries should have been included in the SRI. A follow-up interview on 08/08/19 at 3:07 P.M. with the DON verified Resident #72 did have blood coming from his nose as a result of the resident to resident altercation but did not know if Resident #72 or Resident #151 caused the bleeding as both residents' arms had been swinging around. The DON confirmed Resident #72 had a presumed nasal fracture per the emergency room report. Review of additional information provided to the surveyor on 08/08/19 at 3:07 P.M. revealed communications with outside veteran services revealed Resident #72 was hit in the nose after taking a peer's coffee and his nose would not stop bleeding. He returned to the facility with an order to follow up with an ENT for possible nasal fracture and a computed tomography (CT- x-ray measurements from different angles which produce cross-sectional images of a specific area) scan was requested. Review of a CT scan completed for Resident #72 on 04/04/19 revealed comminuted fractures in the bilateral nasal bones with three millimeters of displacement and rightward angulation of the fracture fragments. Review of an outside provider consultation dated 04/03/19 revealed Resident #72 suffered nasal trauma on 03/23/19 during a peer to peer altercation at the facility. Resident #73 had a shifted nasal pyramid to the left. Surgery for closed reduction of Resident #72' s nose was scheduled for 04/08/19 and completed on that date. Review of a follow-up note dated 04/26/19 revealed Resident #72 was noncompliant with the nasal splints post surgery and pulled them out; more extensive surgical intervention would be required to correct the injury and Resident #72 was to be seen in four months for a follow-up. A follow-up interview was conducted with the DON on 08/08/19 at 4:50 P.M. The surveyor again asked for LPN #503's written statement. The DON stated the SRI report was LPN #503's written statement and verified no additional documentation regarding the resident to resident incident was available for surveyor review. A phone interview was conducted with LPN #503 on 08/08/19 at 6:46 P.M. LPN #503 verified her nurses' note from 03/22/19 and recalled Resident #72 and Resident #151 swinging their arms at each other. LPN #503 stated Resident #72's nose was swollen, didn't look right and had bloody drainage coming from it. LPN #503 shared she had documented in her nurses' note as well as completed a written statement regarding this resident to resident incident. Review of the facility policy on Abuse, Neglect and Misappropriation dated 11/21/16 revealed it was facility policy to investigate all alleged violations involving abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 2. Review of Resident #106's medical record revealed an admission date of 09/11/15 with diagnoses including hypertension (high blood pressure), spinal stenosis, anxiety disorder, recurrent depressive disorders, psychosis, bipolar disorder, dysphagia, dementia with behavioral disturbance, noncompliance and chronic viral hepatitis C. Review of a quarterly MDS 3.0 comprehensive assessment dated [DATE] revealed Resident #106 had moderate cognitive impairment, had inattention behaviors, and had other behavioral symptoms not directed towards others four to six days in the review period. Review of care plans for Resident #106 revealed a care plan for disturbing behavior, verbal and physical aggression and poor impulse control sometimes striking out at peers. Listed interventions included to attempt to identify what triggers behavior, discuss feelings of anger/guilt and options of appropriate channeling of these feelings with resident and educate resident on negative outcomes related to non-compliance. Review of Resident #1's medical record revealed an admission date of 04/11/19 and diagnoses including vitamin D deficiency, dementia with behavioral disturbance, depressive disorder, schizophrenia and diabetes. A MDS 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and had verbal behaviors one to three days in the review period. A care plan for Resident #1 revealed the resident had dementia and behavioral symptoms. Listed interventions included being patient with the resident, monitor for signs and symptoms of frustration and take measures to remove these and provide cues or reminders and address concerns promptly. Review of a facility SRI dated 06/10/19 at 5:30 P.M. revealed an allegation of physical abuse involving Resident #106 and Resident #1. Resident #106 was observed to be getting up the floor in the hallway and stated Resident #1 struck him, causing him to fall. Resident #1 alleged Resident #106 struck him then fell. Both residents were separated. The facility found the allegation to be unsubstantiated. Review of the facility investigation documentation revealed no witnesses were present, safety checks were started, notifications were made and aggression risk assessments were completed. Resident #1 and Resident #106 were examined and interviewed. A single statement was included with the investigation from Registered Nurse (RN) #500 revealed she noted Resident #106 getting up off the floor and that he stated Resident #1 struck him on the face and he fell. Resident #1 stated Resident #106 had been standing next to him, told him to sit down and called him names, hit him in the face then fell. The residents were separated, both residents were noted to be confused. No other staff or resident statements were included with the facility's investigation. Review of a nurses' note from Resident #106's medical record dated 06/10/19 at 5:30 P.M. revealed RN #500 noted Resident #106 getting up the floor of the hallway, agitated and arguing with his peer, Resident #1. When asked, Resident #106 stated Resident #1 struck him on the face and he fell. Resident #106 denied hitting Resident #1. Resident #106 was assessed, placed on 15-minute safety checks and the physician and family were notified. Review of a nurse's note in Resident #1's medical record dated 06/11/19 revealed Resident #1 was agitated about having neurological checks done, stating he didn't hit me and I didn't hit him, we were just swinging our hands in the air, missing each other. Interview on 08/08/19 at 1:00 P.M. with the Director of Nursing (DON) revealed interviewing staff about residents' behavior prior to an incident was part of a thorough investigation and acknowledged that should have been done with the investigation. When asked about the incident on 06/10/19, the DON stated Resident #1's comment about neither resident hitting each other could have been included with the facility investigation. The DON agreed as the incident occurred in the hallway, there could have been other witnesses to interview as part of a thorough investigation. A follow-up interview on 08/08/19 at 3:07 P.M. with the DON verified there was no additional information for review regarding the SRI investigation on 06/10/19. Review of the facility policy on Abuse, Neglect and Misappropriation dated 11/21/16 revealed it was facility policy to investigate all alleged violations involving abuse. The facility was to ensure all allegations were reported immediately to the Administrator and have evidence all alleged violations were thoroughly investigated. The policy did not clearly identify what constituted a thorough investigation and did not give extensive guidance on preventing and investigating resident to resident incidents. 3. Review of Resident #52' s medical record revealed an admission date of 01/30/18 with diagnoses including chronic obstructive pulmonary disease, dysphagia (difficulty swallowing), mild intellectual disabilities, noncompliance, unspecified mental disorder due to known physiological condition, bipolar disorder and paranoid schizophrenia. A quarterly MDS 3.0 comprehensive assessment dated [DATE] revealed Resident #52 had moderate cognitive impairment and wandered, had verbal and other behaviors not directed towards others on a daily basis. A care plan for Resident #52 revealed the resident had cognitive impairment and required oversight, cues and assistance daily with noted behaviors including yelling out daily, pacing and verbal aggression. Listed interventions included monitoring for changes in cognition and monitor for signs and symptoms of frustration and take measures to remove these. Review of Resident #108's medical record revealed an admission date of 04/23/13 and diagnoses including dysphagia (difficulty swallowing), impulse disorder, anxiety, diabetes and Parkinson's disease. A significant change MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Care plans revealed Resident #108 received Hospice services. Review of a facility SRI dated 03/29/19 at 6:45 P.M. revealed an allegation of physical abuse involving Resident #52 and Resident #108. When Resident #52 was attempted to be interviewed, he stated, I don't want to talk about it. Resident #108 was interviewed and revealed Resident #52 kept turning the light on and off so he struck out at Resident #52. The facility determined the allegation to be unsubstantiated. Review of the corresponding facility investigation revealed a single statement written by Licensed Practical Nurse (LPN) #501 dated 03/29/19. LPN #501 heard Resident #52 yelling, get him off of me as she turned from the medication cart and saw him in the doorway of his room and he left before she could enter the room. Resident #108 was sitting in his wheelchair next to Resident #52's bed. LPN #501 asked Resident #108 what happened and he stated Resident #52 wouldn't leave the light on and he said he punched his arm. LPN #501 attempted to interview Resident #52 and he stated, I don't want to talk about it, it's not worth it, and refused assessment. Both residents were started on 15-minute checks. No additional resident or staff statements were available for review as part of the facility's investigation. A nurses' note from Resident #52's medical record dated 03/29/19 and written by LPN #501 revealed she heard Resident #52 yell, get him off of me and saw the resident in the doorway of his room but he left before she could enter. Resident #52 told staff he did not want to talk about it and it's not worth it. Resident #52 denied injury and refused assessment; notifications were made and 15 minute checks were initiated. Interview on 08/08/19 at 1:00 P.M. with the Director of Nursing (DON) revealed interviewing staff about residents' behaviors prior to an incident was part of a thorough investigation and acknowledged that should have been done with the investigation. The DON agreed there could have been other witnesses to interview as part of a thorough investigation. A follow-up interview on 08/08/19 at 3:07 P.M. with the DON verified there was no additional information for review regarding the SRI investigation on 03/29/19. Review of the facility policy on Abuse, Neglect and Misappropriation dated 11/21/16 revealed it was facility policy to investigate all alleged violations involving abuse. The facility was to ensure all allegations were reported immediately to the Administrator and have evidence all alleged violations were thoroughly investigated. The policy did not clearly identify what constituted a thorough investigation and did not give extensive guidance on preventing and investigating resident to resident incidents. 4. Review of Resident #7's medical record revealed an initial admission date of 04/29/09. Diagnoses included end stage renal disease, anemia, anxiety disorder, history of a traumatic brain injury, bipolar disorder, paranoid schizophrenia, personality disorder, and mild cognitive impairment. A plan of care initiated 05/06/09 indicated Resident #7 had the potential for impaired social interaction related to impaired cognition, insight, and judgment. Resident #7 had a tendency to keep to himself and pace hallways. Resident #7 exhibited mood states that were not easily altered. Interventions included allowing Resident #7 to wander freely within the unit/facility and to encourage self-control and problem solving. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was able to make himself understood and was usually able to understand others. Resident #7 was assessed as having no short or long term memory problems and moderately impaired cognitive skills for daily decision making. Resident #7 had behavioral symptoms not directed toward others every day. Resident #7 walked in the corridor and in his room with supervision. Review of a facility SRI revealed on 07/06/18 Resident #7 reported to staff that Resident #455 had attempted to strike out at him while in front of the nursing station. The investigation indicated during the investigation Resident #7 was unwilling to give more details and Resident #455 was unable to provide details. Both residents were placed on safety checks. Review of the facility's investigation revealed Resident #146 was listed as a witness. The summary of the incident revealed Resident #146 reported Resident #455 was looking for a fight. There was no evidence Resident #146 was interviewed regarding what he meant when he stated Resident #455 was looking for a fight. There was no interview indicating Resident #146 was asked what he observed. On 08/07/19 at 5:12 P.M., the Director of Nursing (DON) was interviewed regarding the incident that occurred on 07/06/18. The DON stated she recalled when Resident #146 stated Resident #455 was looking for a fight all Resident #455 did was enter Resident #7's room. On 08/08/19 at 3:10 P.M., the DON was again interviewed regarding her statement that when Resident #146 reported Resident #455 was looking for fight it was because Resident #455 wandered into Resident #7's room. However, the investigation revealed the incident occurred in front of the nursing station. The DON verified the discrepancy. The DON verified she had not received clarification regarding what Resident #146 meant or what he observed. The DON verified with Resident #146 being the only witness, it would have been imperative to determine if something had precipitated the interaction in order to identify triggers and prevent possible further aggressive behaviors. When the DON was informed the investigation did not appear to be complete as was referred to in the abuse policy, she did not disagree. 5. Review of Resident #145's medical record revealed an initial admission date of 02/22/11. Diagnoses included dementia, unsteadiness on his feet, generalized muscle weakness, history of traumatic brain injury, anxiety disorder, schizoaffective disorder, borderline personality disorder, and psychosis. An annual MDS assessment dated [DATE] indicated Resident #145 had unclear speech. Resident #145 was usually able to make himself understood and usually understood others. Resident #145 was assessed with short and long term memory problems and had moderately impaired cognitive skills for daily decision making. Resident #145 exhibited behavioral symptoms not directed toward others daily. The assessment indicated Resident #145's behaviors did not place him or others at risk. Resident #145 wandered daily but not to potentially dangerous places and wandering did not significantly intrude on the privacy or activities of others. Resident #145 required supervision while walking in the room and corridor. A nursing note dated 03/18/19 at 6:15 P.M. indicated staff observed another resident holding onto Resident #145 at the waist on the floor. The other resident was striking out at Resident #145 and staff separated the residents. Review of a facility SRI revealed on 03/18/19 staff observed Resident #455 holding onto Resident #145's waist and they were on the floor. The SRI indicated Resident #455 attempted to strike Resident #145. After being separated, Resident #455 wandered over to Resident #550 and put his arms around her waist while she was seated in her wheelchair. Staff immediately separated and redirected both residents. The SRI revealed Resident #550 stated she was alright and said Resident #455 was a confused man. Review of the facility investigation of the incident did not include an interview from Resident #550 to determine what, if anything, she observed occur between Residents #145 and #455. On 08/08/19 at 3:10 P.M., the DON verified Resident #550 had not been interviewed regarding the altercation between Residents #145 and #455. The DON was informed the investigation did not appear to be thorough as addressed in the facility's abuse policy without the interview of the possible witness. The DON indicated she had no additional information. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16, revealed in the case of resident to resident abuse, the parties were separated from one another until the investigation was completed. The policy indicated all alleged violations involving abuse were to be thoroughly investigated.