**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, facility investigation, medical record review, observation and interview, the facility failed to prevent abuse of 1 resident (#2) of 5 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect, Misappropriation Protocol revised 2/2018 showed .policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .abuse is the willful inflection of injury .willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #2 was admitted to the facility on [DATE] and discharged on 4/13/2023 with diagnoses including Dysphagia, Neurocognitive Disorder with Lewy Bodies, Dementia, Alzheimer's Disease, and Schizoaffective Disorder. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Staff interview showed both short- and long-term memory problems. The resident had behaviors of physical behavioral symptoms directed toward others 1 to 3 days, verbal behavioral symptoms directed toward others 1 to 3 days, other behavioral symptoms not directed toward others 1 to 3 days, rejection of care 1 to 3 days during the assessment period. The resident was dependent with 2-person assist with dressing, toilet use, personal hygiene, dependent with 1-person assist with eating, extensive assistance with 2-person assist with bed mobility, transfer, extensive assist 1-person assist with locomotion, walking did not occur, and always incontinent of bowel and bladder Review of a Facility Investigation Report dated 3/20/2023 showed Certified Nursing Assistant (CNA) #2 was assisting Resident #2 with his breakfast when Resident #3 was brought to the table beside Resident #2. Within a couple of minutes Resident #3 hit Resident #2 in the face with a washcloth. The CNAs immediately separated the residents and moved Resident #3. Emotional support was given to Resident #2. Staff was instructed that if Resident #3 became sick again to move him to the other side of his room to clean room as he did not have a roommate and would rather have been in his room. Summary of Incident Investigation Resident #2 experienced unprovoked slap in the face with a dry washcloth by another resident who was sitting next to him in the dining room. Emotional support was given. Patient with no change in his behavior unable to recall event a few minutes later. Patients separated immediately. Abuse policy reviewed with staff. Do not place other resident near Resident #2 when in dining room. Move Resident #3 to the other side of his room when housekeeping is cleaning his room. Avoid sitting him too close to other residents when up in dining room as much as possible. Review of Resident #2's Nurses' Progress Note dated 3/20/2023 showed .Pt. [patient] was sitting beside another resident in the dining room when [Resident #2] experienced an unprovoked slap in the face with a dry washcloth. Other resident stated, 'he was looking at me.' No injury noted no red marks. Pt.'s [patients] separated immediately. Emotional support given. No change in [Resident #2's] behavior and unable to recall event a few minutes later . Review of Resident #2's comprehensive care plan revised on 3/20/2023 showed .incident with another resident. No injury noted. Residents separated .emotional support was given to [Resident #2] . Review of Resident #2's Nurses' Progress Note dated 3/21/2023 at 12:00 AM, showed .no c/o [complain of] pain or s/s [signs/symptoms] injury or emotional distress noted at this time d/t [due to] recent R/R [resident to resident] incident . Review of Resident #2's Nurses' Progress Note dated 3/21/2023 at 9:00 AM, showed .no c/o pain/discomfort or distress noted or emotional distress at this time d/t recent R/R incident . Review of Resident #2's Nurses' Progress Note dated 3/22/2023 at 9:00 AM, showed .no c/o pain or discomfort noted . Review of Resident #2's Nurses' Progress Note dated 3/23/2023 12:00 AM showed .no behavior issues noted this past shift no s/s of distress .no s/s of any pain or discomfort at this time . Resident #3 was admitted to the facility on [DATE] and discharged on 6/27/2023 with diagnoses including Malignant Neoplasm of Prostate, Spinal stenosis, Polyarthritis, Cerebral Infarction, Dementia, Dysphagia, Gastrointestinal Hemorrhage, Esophagitis, Adult Failure to Thrive, Nausea with Vomiting, Diverticulum of Esophagus, and Diaphragmatic Hernia. Review of Resident #3's comprehensive care plan showed the care plan was revised on 1/2/2023 and showed .continues to verbally and physically abusive towards staff and attempts with residents, intervened by staff. Refuses meds showers, care often . Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 7 indicating severe cognitive impairment. The resident exhibited behavioral symptoms of physical behavioral symptoms toward others 1 to 3 days, verbal behavioral symptoms toward others 1 to 3 days, rejection of care 4 to 6 days during the assessment period. The resident required limited assistance with 1-person assist with bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, supervision with set up for eating, and was occasionally incontinent of bladder, frequently incontinent of bowel. Review of Resident #3's Nurses Note dated 3/20/2023 showed .this nurse spoke with resident prior to following incident resident was pleasant. Res. [resident] had been moved out of his room for housekeeping to clean his room. Res was placed beside another resident. [Resident #3] became unexpectedly upset and struck another resident in the face with a dry washcloth that [Resident #3] was holding in his hand. Stated he became 'mad' because the other res was 'looking at him' also stated he 'didn't like being moved out of his room.' Res was separated and emotional support. No injury, new order move Res to other side of room when housekeeping is cleaning [Resident #3's] room. Avoid setting Res to close to other Res. When up in day room as much as possible . Review of Resident #3's comprehensive care plan showed the care plan was revised on 3/20/2023 and showed .incident with another resident .new interventions from incident .move [Resident #3] to the other side of room when housekeeping is cleaning his room .avoid sitting to close to other residents when up in day room as much as possible . During an interview with Licensed Practical Nurse (LPN) #1 on 6/26/2023 at 7:50 AM, she stated .I was passing medications .I didn't see him actually hit him .they used to be roommates when [Resident #2] was first admitted .[Resident #2] was in the dining room .the housekeeper was cleaning [Resident #3]'s room .he did vomit often due to his esophagus, in the past he had to go out to get his esophagus stretched .the CNA brought him to the dining room, before she took him in, I asked her to wait and let me rub his feet with lotion. He was in a good mood he wasn't combative or agitated .he raised both feet up for me and let me take his socks off with ease. Not even 5 minutes of him being in the dining room .the CNA came to me and said she had parked [Resident #3] by [Resident #2] in the dining room, and [Resident #3] had a dry rag in his lap, [Resident #2] was setting there and [Resident #3] accused [Resident 2] of looking at him and [Resident #3] took his dry rag and swatted [Resident #2] in the face. [Resident #2] was declining and sadly he didn't even realize what had happened .we removed [Resident #3] away from [Resident #2] when I asked [Resident #3] why he had done that he stated he was mad because he had been removed from his room. I took him back to his room, and told him he could eat in his room if he liked and we kept them separated for the rest of the time before [Resident #2] passed away .there were no marks, no redness on his face and no response at all from [Resident #2] .there was no change in his mood or demeanor after the incident . During an interview with CNA #2 on 6/26/2023 at 8:10 AM, she stated .it happened shortly before [Resident #2] passed away .initially [Resident #2] was aggressive and he was [Resident #3's] roommate. I am not aware of any incidents occurring between them but [Resident #3] just didn't like [Resident #2] .The CNA was not a regular on the unit so she brought him to the table where I was assisting [Resident #2] with his breakfast .it had been so long since they were roommates and honestly I didn't think anything about it .[Resident #2] had been out to Geri-psych, he was no longer aggressive, he had declined mentally and physically and I didn't think about anything happening .[Resident #3] was rolled to the side of the table .he had a rag in his lap and he just took his rag and flung his arm out with the rag in his hand and hit [Resident #2] in the face .I said [Resident #3] why did you do that and he said because I don't like him .we immediately separated them .[Resident #3] was taken back to his room .[Resident #2] didn't act like he even knew anything had happened .we told the nurse and she assessed him there were no red marks, scratches or anything .he didn't ever get any bruising or it didn't ever turn red, he was never upset, there were no changes in his behaviors .we had been sitting there laughing but he didn't really know what he was laughing about but on his good days everything was funny to him, after the incident he stayed in a good mood and kept laughing .yes he hit [Resident #2] on purpose . During an interview with CNA #1 on 6/26/2023 at 8:35 AM, she stated .I don't know if anything was said between them before or not, but I did see [Resident #3] [NAME] the rag at [Resident #2] hitting him in the face .yes he meant to hit him it was deliberate .I didn't talk to either resident immediately after the incident .I didn't see any changes in him after the incident .I didn't see any marks on [Resident #2] after the incident .he didn't act like he knew anything had happened .[Resident #3] could get hateful with residents he didn't like to be called buddy and he would get mad .he would call staff names and say stuff out in general but it wouldn't be directed to a particular resident . During an interview with CNA #3 on 6/26/2023 at 11:50 AM, she stated .I am not aware of [Resident #3] ever making contact with any other resident .he would toss things like empty bowls in a resident's direction, but he never hit anyone and it was more of a toss than a throw with an intention to hit someone .he didn't like having a roommate but I never saw him be physically aggressive to any resident only staff until he hit [Resident #2] . Observation and interview of Resident #3 on 6/26/2023 at 12:30 PM, in his room showed the resident lying in bed turned toward the wall, laying with his legs drawn up midway to his chest. No odor or signs of incontinence or apparent distress were noted. Attempted interview with Resident #3 was unsucessful. During an interview with CNA #5 on 6/27/2023 at 12:00 PM, she stated .I wasn't here the day it happened but I was told about it and was told not to seat [Resident #3] at the table with any other resident .he moved to .real soon after it happened maybe the next day .he could get aggravated at the staff and other residents and say stuff like shut up .some days he was nice and told us he loved us then other days he would be aggressive and combative with care .he has hit me a few times .there was something with these two before .I remember it was right after [Resident #2] came back from Geri-psych .I think that was maybe October .I don't remember exactly what happened but I remember having to sign an in-service paper .I don't think it was an altercation . During an interview with the Director of Nursing (DON) on 6/27/2023 at 2:40 PM, the DON confirmed the facility substantiated the resident to resident incident as abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, facility investigation, medical record review, observation and interview, the facility failed to report the results of an abuse investigation within the required time period for 1 resident (#2) of 5 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect, Misappropriation Protocol revised 2/2018 showed .policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .6 .there are two time limits for reporting of reasonable suspicion of a crime .allegation of abuse and/or serious bodily injury-2 hour time limit .8 .the results of the investigative findings are to be reported in 5 working days . Resident #2 was admitted to the facility on [DATE] and discharged on 4/13/2023 with diagnoses including Dysphagia, Neurocognitive Disorder with Lewy Bodies, Dementia, Alzheimer's Disease, and Schizoaffective Disorder. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Staff interview showed both short- and long-term memory problems. The resident had behaviors of physical behavioral symptoms directed toward others 1 to 3 days, verbal behavioral symptoms directed toward others 1 to 3 days, other behavioral symptoms not directed toward others 1 to 3 days, rejection of care 1 to 3 days during the assessment period. Review of a Facility Investigation Report dated 3/20/2023 showed Certified Nursing Assistant (CNA) #2 was assisting Resident #2 with his breakfast when Resident #3 was brought to the table beside Resident #2. Within a couple of minutes Resident #3 hit Resident #2 in the face with a washcloth. The CNAs immediately separated the residents and moved Resident #3. Summary of Incident Investigation Resident #2 experienced unprovoked slap in the face with a dry washcloth by another resident who was sitting next to him in the dining room. Emotional support was given. Patient with no change in his behavior unable to recall event a few minutes later. Patients separated immediately. Review of Resident #2's Nurses' Progress Note dated 3/20/2023 showed .Pt. [patient] was sitting beside another resident in the dining room when [Resident #2] experienced an unprovoked slap in the face with a dry washcloth. Other resident stated, 'he was looking at me.' No injury noted no red marks. Pt.'s separated immediately. Emotional support given. No change in [Resident #2's] behavior and unable to recall event a few minutes later . Resident #3 was admitted to the facility on [DATE] and discharged on 6/27/2023 with diagnoses including Malignant Neoplasm of Prostate, Spinal stenosis, Polyarthritis, Cerebral Infarction, Dementia, Dysphagia, Gastrointestinal Hemorrhage, Esophagitis, Adult Failure to Thrive, Nausea with Vomiting, Diverticulum of Esophagus, and Diaphragmatic Hernia. Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 7 indicating severe cognitive impairment. The resident exhibited behavioral symptoms of physical behavioral symptoms toward others 1 to 3 days, verbal behavioral symptoms toward others 1 to 3 days, rejection of care 4 to 6 days during the assessment period. Review of Resident #3's Nurses Note dated 3/20/2023 showed .this nurse spoke with resident prior to following incident resident was pleasant. Res. [Resident] Had been moved out of his room for housekeeping to clean his room. Res was placed beside another resident. [Resident #3] became unexpectedly upset and struck another resident in the face with a dry washcloth that [Resident #3] was holding in his hand. Stated he became 'mad' because the other res was 'looking at him' also stated he 'didn't like being moved out of his room.' Res was separated and emotional support. No injury, new order move Res to other side of room when housekeeping is cleaning [Resident #3's] room. Avoid setting Res to close to other Res. When up in day room as much as possible . Review of Resident #3's comprehensive care plan revised on 3/20/2023 showed .incident with another resident .new interventions from incident .move [Resident #3] to the other side of room when housekeeping is cleaning his room .avoid sitting to close to other residents when up in day room as much as possible . During an interview with the Director of Nursing (DON) on 6/27/2023 at 2:40 PM, she confirmed the facility substantiated abuse occurred and the facility had not submitted the required 5-day investigation follow up to the State Survey Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, facility investigation, observation and interview, the facility failed to prevent abuse of 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect, Misappropriation Protocol revised on 10/20/2022 showed .the facility has a zero-tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment .willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #1 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Ocular Hypertension, Glaucoma, and Type 2 Diabetes Mellitus. Review of Resident #1's quarterly Minimum Data Set (MDS) showed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of a facility investigation dated 1/21/2023 showed .Resident [Resident #1] was in her room with her roommate. Her roommate [Resident #2] did not want her talking and told her to shut up then slapped her on the mouth. Resident incident was witnessed by staff and immediately separated. [Resident #2] who slapped [Resident #1] was moved to another room without a roommate and placed on 1:1 observations when out of her room throughout the night for cooling off period .Report of Resident Incident .staff heard yelling et [and] came to room to see [Resident #2] slap resident [Resident #1] .Resident Statement: [Resident #2] she wouldn't shut up, so I gave her a little pop in the mouth .Resident Statement: [Resident #1] She's crazy yelling at me . Observation of Resident #1 on 2/8/2023 at 7:45 AM, in her room, showed the resident seated in a wheelchair, she was awake, alert, well-groomed and dressed appropriately for the inside temperature. No fearful or anxious behaviors were observed. During an interview with Resident #1 on 2/8/2023 at 7:45 AM, Surveyor asked the resident if she recalled an incident with another resident hitting her and Resident #1 stated .she just popped me in the mouth. I think she just didn't want me in there .it hurt at the moment, but that was all .I wasn't used to people doing me like that, so I didn't respond. I just thought she was an ignorant woman .I was raised a Christian, so I didn't do anything back to her . The resident was smiling and chuckling while speaking to Surveyor. The resident stated .I'm okay now . she stated she was not afraid and felt safe in the facility. Resident #2 was admitted to the facility on [DATE] with diagnoses including Anemia, Severe Protein-Calorie Malnutrition, Dementia with Behavioral Disturbance, Anxiety Disorder, Adjustment Disorder, Alzheimer's Disease, Cerebral Ischemia, and Adult Failure to Thrive. Review of Resident #2's comprehensive care plan dated 9/5/2022 showed .impaired mood behavior/psychosocial .wants shoes on before she gets out of bed .daughter reports resident will get angry if she doesn't have footwear provided prior to getting up .has exhibited episodes of wandering .provide consistent care givers and routine .if resisting care, have another staff member attempt and attempt at a later time .provide diversional activities .ensure adequate lighting both day and night-she does not like to be in the dark . The care plan was revised on 1/23/2022 and showed .incident involving another resident .residents were separated .[Resident #2] was moved to room .her safety was ensured, and emotional support provided. Staff provided 1:1 when out of room [ROOM NUMBER] hours .Redirect as needed .monitor when in dining room. Do not leave unattended . Observation with Resident #2 on 2/8/2023 at 7:55 AM, in the dining room, showed the resident seated in a wheelchair at a dining room table, no other residents were seated with the resident, but other residents were in the dining room. No anxious, agitated, or aggressive behaviors were noted. Resident #2 was awake, alert, well-groomed, dressed appropriately for the inside temperature and location. During an interview with Resident #2 on 2/8/2023 at 7:55 AM, the resident was asked if she recalled an incident where she hit another resident she stated .we are still friends .I'm going to take my Bible back to my room, you watch my stuff, that's my water . During the interview the Surveyor was unable to determine if the resident could recall the incident with Resident #1. Resident #2 was not observed to have any aggression or agitation. Resident #2 was admitted to the facility on [DATE] with diagnoses including Anemia, Severe Protein-Calorie Malnutrition, Dementia with Behavioral Disturbance, Anxiety Disorder, Adjustment Disorder, Alzheimer's Disease, Cerebral Ischemia, and Adult Failure to Thrive. Review of Resident #2's comprehensive care plan dated 9/5/2022 showed .impaired mood behavior/psychosocial .provide consistent care givers and routine .if resisting care, have another staff member attempt and attempt at a later time .provide diversional activities .ensure adequate lighting both day and night-she does not like to be in the dark . The care plan was revised on 1/23/2022 and showed .incident involving another resident .residents were separated .[Resident #2] was moved to room .her safety was ensured, and emotional support provided. Staff provided 1:1 when out of room [ROOM NUMBER] hours .Redirect as needed .monitor when in dining room. Do not leave unattended . During an interview with Certified Nursing Assistant (CNA) #1 on 2/8/2023 at 8:10 AM, she stated .I've been told [Resident #2] will push staff's arm away during care but she hasn't done that to me. She will sometimes get upset if another resident disagrees with her, but she would just roll away. I had never seen her be aggressive toward any resident .I heard hollering, so I went into [Resident #1 and Resident #2's] room, [Resident #2] was going to the bathroom, [Resident #1] wasn't upset she was just sitting in her chair. I didn't see anything wrong, so I left the room. It was just a little bit later, I heard yelling again, I went in the room and about the time I walked in the room, I saw [Resident #2] pop [Resident #1] on the mouth. [Resident #1] said 'she hit me', and she was pouting. [Resident #2] said 'I didn't hit do it hard'. [CNA #2] was in the room by then, and then the nurse came in we immediately took [Resident #2] out of the room to an empty room .they bickered like sisters, [Resident #2] wanted to tell [Resident #1] what to do. [Resident #1] would say 'stop telling me what to do' but they wanted to sit together, they would talk, I never saw any aggressive behaviors between them before . During the interview CNA #1 stated .it was just a pop like a mother would pop their child for having a smart mouth .yes she did it willfully and said she didn't do it that hard . During an interview with Licensed Practical Nurse (LPN) #1 on 2/8/2023 at 8:30 AM, she stated .I was the dayshift nurse and it happened at the end of my shift .[Resident #2] would come out in the hall and say that [Resident #1] needed to go to the bathroom and when we would go check [Resident #1] would say 'I didn't tell her that. I don't have to go to the bathroom.' They wanted the chairs beside each other, and they would watch television together .it had been an uneventful day there hadn't been any sharp words or anything like that between them .It happened suddenly .I guess [Resident #2] told [Resident #1] to shut up and then popped her in the mouth .We moved [Resident #2] to a private room across the hall. We had a staff member in the dining room so she could watch both room doors, neither resident tried to go to the other resident's room .[Resident #2] seemed to remember what had happened because she wanted to apologize, and we let her .[Resident #2] can get aggravated but I have never seen her aggressive toward any other resident, and I have not had any reports of her being aggressive with residents .she is very particular and set in her ways, she gets focused on things .I assessed both residents. [Resident #1] took out her dentures and let me look in her mouth with a flashlight, there was no redness, no swelling, bleeding, scrapes or any sign of injury in her mouth or her face and she denied pain. I didn't see any injuries on [Resident #2] . During an interview with the Administrator on 2/8/2023 at 1:20 PM, she stated .the policy and regulation says willful .in the moment I think she reacted without thinking . but according to the definition of abuse there was a willful intent . During the interview the Administrator confirmed the facility failed to prevent abuse of Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, the facility failed to notify the responsible party and the medical provider timely of a change in skin condition for 1 resident (Resident #230) of 5 residents reviewed for pressure ulcers. The findings included: Resident #230 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Neuropathy, Difficulty in Walking, Acquired Absence of Left leg Above the Knee, Chronic Pain, Adult Failure to Thrive, Abnormalities of Gait and Mobility, and Need for Assistance with Personal Care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #230 was cognitively intact, independent with bed mobility, locomotion on and off the unit, and eating. The resident had occasional urinary incontinence. Resident #230 was at risk for developing pressure ulcers with no pressure ulcers documented. Review of the discharge MDS assessment dated [DATE], showed Resident #230 had an unplanned discharge with return anticipated from the facility to an acute hospital. Since last assessment there was no skin conditions documented. Review of the comprehensive care plan showed Resident #230 required minimal assistance with activities of daily living, had occasional urinary incontinence, was at risk for fall related to impaired balance, unsteady gait, and left below the knee amputation. Resident #230 was at risk for skin breakdown related to impaired mobility and refusal of bathing at times. Interventions included to apply lotions, creams, ointments, and powders as needed; and to observe skin daily and report and treat any breaks in skin as indicated. Review of a handwritten witness statement dated 10/23/2022, showed Certified Nursing Assistant (CNA) #5 wrote after completion of Resident #230's shower on 10/23/2022 an open area was noticed on right buttock. The resident went out for a day pass with the family, the nurse and the wound care nurse were not notified until later after the resident had left the facility. During a telephone interview on 11/29/2022 at 5:22 PM, Family Member #1 of Resident #230 stated they were not informed of any change in skin conditions, until they had taken Resident #230 to the emergency room when the skin conditions were identified, and the resident was admitted with cellulitis of the buttocks. During an interview on 11/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #1 stated she cared for Resident #230 the Thursday prior to him leaving on 10/23/2022. He had reddened areas to entire buttock, but no open areas. During an interview on 11/30/2022 at 1:53 PM, the Administrator confirmed the Medical Director and family was not notified until 10/23/2022 of Resident #230's skin issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to complete weekly skin assessments to prevent the development of a skin condition for 1 resident (Resident #230) of 5 residents reviewed for pressure ulcers. The findings include: Review of the facility policy titled, Skin Care-Key Procedural Points Wound Management, undated showed .Nurses are to do a weekly skin assessment on each resident . Resident #230 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Neuropathy, Difficulty in Walking, Acquired Absence of Left Leg Above the Knee, Chronic Pain, Adult Failure to Thrive, Abnormalities of Gait and Mobility, and Need for Assistance with Personal Care. Review of the weekly skin assessments dated 9/2022, showed pink area to the buttocks. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #230 was at risk for developing pressure ulcers with no pressure ulcers documented. Review of the comprehensive care plan showed Resident #230 was at risk for skin breakdown related to impaired mobility and refusal of bathing at times. Interventions included to apply lotions, creams, ointments, and powders as needed; and to observe skin daily and report and treat any breaks in skin as indicated. Review of the Weekly Skin assessments dated 10/14/2022, Resident #230 had pink areas to buttocks. Skin assessments were not completed on the prior week of 10/7/2022 or 10/21/2022. Review of a handwritten witness statement dated 10/23/2022, showed Certified Nursing Assistant (CNA) #5 wrote after completion of Resident #230's shower on 10/23/2022 an open area was noticed on right buttock. The resident went out for a day pass with the family, the nurse and the wound care nurse were not notified until later after the resident had left the facility. Review of the hospital Wound Care Consult notes dated 10/24/2022, showed .Chief Complaint: Concern for pressure injuries to bilateral buttocks .On assessment there are no pressure injuries present. Bilateral buttocks with erosions and maceration consistent with moisture .No open wounds . During a telephone interview on 11/30/2022 at 8:16 AM, CNA #5 stated on 10/23/2022 after providing a shower to Resident #230 a sore was noted to the resident's right buttock. The skin condition was described as a quarter sized open area, .like a blister had busted and opened . and the left side of buttock was red. CNA #5 stated family had taken Resident #230 on a day pass before she could inform the wound care nurse, or the charge nurse. CNA #5 stated skin barrier protectant was applied to the areas, before the resident left the facility with the family. During an interview on 11/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #1 stated she cared for Resident #230 the Thursday prior to him leaving on 10/23/2022. He had reddened areas to entire buttock, but no open areas. She stated she was the primary nurse responsible for completion of the weekly skin assessments for Resident #230. She confirmed she only completed one skin assessment during the month of 10/2022, dated 10/14/2022, that showed the buttocks were pink. She confirmed the skin assessment for 10/7/2022 and 10/21/2022 were not completed. During an interview on 11/30/2022 at 1:53 PM, the Administrator (ADM) stated it was her expectation skin assessments were to be completed weekly. If a resident was not in the facility at the time of the weekly skin assessment, then the skin assessment was to be completed upon return to the facility. The ADM confirmed the weekly skin assessments were not completed for Resident #230 on 10/7/2022 and 10/21/2022. She stated the skin observation made by the CNA should have been reported immediately to the charge nurse or the wound care nurse. During an interview on 11/30/2022 at 3:50 PM, the Physician stated he was unable to recall Resident #230. He stated if one of the residents had a moisture associated skin condition, he would order some type of skin barrier, an ointment, or Nystatin and then would monitor for further breakdown. Treatments would be changed as needed for the resident's skin concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (Resident #64) of 5 residents reviewed for falls. The findings include: Review of the facility's policy titled, Falls Management undated showed .Residents at risk for falls are identified to prevent future falls and maintain maximum level of function through use of interventions, as appropriate . Review of the facility policy titled, Accidents and Injuries-Resident, undated, showed .Accidents .incidents will be investigated, documented and reported .An incident report form will be competed on the shift that the accident .incident occurred. All incident .accident are reportable . Resident #64 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Muscle Weakness, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of Resident #64's quarterly Minimum Data Set assessment dated [DATE], showed Brief Interview for Mental Status score was 4 which indicated resident had severe cognitive impairment, and resident required limited assistance with ambulation, transfers, and toileting. Resident had documented 2 falls with no injury and 1 with injury not major. Review of Resident #64's care plan dated 6/15/2021 showed interventions to prevent falls non-skid socks, call light in reach, handrails to bed to assist resident with mobility, and assist with toileting. Care plan was updated on 9/7/2022 with added intervention impact mat to left side of bed after a fall with a skin tear to right arm on 9/7/2022. During an observation on 11/28/2022 at 10:30 AM, showed Resident #64 sitting up in bed no impact mat at the left side of the bed. During an observation on 11/29/2022 at 7:45 AM, showed resident sitting upon side of the bed feeding self-breakfast, no impact mat at the left side of the bed. During an observation on 11/29/2022 at 12:34 PM, showed resident had no impact mat to left side of the bed. During an observation on 11/30/2022 at 7:45 AM, showed resident lying in bed positioned on left side with top side rail up, no impact mat by the left side of the bed. During an interview and observation on 11/30/2022 at 7:52 AM, Licensed Practical Nurse (LPN) #4 confirmed no impact mat was in place to the left side of Resident #64's bed. During an interview on 11/30/2022 at 10:49 AM, the Director of Nursing confirmed the care plan was to be followed for Resident #64. The impact mat was an fall intervention and should have been placed on the left side of the resident's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician order for a fluid restriction for 1 resident (Resident #20) of 2 residents reviewed for nutrition. The findings include: Review of the facility's undated policy titled, [Facility Name], showed .Residents Undergoing Hemodialysis [the process of purifying the blood of a person whose kidneys are not working normally] .Dietary management and fluid management per physician's orders . Resident #20 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease and Diabetes Mellitus. Review of the Physician's Orders dated 9/22/2022 showed .FLUID RESTRICTION 1000ML [milliliter] . Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #20 had a Brief Interview for Mental Status score of 15, which indicated he was cognitively intact, needed limited assistance of 1 staff member for activities of daily living (ADL) and received dialysis. Review of a nurse's note dated 10/8/2022, showed .Fluids encouraged . Review of a nurse's note dated 10/20/2022, showed .Fluids encouraged . Review of a nurse's note dated 10/30/2022, showed .Fluids encouraged . An observation on 11/28/2022 at 10:33 AM, in Resident #20's room, showed a water jug with lid on the top. The resident stated there was water in the jug. During an observation and interview on 11/29/2022 at 12:15 PM, in Resident #20's room, Certified Nursing Assistant (CNA) #1 confirmed a white plastic jug with name of facility on it was on the resident's table, was full of water and available for consumption. The CNA stated she filled the jug whenever the resident asked and liquid volumes were not measured or documented by the nursing staff. During an interview on 11/29/2022 at 1:15 PM, the Registered Dietician (RD) revealed Resident #20 had a renal diet with a fluid restriction of 1800 ml, and the dietary department sends set amounts with each tray. The RD stated the remaining amounts allowed before restriction is reached should be measured, monitored, and documented by nursing. During an interview on 11/29/2022 at 1:30 PM, Central Supply stated that the white jugs with the facility's name on them were given with a welcome kit and had a volume of 32 ounces (oz), which was approximately 950 mls. During an interview on 11/29/2022 at 2:35 PM, CNA #2 stated she didn't have any residents on her hall with fluid restrictions. The CNA stated the nurse reported to her if there was a fluid restriction, and it was clearly marked on the diet card, which came on the tray at mealtime, if the resident had one. Review of an ADL report sheet (a sheet that indicates resident orders and needs) with the CNA showed no documentation of orders for fluid restriction for Resident #20. Review of the nurse's notes from 9/22/2022 to 11/29/2022, showed no documentation Resident #20 had any adverse outcome related to the staff's failure to monitor fluid intake. Review of the dialysis communication forms dated 11/15/2022, 11/17/2022, 11/19/2022, 11/23/2022 and 11/26/2022 showed pre and post-dialysis vital signs and weights. No respiratory difficulties or excessive weight removal were documented on those reports. During an observation and interview on 11/30/2022 at 9:22 AM, in Resident #20's room, CNA #2 confirmed the breakfast tray on the table had an empty coffee cup (240 ml) and a half full glass of juice (120 ml) sitting on the tray. The resident stated he drank all the coffee and half of the juice and was not educated on any fluid restriction. During an interview on 11/30/2022 at 9:46 AM, the Nurse Practitioner stated staff were to follow physician's orders, and it was expected a resident with fluid restriction would have fluids closely monitored and the resident's intake and output measured and documented. During an interview on 11/30/2022 at 12:15 PM, the Assistant Director of Nursing stated both dietary and nursing were to follow physician orders for fluid restrictions.

Based on facility policy review, observation, interview, and temperature log review, the facility failed to ensure expired and molded food items were not available for resident use and failed to ensure dry goods were properly stored in 1 of 1 kitchen, and failed to properly store and label food items and maintain a temperature log in 1 of 4 nourishment refrigerators which had the potential to effect 66 of 72 residents. The findings include: Review of the facility's policy titled, Use and Storage of Foods Brought to Residents by Family and Visitors, dated 10/2017, showed .The facility provides safe and sanitary storage and handling of foods brought in from the outside by family and visitors .Food item(s) will be labeled with the resident's name, content, the date it was prepared, if known, and a discard/use by date .All refrigeration units will have internal thermometers to monitor for safe food temperatures, in accordance with state and federal standards. Designated staff .will monitor and document unit refrigerator temperatures daily . Review of the facility's undated policy titled, Expiration date policy, showed .All Store Bought Food Or Food delivery Service items should be disposed of by Manufactures Expiration date . Review of the facility's undated policy titled, Policy: Scoops, showed .Any food item .that Requires scoops, will be placed in zip lock bag. Placed on top of the container . Review of the facility's undated and untitled policy showed .Practices to maintain safe refrigerated storage include .Monitoring food temperatures and functioning of the refrigeration equipment daily .Labeling, dating, and monitoring refrigerated food .Additional strategies to prevent foodborne illness include .Preventing cross-contamination of foods . Review of the facility's undated and untitled policy showed .The refrigerators are intended for storage of patient food supplies only .Nursing will monitor and record temperatures of refrigerator .daily .All snacks/nourishment stored in refrigerator/freezer must be labeled . Observation of the kitchen with the Dietary Manager on 11/28/2022 at 10:08 AM, showed the following items on the bread shelf: -1 package of 8 hot dog buns with a best if used by date of 11/3/2022 (25 days past expiration date). -1 package of 8 hot dog buns with a best if used by date of 11/8/2022 (20 days past expiration date). -1 package of 6 hoagie rolls undated and with mold on 2 of the hoagie rolls. During an interview on 11/28/2022 at 10:15 AM, the Dietary Manager confirmed the package of 8 hot dog buns with the best by date of 11/3/2022 and the package of 8 hot dog buns with the best by date of 11/8/2022 were out of date and available for resident use. Further interview with the Dietary Manager confirmed the package of hoagie rolls were undated, molded, and available for resident use. It was the facility's expectation that bread was dated on the date of delivery and discarded 1 week later. Observation and interview of the kitchen with the Dietary Manager on 11/28/2022 at 10:21 AM, showed a container of sugar located under the tea table. The container of sugar was open to air with the scoop stored inside the container. The Dietary Manager confirmed the sugar container was open to air with the scoop stored inside the container and it was the facility's expectation that the container was covered when not in use to prevent contamination and the scoop was to be stored in a zip lock bag on top of the container. Observation and interview of the kitchen with the Dietary Manager on 11/28/2022 at 10:29 AM, showed a container of salt stored under a food preparation table. The container of salt was open to air with the scoop stored inside the container. The Dietary Manager confirmed the salt container was open to air with the scoop stored inside the container and it was the facility's expectation that the container was covered when not in use to prevent contamination and the scoop was to be stored in a zip lock bag on top of the container. Observation of the 300-unit nourishment refrigerator with Certified Nursing Assistant (CNA) #3 on 11/30/2022 at 8:53 AM, showed the following items: -1 10-ounce glass jar of apple butter open,unlabeled, and undated. -1 32-ounce container of coffee creamer opened and undated. -1 24-fluid ounce bottle of ranch dressing open, unlabeled, and undated. During an interview on 11/30/2022 at 8:55 AM, CNA #3 stated the nourishment refrigerator was for storage of resident items only and staff were to store their food items in a separate location. Food items placed in the nourishment refrigerator were to be labeled with the resident's name and dated. CNA #3 confirmed the jar of apple butter and the bottle of ranch dressing were not labeled or dated and was unaware what residents the items belonged to. CNA #3 confirmed the name on the container of the coffee creamer was the name of a nurse at the facility. Review of the 300-unit nourishment refrigerator temperature log dated 11/2022, showed a temperature reading of 42 degrees Fahrenheit on 11/30/2022. The log showed no nourishment refrigerator temperature readings from 11/1/2022 - 11/29/2022. During an interview on 11/30/2022 at 8:59 AM, CNA #3 stated .I believe temperatures are obtained once a day . and .if I'm being honest, I don't know who is responsible for doing that . CNA #3 confirmed the entry on 11/30/2022 was the only temperature recorded on the 11/2022 300-unit nourishment refrigerator temperature log. During an interview on 11/30/2022 at 9:48 AM, the DON confirmed nourishment refrigerators were to contain resident food items only and staff food items were to be stored in the break room refrigerator. Resident food items stored in nourishment refrigerators were to be labeled with the resident's name and dated. The DON confirmed the 11/2022 300-unit nourishment refrigerator temperature log had only 1 temperature reading on 11/30/2022 and it was the facility's expectation that temperature was documented daily by unit staff according to each unit's plan. During an interview on 11/30/2022 at 9:58 AM, the Administrator stated nurses are responsible for documenting nourishment refrigerator temperatures daily and .We need to do a solid reboot of our plans, policy, and expectations for temperature logs with the staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility investigation, observation, and interview, the facility failed to ensure 1 resident (#1) was free from abuse of 3 residents reviewed for abuse of 37 sampled residents. The findings include: Review of the facility policy, Definitions/Identification, undated, revealed .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse .Willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavior Disturbance, Major Depressive Disorder, and Anxiety Disorder. Medical record review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. The resident required limited assistance for bed mobility, transfer, and dressing, and extensive assistance for toileting and ambulation. Medical record review of the resident's care plan dated 10/26/18, revealed the resident had a history of impulsive and combative behavior with an intervention to keep the resident and others in safe areas as much as possible if the resident exhibited undesirable mood and behaviors. Medical record review of a Nurse's note dated 7/11/19 revealed, .Resident [increased] agitation, verbally toward others (staff and other residents) . Medical record review of a Nurse's note dated 8/7/19 revealed .Resident [#1] was in the dining room when a female resident [Resident #56] walked up to him. They were both conversing when he [Resident #1] suddenly leaned up in his w/c [wheelchair] and punched the female resident [Resident #56] in the mouth. They were both separated immediately . Medical record review of Resident #1's History and Physical dated 8/8/19 revealed .sent to the emergency room due to behavioral issues. Apparently he slapped a friend who was visiting .Patient has advanced dementia . Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia with Behavior Disturbance, and Anxiety. Medical record review of Resident #56's Annual MDS dated [DATE] revealed a BIMS score of 5, indicating the resident had severe cognitive impairment. Resident #56 demonstrated delusions, verbal behavior symptoms, and wandering. Review of the facility investigation report dated 8/7/19 revealed .[Resident #1] hit other resident [#56] on face causing small red area on side of face . Continued review revealed an interview with Registered Nurse (RN) #1, .Res [Resident #1] was in w/c in DR [dining room], resident .[#56] was walking by him. [Resident #1] thought resident [#56] said a 'smart ass remark' and [Resident #1] struck [Resident #56] with a closed fist . Continued review revealed an interview with Resident #1, I hit her because she made a smart ass remark . Observation of Resident #1 on 8/14/19 at 7:22 AM, in the residents room, revealed Resident #1 sleeping in bed. The bed was in low position with the call bell within reach. Observation of Resident #56 on 8/14/19 at 7:28 AM, on the secure unit, revealed the resident sitting in the activity/dining room in a chair. Observation of Resident #1 on 8/14/19 at 12:15 PM, in the secure unit activity room/dining room, revealed the resident sitting in a high back chair at a table with a staff member. Observation of Resident #56 on 8/14/19 at 12:20 PM, on the secure unit, revealed the resident ambulating in the hallway. Interview with RN #1 on 8/14/19 at 7:25 AM, at the secure unit nursing station, confirmed she was working on the secure unit on 8/7/19. Continued interview confirmed Resident #56 walked up to talk to Resident #1 in the dining room, and he suddenly hit her in the face. Further interview confirmed the residents were immediately separated. Further interview confirmed Resident #1 had a history of hitting other residents. Continued interview confirmed staff keeps Resident #56 at a safe distance from Resident #1. Interview with Certified Nursing Assistant (CNA) #1 on 8/14/19 at 2:35 PM, by phone, confirmed she witnessed Resident #1 hit Resident #56 in the dining room on 8/7/19. Continued interview confirmed Resident #1 was sitting in the dining room and Resident #56 walked up to Resident #1 and struck Resident #56 in the face. Continued interview confirmed Resident #1 had a history of agitation and can become aggressive with staff and other residents at times. Interview with the Director of Nursing (DON) on 8/14/19 at 3:00 PM, in the DON's office, confirmed Resident #1 hit Resident #56. The facility failed to prevent abuse for Resident #56.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 resident was free from restraints (#77) of 7 residents reviewed for restraints. The findings include: Review of the facility policy Use of Chemical/Physical Restraints, undated, revealed .Restraints may be appropriate to manage emergency behaviors . Medical record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Displaced Fracture of Femur, Heart Disease, Parkinson's Disease, and Anxiety Disorder. Observations on 8/12/19 at 9:30 AM and 8/13/19 at 10:02 AM, on the secure unit hallway, revealed resident #77 was in a wheelchair with a Lap belt (type of physical restraint that lays across the resident's lap and attaches to back of wheelchair) in place. Continued observation revealed Resident self-propelling in the wheelchair on the secure unit. Medical record review of the current physician's recapitulation orders dated 7/29/19 revealed, .Lap belt while up in w/c [wheelchair] for safety . Medical record review of the resident's plan of care updated 7/15/19 revealed .Risk for Falls/Use of Restraint .is a high fall risk r/t [related to] hx [history] of falls . Interview with the Director of Nursing (DON) on 8/14/19 at 8:32 AM, in the DON office, confirmed the Lap Belt restraint was implemented to prevent falls and not to manage emergency behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (#46) of 20 sampled residents. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Personal History of Traumatic Brain Injury, Encounter for Tracheostomy, Acute and Chronic Respiratory Failure with Hypoxia, Paralytic Syndrome, Pneumonia, and Anxiety Disorder. Medical record review of Resident #46's quarterly nursing documentation dated 9/29/18, 12/27/18, and 3/26/19 revealed .natural teeth .broken/carious . Medical record review of Resident #46's dental consult notes dated 3/8/19 and 6/13/19 revealed .decayed teeth .recommends extractions . Medical record review of Resident #46's Annual MDS dated [DATE] and Quarterly MDS dated [DATE] and 6/23/19 revealed no documentation of obvious or likely cavity or broken natural teeth. Interview with MDS Coordinator #1 on 8/14/19 at 1:07 PM, in the MDS office, confirmed she did not visually assess Resident #46's dental status. Continued interview confirmed she gathered information from the resident's medical record and .missed . the documentation which indicated Resident #46 had multiple cavities. Further interview confirmed Resident #46's admission and Quarterly MDS assessments were inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement a comprehensive person-centered care plan related to falls for 1 resident (#4) of 6 residents reviewed for falls of 31 sampled residents. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including: Repeated Falls, Multiple Fractures of Ribs, Collapsed Vertebra, Spinal Stenosis, Pseudobulbar Affect, and Weakness. Medical record review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of this MDS revealed the resident had a diagnosis of repeated falls. Medical record review of the care plan dated 11/8/17 with revision date 6/6/18 revealed .Resident #4 has a history of falls with fractures. She is at risk for falls .Approaches .Remove w/c [wheelchair] from room after all transfers .check q [every] shift to ensure w/c not left in room . Further review of the care plan revealed .start bed alarm for safety .check q shift for placement . Observation and interview with MDS Nurse #1 on 8/29/18 at 10:35 AM in Resident #4's room confirmed the resident was in bed without a bed alarm in place. Further observation revealed a w/c in the resident's room. Interview with MDS Nurse #1 confirmed .the w/c was not supposed to be there. Further interview with MDS Nurse #1 revealed .I think we need to use the interventions .I think they need to be there .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to have medical justification for use of a urinary catheter for 1 resident (#18) of 3 residents reviewed with urinary catheters of 31 sampled residents. The findings include: Medical record review revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Congestive Heart Failure, Hypertension, Alzheimer's Disease, and Chronic Obstructive Pulmonary Disease. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had an indwelling urinary catheter. Observation on 8/27/18, at 9:00 AM, in Resident #18's room, revealed the resident was sitting in a recliner with a urinary catheter bag. Interview with the Assistant Director of Nursing (ADON) on 8/28/18, at 2:45 PM, in the ADON office, revealed the urinary catheter was placed due to the resident had a pressure ulcer greater than Stage III on his buttock area. Continued interview with the ADON revealed the pressure ulcer resolved on 4/26/18. Interview with the Director of Nursing (DON) and the ADON on 8/28/18, at 2:45 PM, in the ADON's office confirmed there was no medical justification for the use of the urinary catheter at this time.