**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, facility investigation, medical record review and interview, the facility failed to report an allegation of abuse for 1 Resident (#5) of 7 residents reviewed for abuse within the required timeframe. The findings include: Review of a facility policy titled Abuse, Neglect, Exploitation dated 10/18/2022, showed .it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies .within specified timeframes .a. immediately, but no later than 2 hours after the allegation is made . Resident #5 was admitted to the facility on [DATE] and discharged on 7/23/2023, with diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Anxiety Disorder, Psychoactive Substance Dependency, Bipolar Disorder, Parkinson's Disease and Narcolepsy. Review of Resident #5's Social Service Note, dated 6/14/2023 at 9:59 AM, showed .Member wanted to file a complaint and member called and left a message that after making a comment to a CNA [Certified Nursing Assistant] she started yelling at him, asked what comment and he refused to say .he stated that the CNA need not come into his room anymore and if she did he threatened he would be going to jail. Talked to member and let him know we could not threaten people and he stated he did not mean anything by it. He will not he stated do it again .wrote up a grievance report and they [the] CNA will not be going in the room anymore. Member was okay with that. He did apologize for the threat and for what he said, but he did not repeat what he commented to CNA. Report signed and placed in folder . Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview with the Administrator, on 12/4/2023 at 9:31 AM, she stated .I did not receive any report about an allegation of a CNA yelling at [Resident #5]. It should have been reported to me immediately by the Social Service Director when the resident reported it to her .but she did not report it to me . During the interview the Administrator confirmed the facility failed to follow their policy for reporting an allegation of abuse. During an interview with Licensed Practical Nurse (LPN) #1, on 12/4/2023 at 10:10 AM, the LPN confirmed she worked on 6/14/2023 from 6:00 AM-6:00 PM, and was Resident #5's nurse for the shift. During the interview, she stated .the Social Service Director did not say anything to me about [Resident #5] saying a CNA had yelled at him .I would have checked on the resident and then reported his allegation to the Administrator .I was here, and she didn't say anything to me .[Resident #5] didn't ever say anything to me about it and I am not aware of any CNA that was not allowed to be in his room . During an interview with the Director of Nursing (DON) on 12/4/2023 at 11:10 AM, she stated .I do not know anything about [Resident #5] reporting to the Social Service Director that a CNA had yelled at him .that would have been reported to the Administrator .[Resident #5] never said anything to me and I am not aware of any staff member that was not allowed in his room . During an interview with the Staffing Coordinator/LPN #2, on 12/4/2023 at 12:00 PM, she stated .I am an LPN but I do the staff scheduling .I do not recall the Social Service Director or anyone informing me that a particular CNA was not allowed to go into [Resident #5's] room to care for him .if it had been reported to me I would have questioned why, and if it had been reported to me there was an allegation against a CNA, I would have reported it to the Administrator . During an interview with the previous Social Service Director on 12/4/2023 at 12:10 PM, when questioned related to her 6/14/2023 documentation for Resident #5, she stated .I turned in the grievances to the Administrator she kept the log .I don't recall the incident .I don't recall anything about that at all . During an interview with LPN #3 on 12/4/2023 at 1:55 PM, the LPN confirmed she worked on 6/13/2023 from 6:00 PM to 6:00 AM on 6/14/2023, and was Resident #5's nurse for the shift. During the interview she stated .I don't work there anymore but I don't recall anything about a CNA not allowed to go back in his room. I don't recall [Resident #5] ever saying anything like that to me .if he had I would have charted something and if I had heard yelling I would have intervened, had a staff member stay with the resident, and the CNA would have been removed from the room and I would have called the Administrator .we would have done an assessment on the resident and monitored him and it would all have been documented .something like that would have stood out in my mind and I have no recollection of anything like that happening . During an interview with LPN #4 on 12/4/2023 at 2:05 PM, it was confirmed she worked on 6/13/2023 from 6:00 AM-6:00 PM, and was Resident #5's nurse for the shift. During the interview she stated, .I don't know anything about that, I worked all day on the 13th and was in and out of his room, he never said a word about any staff member yelling at him .I didn't get anything in report that happened the night before related to him .I would have reported that to the Administrator .I don't know anything about a CNA or any staff that was not allowed in his room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review and interview, the facility failed to investigate an allegation of abuse for 1 Resident (#5) of 7 residents reviewed for abuse. The findings include: Review of a facility policy titled Abuse, Neglect, Exploitation dated 10/18/2022, showed .it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . Resident #5 was admitted to the facility on [DATE] and discharged on 7/23/2023, with diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Anxiety Disorder, Psychoactive Substance Dependency, Bipolar Disorder, Parkinson's Disease and Narcolepsy. Review of Resident #5's Social Service Note dated 6/14/2023 at 9:59 AM, showed .Member wanted to file a complaint and member called and left a message that after making a comment to a CNA [Certified Nursing Assistant] she started yelling at him, asked what comment and he refused to say .he stated that the CNA need not come into his room anymore and if she did he threatened he would be going to jail. Talked to member and let him know we could not threaten people and he stated he did not mean anything by it. He will not he stated do it again .wrote up a grievance report and they [the] CNA will not be going in the room anymore. Member was okay with that. He did apologize for the threat and for what he said, but he did not repeat what he commented to CNA. Report signed and placed in folder . Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview with the Administrator on 12/4/2023 at 9:31 AM, she stated .I did not receive any report about an allegation of a CNA yelling at [Resident #5]. It should have been reported to me immediately by the Social Service Director when the resident reported it to her .but she did not report it to me, and we did not investigate the incident . During the interview, the Administrator confirmed the facility failed to follow their policy for investigation of an allegation. During an interview with the Director of Nursing (DON) on 12/4/2023 at 11:10 AM, she stated .I do not know anything about [Resident #5] reporting to the Social Service Director that a CNA had yelled at him .that would have been reported to the Administrator and investigated immediately .[Resident #5] never said anything to me and I am not aware of any staff member that was not allowed in his room .to my knowledge there was no investigation . During an interview with the previous Social Service Director on 12/4/2023 at 12:10 PM, when questioned related to her 6/14/2023 documentation for Resident #5 she stated, .I turned in the grievances to the Administrator she kept the log .I don't recall the incident .I don't recall anything about that at all .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review, and interviews the facility failed to protect the residents' right to be free from physical of abuse a resident for 3 residents (Residents #5, #7, #9) of 14 residents reviewed. The findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, dated 10/18/2022 showed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #5 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diverticulitis, Congestive Heart Failure, Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder, and Vascular Dementia. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 10, indicating moderate cognitive impairment. Review of Resident #5's Alert Note dated 2/6/2023 at 7:30 AM, showed .Resident was in dining room with a resident that was with 1 on 1 assigned CNA [Certified Nursing Assistant] when the other resident began spitting and acting out. This resident started going toward the resident in an attempt to reconcile him and the other resident grabbed her hair on the right side of her head and hit her on the right side of the head before the CNA [Certified Nursing Assistant] could intervene .Resident was upset stating that she thought her, and the other resident were friends . Review of Resident #5's Resident to Resident Incident Report dated 2/6/2023, showed Resident #5 tried to console/comfort/calm, Resident #4 when Resident #4 grabbed Resident #5 by her hair on the right side of her head and slapped her across her face. Residents were immediately separated .Resident #5 entered the dining room for breakfast, when she seen Resident #4 spitting, upset, and refusing medications from the nurse. Resident #5 approached Resident #4 to console/calm/comfort him, when Resident #4 grabbed her hair on the right side of her head and then slapped her across the right side of her face. CNA and nurse were in the dining room at the time of the event but were unable to intervene. Resident #4 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Lennox-Gastaut Syndrome, Moderate Protein-Calorie Malnutrition, Dysphagia, Personality and Behavioral Disorders, Impulse Disorder, Anxiety Disorder, Mood Disorder, and Intellectual Disabilities. Review of Resident #4's comprehensive care plan dated 11/16/2022, showed .has behavior problem physical aggression, hitting, spitting, yelling, running wheelchair into staff members, refusal of care, refusal of showers, refusal of medications, throwing objects, hitting self, trying to tip wheelchair backwards r/t [related to] personality and behavioral disorders due to known physiological condition; impulse disorder .generalized anxiety disorder .mood disorder due to known physiological condition .intellectual disabilities .administer medications as ordered .anticipate and meet the resident's needs .assist the resident to develop more appropriate methods of coping and interacting .caregivers to provide opportunity for positive interaction, attention .explain all procedures to the resident before starting .if reasonable, discuss behavior .minimize potential for the resident's disruptive behaviors by offering tasks which divert attention .monitor behavior episodes and attempt to determine underlying cause . Review of Resident #4's quarterly MDS assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 6 indicating severe cognitive impairment. The resident required extensive assistance of 1 person assist with transfers, and was always incontinent of both bowel and bladder. Review of Resident #4's Order Administration Note dated 1/9/2023 showed .Anxiety & agitation-whining, hitting, covering face and turning away from staff, yelling out, running into others and laughing, fast dangerous movements in w/c [wheelchair]. Trying to run over other resident's toes and laughing at them holding up fist at staff when attempting to direct from others . Review of Resident #4's Alert Note dated 1/11/2023 at 1:37 PM, showed .At beginning of shift after patient was dressed and placed to w/c (wheelchair), noted loud laughing and attempting to run into people making him laugh more . Review of Resident #4's Behavior Team Note dated 1/22/2023, showed .patient following CNA's around after lunch and playing and talking with them. When staff began their scheduled rounds were unable to continue with him, he went to group of geriatric residents and attempted to play with them. When the other residents told him 'no' he became agitated. Patient spitting and yelling at them, attempted to hit with fist and run into them with them with his w/c. Staff removed patient from the group. Other patient began to yell at this patient and this patient became more agitated. Patient began hitting staff and yelling . Review of Resident #4's Incident Report Resident to (Resident) dated 2/6/2023 showed .Location Dining room .Resident [#4] has diagnosis of cerebral palsy and intellectual disability. Often very hard to redirect. Also has hx [history of] impulsiveness and combative behaviors .Resident was one on one with staff member in the dining room when Resident [#3] entered dining room. Resident [#4] was setting in his wheelchair in the dining room, spitting. Floor nurse attempted to administer morning medications when resident continued to spit and refuse medication . During an interview with Resident #5 on 11/1/2023 at 9:00 AM, the resident recalled the incident and she stated .we were in the dining room [Resident #4] was upset .I rolled toward him to calm him down .he wasn't eating he was upset .when I got close to him he pulled my hair and slapped my face .it did hurt a little when he pulled my hair and smacked me but it didn't hurt but just a minute .I didn't have any bruises or anything like that .It hurt my feelings because he always sat by me, and we were friends .I didn't know why he acted that way .but [facility staff] explained he wasn't mad at me it was just his disease process and I was fine .I don't have any hard feelings .he isn't here anymore and I really miss him .they told me not to get to close to him anymore . During an interview with the Administrator on 11/2/2023 at 11:15 AM, she stated .[Resident #4] was on 1:1 and was in the dining room with a CNA and a nurse present, he was having behaviors and the staff had backed away from him due to his history of swing at staff, putting himself in the floor and throwing objects. [Resident #5] began to roll over toward [Resident #4] .the staff told her not to roll over to him, but she continued to go anyway in an attempt to console him that is when [Resident #4] pulled her hair and hit her in the face .[Resident #5] was assessed for injuries with no injuries noted. She was upset because she thought [Resident #4] and herself were friends .I was at the facility within 30 minutes of the incident and I went straight to [Resident #5] she had already calmed down and I explained to her that they were friends his mental status prevented him from controlling his actions and the incident had nothing to do with her personally .this was a witness event .when he was having behaviors he would sling his arms throw himself in the floor and when she rolled toward him he did grab her hair and hit her in the face .it was not a reflex .it was intentional he has cerebral palsy, intellectual disabilities and a BIMS of 0, and he cannot be educated . During the interview she confirmed the facility failed to prevent the abuse of resident #5 . During an interview with Licensed Practical Nurse (LPN) #1 on 11/8/2023 at 11:05 AM, she stated .I was in the dining room when it happened .he was 1 on 1 and was getting upset he was spitting .the CNA had backed off to give him a little space and [Resident #5] started rolling toward him .we told her to back up but rolled right up to him when she did he instantly grabbed her hair and smacked her on the face it was more of a graze but he did make contact .she didn't have a red mark but she was startled .she thought she could calm him down she is motherly and nurturing to all of the residents .she was fine within 5 minutes, she did say it hurt at the moment but nothing after that . Resident #6 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Congestive Heart Failure, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #6's annual MDS assessment dated [DATE], showed a BIMS assessment score of 6 indicating severe cognitive impairment with no behaviors noted during the assessment period. Review of Resident #6's Incident Report dated 3/18/2023, showed floor nurse heard yelling and cursing coming from resident's room. When entered resident's room, nurse found Resident #7 and Resident #6 to be yelling and calling each other [elicit name]. Floor nurse separated residents. When asked Resident #6 what happened she stated that resident #7 had entered her room and threw water on her. Resident #6 then followed Resident #7 into the room belonging to Resident #7 and began to yell and curse at resident #7 which led to both residents yelling and cursing each other. Resident #6 stated that Resident #7 had hit her with a hairbrush .Resident #7 yelled at Resident #6 to 'get the hell out of here. Floor nurse had to request and cue Resident #6 several times to exit the room belonging to Resident #7 before Resident #6 would comply with the request. Resident #7's roommate Resident #8 witnessed the entire event, stated she observed both residents entering the room shared between she and Resident #7 when they both began to argue and call each other names. Resident #8 stated she saw both residents hit each other. Residents were separated . Resident #7 was admitted to the facility on [DATE] with diagnoses including Malignant Melanoma of Skin, Atherosclerotic Heart Disease, Psychotic Disorder, Depression, Adult Failure to Thrive, Dementia, and Chronic Pain. Review of Resident #7's Alert Note dated 1/18/2023 at 12:14 PM, .resident had an episode of agitation and swinging her fist at people this AM in dining room. Resident redirected and returned to her room. NP (Nurse Practitioner) called and gave order to continue Hydroxyzine 25 mg po every 8 hours PRN [as needed] X 2 weeks. Also obtain UA [urinalysis] C&S [Culture and Sensitivity] in AM . Review of Resident #7's Alert Note dated 3/18/2023 at 4:30 PM, showed .this writer was alerted to patient's room d/t [due to] hearing female voices yelling. This writer entered room and noted that patient and resident from across hall are in room and arguing with each other. Both were verbally threatening each other and calling each other [elicit name]. This writer is able to get between them and ask them what was happening. Patient [#7] continued to yell out and tell other patient [#6] to 'get out of here.' Other patient states that this patient 'came into my room and threw water on me.' This writer able to see across hall into other room and noted that floor is covered in liquid. This patient [#7] is unable to answer questions appropriately. Other patient states she followed this patient across hall after having water thrown at her to ask her 'what the hell she was doing?' Patient [#6] states that they began to have a verbal altercation and then [Resident #6] was hit with a hairbrush. Patient denies any pain at this time. This writer was able to get other patient [#6] to exit room and go back into hallway with several request and cueing. This patient [#7] is now sitting in her w/c with eyes closed and arms crossed. Spoke to this patient's roommate [Resident #8] that was sitting in room next to window [and saw] the whole episode. Roommate states that both entered room and began to yell at each other and then 'it seemed they may have been hitting each other.' This patient [#8] has no s/s [signs and symptoms] of distress or discomfort at this time . During an interview LPN #2 on 11/1/2023 at 2:15 PM, she stated .we heard someone down the all yelling we went down the hall and [Resident #6] was in [Resident #7's] room [Resident #6] was yelling at [Resident #7] [Resident #6] was mad so we pulled her back toward the room door and [Resident #7] was up next to her headboard [Resident #6] was threatening [Resident #7] we were trying to calm her down and find out why she was mad .she was saying [Resident 7] had no right to be here, I explained that she was in her room .but what she was trying to tell me was that [Resident #7] had come in her room and had thrown tea all over her. I could see across the hall and there was tea everywhere, but I didn't see any on her .We moved [Resident #6] out in the hallway got her calmed down and cleaned up her room .we sat and talked to her for a while she had gotten upset because she and [Resident #7] used to be best friends, they would go to the dining room together they were roommates, and they did everything together. If you saw one of them, you saw the other .but due to [Resident #7]s progression in her dementia that all changed and [Resident #6] couldn't understand what was wrong. Why she had changed .one staff member stayed with [Resident #7] and within 5 minutes she had forgotten about the incident .[Resident #6] did have a very small 1 cm straight skin tear to her left posterior forearm .I had to tell her that she had a skin tear she didn't even know it was there .she was not complaining of any pain, after I cleaned the skin tear I could see there was no active bleeding or bruising and I don't recall it ever bruising .I saw the blood on her arm while she was talking with her hands .I don't know when it occurred that was just the first time I saw it .she didn't know when it happened .like I said she didn't even know it was there .she was just mad because she [Resident #7] had come in her room and threw tea .it was tea not water, but I did not see any on her just her floor .she couldn't understand the shift in their relationship . During an interview with Resident #8 (witness to the altercation) on 11/1/2023 at 12:55 PM, she stated she did recall the incident .I don't know what set it off .they use to be roommates but some time back [Resident #7] moved in with me .they use to go to the dining room together .she doesn't bother anything much she just does her own thing .she will roll over here and mess with the unit [heating/cooling unit] and just roll off, or she will come piddle in the closet and wash her hands .she is hard of hearing and will usually just answer yeah to whatever you ask her .that afternoon [Resident #7] just calmly rolled over to [Resident #6'] room and I saw her throw a cup of water .I was shocked, but then she just turned around and rolled right back like nothing .[Resident #6] followed her back in here .they were yelling at each other and [Resident #6] hit [Resident #7] then [Resident #7] hit her back .I might have yelled but I think I used my call light to call the nurse .neither of them said anything about being hurt they were just spouting off to each other .no one was crying .[Resident #7] did pick up her bed remote and hit at [Resident #6] not sure where she hit her with the remote, but she said it was a hairbrush and there was no hairbrush .the remote was just handy and when [Resident #6] hit her she just picked up the remote and hit her back .the nurse came in and separated them, after it was over [Resident #7] was just like she was before just doing her own thing . During an interview with Resident #7 on 11/1/2023 at 1:10 PM, Surveyor had to get directly in the residents' line of site to get her attention. When asked how she was doing she stated, I'm okay .I color a lot I like to color . Surveyor was unable to hold the resident's attention for any further questions. During an interview with Resident #6 on 11/2/2023 at 4:20 PM, she stated everything was going fine and she did not remember having an altercation with any resident. She stated, I get along with everybody here. During an interview with the Administrator on 11/2/2023 at 11:35 AM, she stated .[Resident #7] rolled across the hall to [Resident #6's] room and threw a cup of tea, [Resident #7] went back to her room and [Resident #6] followed. [Resident #8] witnessed [Resident #6] and [#7] arguing over the incident and stated [Resident #6] had started the physical altercation between them. [Resident #8] called for help and the nurse [LPN #2] was the first to the room to separate the residents. Both residents were assessed for injuries. [Resident #7] had no injuries. [Resident #6] had a skin tear to her left posterior forearm and was unable to say how or when the skin tear occurred. [Resident #8] said she saw [Resident #6] hit [Resident #7] first then [Resident #7] had picked up her bed remote and hit [Resident #6] back she didn't know where she hit [Resident #6] with the remote at .both [Resident #6] and [Resident #7] have a diagnosis of Alzheimer's and are unable to remember actual and current events. [Resident #7] could not give any details. [Resident #6] stated that [Resident #7] threw water on her and when she went over to ask her why [Resident #7] had hit her with a hairbrush and she could not remember where she was hit. She said she didn't know .the floor nurse had to request [Resident #6] exit [Resident #7's] room several times multiple times after they were separated .[Resident #8] reported it was a bed remote not a hairbrush .[Resident #6] denied hitting [Resident #7] but [Resident #8] with a BIMS of 15 reported [Resident #6] hit first .[Resident #7] could not recall any event and had no injuries .[Resident #8] reported she was not aware of anything that had happened prior to the incident .she stated [Resident #7] just calmly rolled over to [Resident #6's] room and threw the cup of water .based on the eye witnesses statement I cannot say there was willful intent from [Resident #7] to throw water on or at [Resident #6] or if she just threw the water, she had thrown her water pitcher in the hall a few days before, and due to earlier in the day she was noted to be crying, talking to self, arguing with self, having pacing like actions and packing her belongs. Staff did administer her PRN and noted it to be effective at the time, but that was 5 hours before the event .however [Resident #6] did willfully per witness hit [Resident #7] after water had been thrown in her room .During the interview the Administrator confirmed the facility failed to prevent abuse of Resident #7. Resident #9 was admitted to the facility on [DATE] with diagnoses including Hydrocephalus, End Stage Renal Disease, Kidney Transplant Failure, Dependence on Dialysis, Anxiety Disorder, Heart Failure, Major Depressive Disorder and Seizures. Review of Resident #9's quarterly MDS assessment dated [DATE], showed a BIMS assessment score of 15 indicating he was cognitively intact. No behaviors were noted during the assessment period. Review of Resident #9's Alert Note dated 6/4/2023 at 6:15 PM, showed .at approximately 6:15 PM, this resident was hit in the back by another resident within the facility. This resident states he is not hurt injured nor in pain. This resident states that the other resident was frustrated with him for visiting his roommate. Residents were immediately separated by facility staff member . Review of Resident #9's Incident Report dated 6/4/2023, showed Resident #10 was sitting at the nurse's station when he became agitated and started cursing Resident #9 regarding him visiting Resident #10's roommate the night prior. Resident #10 stated he did not want Resident #9 in his room because he wants to go to bed. Resident #9 was in his wheelchair and was moving away from Resident #10 when Resident #10 took his fist and struck Resident #9 once in the upper back between his shoulder blades. Resident #10 was admitted to the facility on [DATE], with diagnoses including Sjogren syndrome, Type 2 Diabetes Mellitus, Thoracic Aortic Aneurysm, Major Depressive Disorder, Parkinson's Disease, and Anxiety Disorder. Review of Resident #10's quarterly MDS assessment dated [DATE], showed a BIMS assessment score of 15 indicating he was cognitively intact. No behaviors were noted during the assessment period. Review of Resident #10's Alert Note dated 6/4/2023 at 8:33 PM, showed .at approximately 6:15 PM, this resident hit another resident on the back with his fist. This resident states he was frustrated with him for visiting his roommate at a time that he was ready to go to bed. Residents were immediately separated by facility staff member and charge nurse was notified . During an interview with Resident #10 on 11/2/2023 at 10:35 AM, he stated he would like to do the interview where he was instead of going to his room .and stated .it's fine right here .I was nothing really .I was just probably upset with him .I didn't hit him hard .things just happen sometimes .that was a long time ago and we haven't had any more problems . The resident did not provide any additional information related to the incident. During an interview with Resident #9 on 11/2/2023 at 10:50 AM, he agreed to self-propel himself into the dining room where no other residents were present for an interview. He stated .he hit me in the back .I guess with his fist I don't really know .we haven't had any more trouble .I just don't go around him anymore .I don't know what his problem was .it didn't scare me it did startle me because I wasn't expecting it .did kinda made me mad for a minute but I got over it .I was fine . During an interview on 11/2/2023 at 12:05 PM, Administrator #1 stated Resident #9 was hit in the back one time at the nurses' station by Resident #10. There were 2 CNA's that were present at the nurses' station. Resident #9 had turned up his music loud when Resident #10 asked him to turn it down. Resident #9 did not. Resident #9 instead attempted to roll away in his wheelchair that is when Resident #10 hit Resident #9 in the back . During the interview the Administrator confirmed Resident #10 did willfully hit Resident #9 and the facility failed to prevent abuse of Resident #9 . During an interview on 11/6/2023 at 4:30 PM, Registered Nurse (RN) #1 stated .[Resident #10] is normally laid-back guy, [Resident #9] just got on his nerves, I guess. [Resident #10] wanted [Resident #9] to turn his music down. [Resident #9] would visit [Resident #10's] roommate and he was already irritated with him .[Resident #9] talks loud and he likes to visit, it wasn't like a punch it was like a swat and it was not hard it was not red it wasn't scratched or bruised .he had never done anything like that before .[Resident #9] was more shocked than anything when it happened he wasn't upset. I think maybe his feelings were hurt because he is very personable with everyone .but more shocked than anything .[Resident #10] is very small and he didn't have very much strength to hit him very hard .he did mean to hit him it wasn't an accident, but it was more of a swat than anything . During an interview on 11/8/2023 at 2:35 PM, CNA #1 stated .it had been normal evening, I was just happened to be walking by [Resident #9] was blasting out his music on his phone .the next thing I knew [Resident #10] hit him in the back. I don't mean to be disrespectful but [Resident #10] moves slowly so he didn't hit him hard it was with his fist, but it was more of an attempt .his hands are sort of deformed like he has arthritis. He was in his wheelchair so he had to stretch and in slow motion to even hit him .there was no marks on [Resident #9] at all there wasn't even a reddened area .I can't be 100% sure he actually made contact, but I immediately separated them .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain an accurate medical record for 1 resident (#31) of 24 residents reviewed for medical records. The findings include: Review of a facility policy titled Residents' Rights Regarding Treatment and Advance Directives, undated, showed .it is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical treatment .during the care planning process, the facility will identify, clarify, and review with the resident .to make any changes .and whether the resident wishes to change or continue these instructions .the resident's choices will be documented in the resident's medical record . Resident #31 was admitted to the facility on [DATE] with diagnoses including Left Sided Hemiplegia, Hypothyroidism, Pain, Hypertension, Anxiety, Hyperlipidemia, Depression, and Schizoaffective Disorder. Review of an Order Summary Report for Resident #31 showed .FULL CODE . with a start date of [DATE] and no end date indicated. Review of the comprehensive care plan initiated [DATE] showed Resident #31 was .Full code . Review of the Tennessee Physician Orders for Scope of Treatment (POST) form for Resident #31 dated [DATE] showed .Do Not Attempt Resuscitation (DNR/no CPR [cardiopulmonary resuscitation]) (Allow Natural Death) . During an interview and observation on [DATE] at 4:01 PM, the Director of Nursing (DON) confirmed the physician order and the comprehensive care plan for Resident #31's medical record was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility investigation, observation, and interview, the facility failed to ensure the safety of 1 resident (#10) of 5 residents for accidents. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Anxiety, Depression, Guillain-Barre Syndrome (immune system attacks the nerves causing paralysis), and Abnormalities of Gait and Mobility. Medical record review of the resident's Care Plan, dated 1/17/19, revealed interventions for .ADLs [Activities of Daily Living] = Dependent on staff assistance for ADL's r/t [related to] to maintain daily needs .Bed Mobility: Two person extensive assistance . Medical record review of a Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Continued review revealed Resident #10 required extensive 2 person physical assist for bed mobility. Medical record review of a progress note dated 7/8/19 revealed, .CNA [Certified Nursing Assistant #1] called nurse to room .CNA reported to this nurse while giving .bed bath .resident was rolled .left leg began to slide over the side .slid onto the floor . Review of a fall investigation dated 7/9/19 revealed .Skin tear to upper right side, under breastbone and lower right abdominal folds .intervention .staff education .2 person assist c [with] toileting/changing/bed bath . Observation and interview with Resident #10 on 09/22/19 at 9:24 AM, in her room, revealed she had fallen out of bed when only one CNA was performing ADL care. Interview with Director of the Nursing (DON) on 9/23/19 at 2:30 PM, in the Administrators office, confirmed Resident #10 was an extensive 2 person assist with bed mobility prior to fall on 7/8/19. Continued interview confirmed Resident #10 on 7/8/19 was given a bed bath without 2 staff members present resulting in a fall. Telephone interview with CNA #1 on 9/23/19 at 3:18 PM, confirmed she provided personal hygiene care for Resident #10 on 7/8/19, without assistance from other staff resulting in a fall.

**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 obtain a Physician's Order for the use of oxygen for 1 resident (#4) of 6 residents reviewed for respiratory care. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Respiratory Disorder, Chronic Pain Syndrome, and Acute Kidney Failure. Review of the facility policy Oxygen Administration dated 10/2010 revealed .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Medical record review of the Comprehensive Care Plan dated 5/29/19 revealed .Administer/monitor effectiveness of treatments .Oxygen . Medical record review of the Significant Change of Status Minimum Data Set, dated [DATE] revealed Resident #4 received oxygen therapy. Medical record review of the Physician Orders dated 9/2019 revealed no order for oxygen therapy. Observation of Resident #4 on 9/22/19 at 9:45 AM, in resident's room, revealed the resident lying in bed with oxygen administered via nasal cannula at 2 liters per minute. Observation of Resident #4 on 9/22/19 at 1:35 PM, in resident's room, revealed the resident lying in bed with oxygen administered via nasal cannula at 2 liters per minute. Interview with the Director of Nursing (DON) on 9/22/19 at 1:40 PM, in the resident's room, confirmed Resident #4 was receiving oxygen at 2 liters per minute. Continued interview with the DON confirmed Resident #4 had no Physician's Order for the use of oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain a physician ordered lab for 1 resident (#16) of 5 residents reviewed for labs of 14 residents sampled. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Biliary Tract, Anemia, Muscle Weakness, Methicillin Resistant Staph Infection, and Insomnia. Medical record review of a physician's order dated 11/24/18 revealed .Vanco [an antibiotic medication] trough [lab to monitor medication level in the blood] to be drawn @ [at] 11:45 pm on 11/25/18. Fax results to pharmacy . Medical record review of the laboratory results revealed no documentation the trough had been drawn on 11/25/18. Interview with the Director of Nursing on 11/28/18 at 9:58 AM, in the conference room, confirmed the facility failed to obtain the trough level on 11/25/18 for Resident #16 per the physician's order.

**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 staff wore appropriate Personal Protective Equipment (PPE) before entering a resident's room on transmission based precautions for 1 of 1 residents observed. The findings include: Review of the facility policy, Isolation Precautions, undated revealed .Contact Precautions .Wear clean gloves when entering the room . Medical record review revealed Resident #16 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of the Biliary Tract, Anemia, Methicillin- Resistent Staphylococcus Aureous and Malnutrition. Medical record review of a physician's order dated 11/26/18 revealed .Contact Isolation through 12/6/18 . Observation of Licensed Practical Nurse (LPN #1) on 11/26/18 at 11:35 AM, revealed the LPN retrieved a lunch tray from the cart, entered Resident #16's room, placed the lunch tray on the bedside table and exited the room without applying gloves. Further observation revealed a cart with PPE equipment was outside the resident's door and a sign was on the door to indicate staff are to stop at the nurse's station for information. Interview with LPN #1 on 11/26/18 at 11:42 AM, in the hallway confirmed she was aware the resident was on contact precautions and she did not wear the appropriate PPE before entering the room. Interview with the Director of Nursing on 11/28/18 at 1:20 PM in the conference room confirmed all staff are expected to wear gloves before entering a residents room who are on contact precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to ensure pneumococcal vaccinations were administered to 4 residents (#6, #7,#11, #13) of 5 residents reviewed for vaccinations. The findings include: Review of the facility policy, Pneumococcal Vaccine revised 8/2016 revealed .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Anxiety and Chronic Obstructive Pulmonary Disease (COPD). Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 3/26/18 revealed the consent was signed to receive the pneumonia vaccination. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety and Diabetes. Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 3/26/18 revealed the consent was signed to receive the pneumonia vaccination. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, COPD and Mood Disorder. Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 4/5/18 revealed the consent was signed to receive the pneumonia vaccination. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Mood Disorder, Anxiety Disorder, Major Depressive Disorder and Pneumonia. Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 4/13/18 revealed the consent was signed to receive the pneumonia vaccination. Interview with the Director of Nursing (DON) on 11/28/18 at 1:45 PM, in the conference room, confirmed the facility failed to administer the pneumococcal vaccinations as per the facility policy.