**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation documentation review, observation, and interview the facility failed to protect 1 Resident (Resident #13) from physical abuse of 7 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised 9/2021, revealed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation, and misappropriation of resident property .Abuse includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraints not required to treat the residents' medical symptoms .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia with Mood Disturbance, and Cognitive Communication Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had severe cognitive impairment. No behaviors noted. Review of a comprehensive care plan for Resident #13 dated 9/25/2023, revealed .has outbursts and name-calling directed at staff . Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dementia without Mood Disturbance, and Need for Assistance with Personal Care. Review of an annual MDS assessment dated [DATE], revealed Resident #14 had mild cognitive impairment. No behaviors noted. Review of a comprehensive care plan for Resident 14 dated 1/7/2024, revealed .History of Altercation with another resident, physical contact made, Date Initiated: 12/23/2023 .has the potential to be physically/verbally aggressive with others r/t [related to] cognitive impairments/Poor impulse control . Review of a Sheriff's Office report dated 12/23/2023 at 5:36 PM revealed .Prior to my arrival on scene dispatch advised .suspect [Resident #14] had been transported to [local hospital] for a mental status change and the victim [Resident #13] was still on scene .I spoke with another patient who was near by and she stated [Resident #13 and Resident #14] were in a verbal argument over sharing food .The witness stated the argument continued and [Resident #14] did in fact walk over to [Resident #13] and strike her once in the face causing a loud noise .[Resident #13] did not have any visible injuries .she refused medical treatment . Review of a Telephone Physicians' Order for Resident #14 dated 12/23/2023, revealed .1 on 1 sitter now .send to [local hospital] ER [emergency room] mental status changes . Review of a Nursing Progress Note for Resident #14 dated 12/23/2023, revealed .Allegation of physical aggression initiated, with residents separated, 1:1 sitter placed until resident sent to ER . Review of a Nursing Progress Note for Resident #13 dated 12/23/2023 at 7:24 PM, revealed .Allegation Physical aggression received. Immediate separation of residents, physical exam, notification of family and MD [Medical Doctor], Psych [Psychiatric] NP [Nurse Practitioner], LCSW [Licensed Clinical Social Worker] to increase visits . Review of a Nursing Progress Note for Resident #13 dated 12/23/2023 at 11:58 PM, revealed .Head to toe skin assessment .Denies pain. No redness or bruising to entire body. States she feel safe, and isn't afraid . Review of a Nursing Progress Note for Resident #14 dated 12/24/2023 at 2:56 AM, revealed .Room change .for better placement [upon return] . Review of a Nursing Progress Note for Resident #14 dated 12/24/2023 at 7:25 AM, revealed .Alert Note .Resident returned from the ER, no new orders noted. 1:1 sitter in place . Review of a Psychotherapy Progress Note for Resident #14 dated 12/27/2023, revealed .Pt presented with a stable mood .He discussed how he lashed out at another resident, over the weekend, stating she was cussing me, and I asked her to stop but she didn't and then I tapped her on her shoulder [shoulder], if I hurt her, please tell her I'm sorry. We discussed how it is inappropriate to touch anyone without their consent, especially hitting them for any reason, and how he can better handle his reactions in the future . Review of a Physicians' Progress Note for Resident #14 dated 12/27/2024, revealed .had altercation with another resident and struck her. He doesn't remember striking her but does recall [the] verbal assault . Review of a Nursing Progress Note for Resident #13 dated 1/1/2024, revealed .Alleged incident .Resident does not recall having an altercation with another resident. She reports that she feels safe .She does not appear to be in any acute distress. Residents were separated immediately. Continue current plan of care . Review of the facility's investigation titled, Summary of Investigation, dated 1/3/2024, revealed .Brief summary of incident .Both residents in dining room. [Resident #13] was asking [Resident #14] for food. He [Resident #14] stated he did not have food and she continued to ask, he told her to shut up and asked if she wanted him to come over and smack her in the face. [Resident #14] went over to her and used the back of his hand and hit her in the face and returned to his table . Further review revealed .residents immediately separated .1 on 1 sitter placed with [Resident #14] .actions taken .[Resident #14 was sent to [the] ER for [a] mental status change .returned to [a] private room on a different unit with a 1 on 1 sitter .psych NP and medical to eval [evaluate] . During an interview on 7/15/2024 at 11:50 AM, Resident #13 was asked by the surveyor if anyone at the facility had ever done anything mean or hurtful to her, Resident #13 denied abuse and stated, .No .I'm doing ok .I'm fine . During an interview on 7/15/2024 at 11:55 AM, Resident #14 was asked by the surveyor about the allegation of physical abuse that allegedly occurred between himself and Resident #13 on 12/23/2023; Resident #14 stated .I don't think so .no .I don't believe I did [physically abuse Resident #13] . Resident #14's multiple accounts of the incident were inconsistent with investigation and witness statements of Resident #32 and Resident #33. Medical record review revealed Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Subsequent Encounter for Closed Fracture with Routine Healing, Hypertensive Chronic Kidney Disease, and Need for Assistance with Personal Care. Review of a quarterly MDS assessment dated [DATE], revealed Resident #32 was cognitively intact. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, and Essential Tremor. Review of a quarterly MDS assessment dated [DATE], revealed Resident #33 was cognitively intact. During an interview on 7/15/2024 at 2:50 PM, Resident #32 stated she was present during the altercation on 12/23/2023 and heard both residents (Resident #13 and Resident #14) arguing. Further interview revealed Resident #32 had seen Resident #14 go over to Resident 13's table and hit her in the face with the back of his right hand. During an interview on 7/15/2024 at 3:05 PM, Resident #33 stated she was in the dining room when Resident #14 had struck Resident 13 in the face after a verbal argument. Resident #33 stated .she did not recall if [Resident #13] provoked him [Resident #14] or not, but he hit her . During a telephone interview on 7/15/2024 at 3:10 PM, Licensed Practical Nurse (LPN) A stated she was the weekend supervisor when the allegation of physical abuse occurred on 12/23/2023. LPN A stated she responded to the incident promptly and the residents had already been separated by the staff ( LPN A was unable to provide additional names). LPN A stated she interviewed Resident #14 and was told by him Resident #13 had .ran her mouth to where it was annoying .stated he [Resident #14] said to her [Resident #13] .Do you want to see what this [racial expletive] can do .Resident #13 dared him .and he [Resident #14] went over and hit [Resident #13] . LPN A stated there were 2 other residents' present [Resident #32 and Resident #33] who were eyewitnesses the incident. LPN A stated she had conducted interviews with the 2 other residents [Resident #32 and Resident #33] their recollection of the event was collaborated with the altercation. LPN A stated she assessed both residents [Resident #13 and Resident #14] and no injuries were observed to either resident. During an interview on 7/16/2024 at 9:29 AM, the Director of Nursing (DON) confirmed an act of physical abuse occurred on 12/23/2023. A verbal exchange resulted in physical contact when Resident #14 left his table, propelled over to Resident #13, and struck Resident #13 in the face with the back of his hand. The DON stated .he hit her .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to report the suspicion of a crime for 1 resident (Resident #1) of 1 resident reviewed to the State Survey Agency, local law enforcement, adult protective services, and other officials (where state law provides for jurisdiction in long-term care facilities) in accordance with State law. The findings included: Review of the facility policy titled, Investigating Incidents of Assault, Rape or Other Violent Crime, dated 4/2021, showed .If a resident .is thought to be the victim of .crime the victim is stabilized and the scene of the crime is preserved for evidence. The following actions must be taken .Call .911 .Do not disturb the area where the incident is thought to have occurred .Do not .clean the area so as not to disturb evidence .Notify appropriate agencies .to include DOH, APS, Ombudsman . Review of the facility policy titled, Opioid Overdose Response (Naloxone), dated 10/2023, showed .Follow state department of health requirements for opioid overdose reporting . Resident #1 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Acute Kidney Failure, Psychoactive Substance Abuse, Human Immunodeficiency Virus, and Cerebral Infarction. Review of the comprehensive care plan dated 11/15/2023, showed .hx [history] of drug abuse and could be prone to drug seeking behaviors . Review of a Nursing Note dated 12/7/2023, showed .post visitor/mother this evening this nurse and staff cont [continued] frequent room checks per admin req [request] as precaution . Review of a Psychotherapy Progress Note dated 12/8/2023, showed .goal for the weekend will be to not contact anyone who can bring her drugs. [Resident #1] admitted to having thoughts of calling someone but knows what will happen if she does . During an interview on 12/18/2023 at 2:26 PM, Nursing Supervisor #1 stated she recalled an incident where a white powdery substance was confiscated from Resident #1's room (unsure of the date), during a supervised visit with the resident's mother. Nursing Supervisor #1 stated she was informed of the incident during verbal shift report from Licensed Practical Nurse (LPN) #1. During an interview on 12/19/2023 at 9:28 AM, the Psychiatric Nurse Practitioner (Psych NP) stated she was very familiar with Resident #1. She was made aware of a white powdery substance discovered in resident's room by the Director of Nursing (DON). She was informed the mother had dropped the white substance during a supervised visitation and that is how it was discovered. During interviews on 12/19/2023 at 2:40 PM, with the Administrator (ADM) and DON stated they recalled the event that occurred on 12/7/2023 with Resident #1. An unknown white powdery substance was confiscated by LPN #1, during a supervised visit between Resident #1 and her mother. The DON stated the mother of Resident #1 was questioned and denied knowing about the unknown substances retrieved from the cell phone wallet. The DON stated she put the paper with the unknown substance in a denture cup, covered with a lid, and took it to the ADM's office. The ADM stated the denture cup containing the unknown substance sat on her desk from 12/7/2023 until 12/11/2023, when she threw it in the trash. She stated, I didn't know what else to do with it. The ADM and DON both confirmed they did not report the incident to the state agency or local law enforcement, they didn't feel it met the criteria of a reportable event. The unknown substance was confiscated prior to reaching the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to protect 1 resident (Resident #58) from abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 9/2021, showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Residents have the right to be free from abuse .Protect residents from abuse including other residents . Resident #58 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Major Depressive Disorder, Insomnia, Generalized Anxiety Disorder, Hypertension, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Review of a care plan revised 9/30/2022, revealed Resident #58 .may be depressed or anxious .Encourage talking about problems initiated .When restless or anxious, provide calm, quiet atmosphere, [Resident #58] has a history of experiencing Suicidal Ideation (SI) .[Resident #58] will be administered medications as directed .[Resident #58] will be referred to by Psych NP [Psychiatric Nurse Practitioner], provide a calm, quiet atmosphere when restless or anxious. Document and report any changes in mood status . Resident #67 was admitted to the facility on [DATE] with Diagnoses including Major Depressive Disorder, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbance, and Hypertension. Review of a Care Plan dated 9/6/2022, revealed Resident #67 .can be uncooperative. May on occasion shout or physically resist care. May use foul or abusive language during care or tx [treatment] . Review of an admission MDS dated [DATE], showed Resident #67 had a BIMS score of 3 indicating the resident had severe cognitive impairment. Review of Resident #67's Psychiatric Progress Note dated 10/6/2022 showed .staff is interviewed, and they report resident has increased resistance to care. They [staff] report that during these episodes he is hard to redirect . Review of progress notes showed Resident #58 and #67 shared a room and there were no documented issues between the residents. During an interview with Resident #58 on 10/25/2022 at 9:54 AM, he stated, my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out. He says [expletive] you and stuff like that . Resident #58 stated he had not reported the verbal abuse to staff. He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. Resident #58 stated he did not remember the names of the staff who overheard the cursing. During an interview on 10/25/2022 at 2:17 PM, Licensed Practical Nurse (LPN) #3 stated she had heard Resident #67 yell at Resident #58 to tell staff something for him, and the staff redirected him. She stated Resident #67 cusses and calls the facility staff names but she had not heard him call Resident #58 names. LPN #3 stated Resident #58 had not reported incidents of verbal abuse to her. During an interview on 10/25/2022 at 2:27 PM, Certified Nursing Assistant (CNA) #2 stated Resident #67 .is sweet sometimes and other times lashing out and aggressive. I have never heard [Resident #67] lash out at his roommate, but he does lash out at the staff . During an interview on 10/25/2022 at 2:36 PM, CNA #3 stated, Resident #67 .has behaviors. I think he [Resident #67] doesn't understand, and he gets loud. Sometimes he [Resident #67] says inappropriate things, cusses and I heard him [Resident #67] call [Resident #58] an asshole .He curses at his roommate and then apologizes. I told [Resident #67] he could not say things like that . The CNA thought she reported the incident to a nurse but was unable to remember the nurse's name. The CNA was unable to recall the date the incident occurred but thought .it was a couple of weeks ago . During an interview on 10/26/2022 at 9:39 AM, the Administrator stated she had not been notified of any incidents between Resident #58 and Resident #67. I was not aware of any behaviors, cursing or abuse. If the staff member had made me aware and I thought there was a problem, we would have separated them. I would have investigated immediately. The CNA should have immediately reported it and made us aware . The Administrator confirmed she was the Abuse Coordinator for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse after a resident-to-resident altercation for 2 residents (Resident #58 and Resident #67) of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 9/2021, showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Abuse includes but is not limited .verbal, mental, sexual or physical abuse .Any employee .who becomes aware of abuse .shall immediately report it per 483.12 Freedom from Abuse, Neglect, and Exploitation .report any allegations within timeframes required by federal requirements . Resident #58 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Major Depressive Disorder, Insomnia, Generalized Anxiety Disorder, Hypertension, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Review of a care plan revised 9/30/2022, revealed Resident #58 .may be depressed or anxious .Encourage talking about problems initiated .When restless or anxious, provide calm, quiet atmosphere, [Resident #58] has a history of experiencing Suicidal Ideation (SI) .[Resident #58] will be administered medications as directed .[Resident #58] will be referred to by Psych NP [Psychiatric Nurse Practitioner], provide a calm, quiet atmosphere when restless or anxious. Document and report any changes in mood status . Resident #67 was admitted to the facility on [DATE] with Diagnoses including Major Depressive Disorder, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbance, and Hypertension. Review of an admission MDS dated [DATE] showed Resident #67 had a BIMS score 3 indicating the resident had severe cognitive impairment. Review of a care plan dated 9/6/2022, showed Resident #67 .can be uncooperative. May on occasion shout or physically resist care. May use foul or abusive language during care or tx [treatment] . Review of resident #67's Psychiatric Progress Note dated 10/6/2022 showed .staff is interviewed, and they report resident has increased resistance to care. They [staff] report that during these episodes he is hard to redirect . Review of progress notes showed Resident #58 and #67 shared a room and there were no documented issues between the residents. During an interview with Resident #58 on 10/25/22 at 9:54 AM, he stated,my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out. He says [expletive] you and stuff like that . Resident #58 stated he had not reported the verbal abuse to staff. He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. Resident #58 stated he did not remember the names of the staff who overheard the cursing. During an interview on 10/25/2022 at 2:36 PM, Certified Nursing Assistant [CNA] #3 stated, Resident #67 .has behaviors. I think he [Resident #67] doesn't understand, and he gets loud. Sometimes he [Resident #67] says inappropriate things, cusses and I heard him [Resident #67] call [Resident #58] an asshole .He curses at his roommate and then apologizes. I told [Resident #67] he could not say things like that . The CNA thought she reported the incident to a nurse but was unable to remember the nurse's name. The CNA was unable to recall the date the incident occurred but thought .it was a couple of weeks ago . During an interview on 10/26/2022 at 9:39 AM, the Administrator stated she had not been notified of any incidents between Resident #58 and Resident #67. I was not aware of any behaviors, cursing or abuse .The CNA should have immediately reported it and made us aware. The CNA should have reported it to her supervisor and then it would have been reported to me . The Administrator confirmed she was the Abuse Coordinator for the facility. The Administrator confirmed the allegation should have been reported to the State Survey Agency within 2 hours of the occurrence and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse for 1 resident (Resident #58) of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 9/2021, showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Investigate .any allegations within timeframes required by federal requirements . Resident #58 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Major Depressive Disorder, Insomnia, Generalized Anxiety Disorder, Hypertension, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Review of a care plan revised 9/30/2022, revealed Resident #58 .may be depressed or anxious .Encourage talking about problems initiated .When restless or anxious, provide calm, quiet atmosphere, [Resident #58] has a history of experiencing Suicidal Ideation (SI) .[Resident #58] will be administered medications as directed .[Resident #58] will be referred to by Psych NP [Psychiatric Nurse Practitioner], provide a calm, quiet atmosphere when restless or anxious. Document and report any changes in mood status . Resident #67 was admitted to the facility on [DATE] with Diagnoses including Major Depressive Disorder, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbance, and Hypertension. Review of a Care Plan dated 9/6/2022 revealed Resident #67 .can be uncooperative. May on occasion shout or physically resist care. May use foul or abusive language during care or tx [treatment] . Review of an admission MDS dated [DATE], showed Resident #67 had a BIMS score 3 indicating the resident had severe cognitive impairment. Review of Resident #67's Psychiatric Progress Note dated 10/6/2022 showed .staff is interviewed, and they report resident has increased resistance to care. They [staff] report that during these episodes he is hard to redirect . Review of progress notes showed Resident #58 and #67 shared a room and there were no documented issues between the residents. During an interview with Resident #58 on 10/25/2022 at 9:54 AM, he stated, .my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out. He says [expletive] you and stuff like that Resident #58 stated he had not reported the verbal abuse to staff. He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. Resident #58 stated he did not remember the names of the staff who overheard the cursing. During an interview on 10/25/2022 at 2:17 PM, Licensed Practical Nurse (LPN) #3 stated she had heard Resident #67 yell at Resident #58 to tell staff something for him, and the staff redirected him. She stated Resident #67 cusses and calls the facility staff names but she had not heard him call Resident #58 names. LPN #3 stated Resident #58 had not reported incidents of verbal abuse to her. During an interview on 10/25/2022 at 2:36 PM, CNA #3 stated Resident #67 .has behaviors. I think he [Resident #67] doesn't understand, and he gets loud. Sometimes he [Resident #67] says inappropriate things, cusses and I heard him [Resident #67] call [Resident #58] an asshole .He curses at his roommate and then apologizes. I told [Resident #67] he could not say things like that . The CNA thought she reported the incident to a nurse but was unable to remember the nurse's name. The CNA was unable to recall the date the incident occurred but thought .it was a couple of weeks ago . During an interview on 10/26/2022 at 9:39 AM, the Administrator confirmed the allegation of verbal abuse had not been investigated. I was not aware of any behaviors, cursing or abuse. If the staff member had made me aware and I thought there was a problem, we would have separated them. I would have investigated immediately . The Administrator confirmed the allegation of abuse should have been investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan after the code status (Resident's wishes for treatment if the heartbeat or breathing stops) changed for 1 resident (Resident #63) of 32 residents reviewed for care plans. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, showed .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary team reviews and updates the care plan .when the resident has been readmitted to the facility from a hospital stay . Record review revealed Resident #63 was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Peripheral Vascular Disease, Hypertension, and Major Depressive Disorder. Review of a care plan updated [DATE], showed, .Advance Directive in place to include Code Status: DNR [Do Not Resuscitate-No Cardiopulmonary Resuscitation-CPR] with Comfort Measures .Interventions Ensure Advance Directives are accurate and up to date. Review at least quarterly . Review of Resident #63's Tennessee Physician Orders for Scope of Treatment (POST Form) dated [DATE], showed .Resuscitate (CPR) .Full Treatment . indicating the resident wanted Full Code status (Resident wished to receive CPR if the heartbeat or breathing stopped). Review of a physician's order dated [DATE], showed .Full Code- Full Treatment . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. During an interview on [DATE] at 2:03 PM, Licensed Practical Nurse (LPN) #3 confirmed Resident #63's POST form dated [DATE] showed the Resident wished to be Full Code status. The LPN confirmed the Resident's care plan dated [DATE] showed DNR with comfort measures. The LPN stated the Resident's care plan had not been updated to reflect the full code status after an updated POST form had been received. During an interview on [DATE] at 2:22 PM, the Administrator confirmed the POST form and physician's order both showed Full Code with Full treatment. She confirmed the care plan had not been revised to reflect the Resident's wishes for Full Code status after she returned from the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assist with care of a colostomy according to the resident's preferences for 1 resident (Resident #446) of 32 residents reviewed for activities of daily living (ADLs). The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder, Encounter for Attention to Colostomy, and Acquired Absence of Digestive Tract. Review of a quarterly Minimum Data Set assessment dated [DATE] showed Resident #446 had moderate cognitive impairment and required supervision of 1 staff with bed mobility, limited assistance of 1 staff with transfers, limited assistance of 1 staff with toileting, and had an ostomy. Review of a care plan showed Resident #446 had a colostomy for bowel elimination with interventions including assist the resident with emptying of colostomy bag as needed. During an observation on 10/24/2022 at 12:25 PM, in Resident #446's room, Certified Nursing Assistant (CNA) #1 responded to the resident's call light, and the resident stated she wanted her colostomy bag emptied. CNA #1 responded, It doesn't need it right now, you'll have to wait til after lunch. During an interview on 10/24/2022 at 12:30 PM, CNA #1 confirmed Resident #446 was told to wait until after lunch and it should be the resident's choice when the ostomy bag was emptied. During an interview on 10/26/2022 at 6:03 PM, the Director of Nursing (DON) stated it was expected that the CNA help with Resident #446's colostomy when the resident requested. The DON confirmed the CNA had not honored the resident's wishes and helped her with ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation, and interview, the facility failed to administer medications through a Percutaneous Endoscopic Gastrostomy (PEG) enteral tube (tube inserted into the abdomen used for nutrition and medications) as ordered by the physician for 1 resident (Resident #40) of 8 residents with enteral tubes. The findings include: Review of the facility policy Administering Medications through an Enteral Tube dated 11/2018, showed .provide guidelines for the safe administration of medications through an enteral tube .remove the syringe and clamp tubing .reattach syringe (without plunger) .when the last of the medication begins to drain from the tubing, flush the tubing with 15 ml [milliliters] of warm purified water (or prescribed amount) .clamp the tubing when the flush is complete . Medical review revealed Resident #40 was initially admitted [DATE] and readmitted on [DATE] with diagnoses including Dysphagia (partial loss of language) following Cerebral Infarction, Gastrostomy Status, Hypertension, Atherosclerotic Heart Disease, Severe Protein-Calorie Malnutrition, and Chronic Obstructive Pulmonary Disease. Resident #40 was readmitted to the facility following a Cerebral Vascular Accident (CVA) with a PEG tube inserted in his left upper quadrant for enteral feeding and medications. Orders revealed NPO (nothing by mouth) diet NGT [nasogastric tube] for nutrition/meds, check for residual every shift and prior to medication administration, and flush PEG via syringe with 30 ml water before and after medication administration. Jevity 1.5 (nutritional supplement) at 65 ml per hour with a water flush of 50 ml/hour was ordered for nutrition. Review of the Care Plan, revised 8/23/2022, showed Resident #40's PEG tube interventions included .check PEG tube placement prior to initiating TF [tube feed] and medication administration by checking gastric residual volume .flushes and hydration as directed . Observation on 10/26/2022 at 8:19 AM, with Licensed Practical Nurse (LPN) #1 during a medication administration pass for Resident #40 showed LPN #1 placed the tube feeding on hold; failed to disconnect the feed tubing, and attached the 60 ml syringe with 30 ml of water with the plunger inserted into the side balloon port, which is not an port to the stomach for administration of feedings, water, or medications. When the water did not free flow into the PEG tubing, she restarted the TF and exited the room. The Unit Manager/LPN entered with LPN #1, disconnected the tubing, flushed the insertion site with the 30 ml of water, and exited the room. LPN #1 attached the 60 ml syringe and plunger with the crushed medications and water to the correct TF insertion port. When the medications did not free flow into the tubing, LPN #1 again exited the room. The Director of Nursing (DON) entered the room and checked the residual content, withdrawing 48 ml of stomach contents. The DON exited the room. LPN #1 attached the 60 ml syringe with the crushed medications and water without removing the plunger. After the medications eventually were administered, LPN #1 flushed with 5 ml of water and later with 30 ml of water. During an interview on 10/26/2022 at 9:00 AM, LPN #1 confirmed she failed to check the residual before giving the enteral medications, failed to flush with 30 ml of water prior to giving the medications, and initially gave 5 ml of water after the medication administration instead of the ordered 30 ml of water. During an interview on 10/26/2022 at 5:30 PM, with the Administrator and the Director of Clinical Services, the Administrator stated the facility failed to ensure physician's orders for enteral medications via a PEG tube were followed for Resident #40.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the facility's 2567 dated 9/18/2019 and 9/22/2021, medical record review, observations, and interviews, the facility's Quality Assurance Performance Improvement (QAPI) program failed to have an effective system in place to sustain compliance with ensuring residents were free from abuse and reporting allegations of abuse for 1 resident (#58) of 24 residents reviewed for abuse. The QAPI committee's failure to effectively monitor previously identified deficient practices and corrective actions to ensure residents were free of abuse and reporting allegations of abuse had the potential to affect all 162 residents in the facility. The findings include: Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 2/2020 revealed .The objectives of the QAPI Program are to .Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators .Implementation .The QAPI Committee oversees implementation of our QAPI Plan .The QAPI plan describes the process for identifying and correcting quality deficiencies .Key components .Tracking and measuring performance .Identifying and prioritizing quality deficiencies .Developing and implementing corrective action/performance improvement activities .Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Design and Scope, dated 2/2020 revealed .The facility QAPI Program is ongoing, comprehensive and addresses all care and services provided by the facility .The QAPI program is designed to address all systems and practices in this facility that affect residents, including clinical care, quality of care, quality of life, resident choice and safety . Review of the facility's 2567 dated 9/18/2019 revealed during a recertification survey conducted on 9/22/2021, the facility was cited F600 Free from Abuse and Neglect. Review of the facility's 2567 dated 9/22/2021 revealed during a complaint survey conducted on 9/22/2021, the facility was again cited at F600 Free from Abuse and Neglect and also F609 Reporting of Alleged Violations. Resident #58 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Major Depressive Disorder, Insomnia, Generalized Anxiety Disorder, Hypertension, and Muscle Weakness. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbance, and Hypertension. During an interview with Resident #58 on 10/25/2022 at 9:54 AM, the resident stated, .my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out .He says [expletive] you and stuff like that He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. During an interview on 10/26/2022 at 7:25 PM, with the Administrator, Director of Nursing, and the Director of Clinical Services, the QAPI program was discussed including review of findings from the recertification survey dated 9/18/2019, and complaint survey dated 9/22/2021 related to abuse. The Administrator discussed the QAPI interventions put in place by the facility to address F-600 and F-609 from the complaint survey on 9/22/2021. The Administrator stated a Performance Improvement Plan (PIP) had been developed for the monitoring of abuse. The PIP developed included reviewing all new admission referrals for a history of violence and aggressive behaviors. The Administrator revealed the facility had tracked and trended abuse in the facility and no concerns were noted. The Administrator stated, We try to find compatible roommates. The Administrator stated, .We have allegations (of abuse) we can't prevent . The Administrator confirmed the facility's QAPI program was not effective in preventing the allegation of abuse between resident #58 and #67. The Administrator revealed the facility developed a PIP related to the Facility's deficiency related to failure to report an allegation of abuse. The Administrator stated all allegations of abuse are to be reported by staff. The Administrator confirmed the QAPI program was unable to sustain compliance with failure to prevent abuse and was unable to sustain compliance with notifying the appropriate authorities of the allegation of abuse for Resident #58.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility abuse policy, medical record review, review of facility documentation, observation and interview, the facility failed to prevent verbal abuse of 1 resident (#17) of 26 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention Policy and Procedure, dated 2/26/18, revealed .The purpose of this written .Prevention Program is to outline the preventive steps taken by the facility to reduce the potential for the mistreatment, neglect and abuse of residents . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Dementia, Schizophreniform Disorder and Diabetes. Medical record review of the Quarterly Minimum Data Set, dated [DATE], revealed Resident #17 scored an 8 on the Brief Interview for Mental Status, indicating severe cognitive impairment, with short and long term memory deficits, and was totally dependent on 2 persons to transfer. Review of the facility's documentation, dated 9/5/19, revealed 2 Certified Nursing Assistants (CNA #1 and #2) were providing care to Resident #17 when CNA #1 became upset with the resident and spoke harshly to him, using foul language. Further review revealed CNA #1 was removed from resident care. Continued review revealed CNA #1 confirmed she became upset with the resident and used the F word. Review of the Director of Nursing's (DON) summary statement revealed, Two CNA's were getting [Resident #17] up and the resident became agitated. He started to flail his arms and [CNA #1] said 'Don't you f***ing hit me.' .[CNA #1] admits to saying F***ing in front of the resident and was terminated . Observation of Resident #17 on 9/16/19 from 2:35 PM until 3:15 PM revealed he was in his wheel chair, using his arms to propel himself through the front halls of his unit. Interview with the Charge Nurse on 9/16/19 at 3:15 PM, at the nursing station, revealed .[Resident #17] is normally in the hall .always mild mannered .doesn't normally resist care . Further interview revealed Resident #17 was diagnosed with a Urinary Tract Infection after the incident on 9/5/19, was treated, and returned to his normal mental status. Continued interview revealed the Charge Nurse had not encountered any problems with CNA #1 prior to 9/5/19 and stated .they [referring to the facility administration] don't tolerate foul language . Interview with CNA #2 on 9/18/19 at 11:40 AM, in the conference room, revealed the facility's documentation of the events on 9/5/19 was correct. Interview with the DON on 9/18/19 at 11:50 AM, in the conference room, confirmed the verbal abuse had occurred and he stated his observation and interview of Resident #17 two hours after the incident, revealed the resident had no memory of the verbal abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one resident (#19) of 3 residents reviewed for discharge MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be completed .within 14 days after the discharge date . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Anxiety, Depression, and Hypertension. Further review revealed the resident was discharged from the facility on [DATE]. Medical record review of the resident's MDS assessments revealed a discharge MDS assessment for Resident #19 had not been completed from the day of discharge, [DATE], to the present day, [DATE]. Interview with the MDS Coordinator on [DATE] at 5:06 PM, in the conference room, confirmed Resident #19 expired on [DATE] in the facility. Continued interview confirmed the facility had not complete a Discharge MDS assessment for Resident #19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility documentation review and interview, the facility failed to ensure unnecessary medications were not administered to 1 resident (#82) of 6 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including Asthma, Localized Edema, Myocardial Infarction, and Major Depression. Medical record review of a Physician Order, dated 6/11/19, revealed .DC [discontinue] levaquin [an antibiotic used to treat infections] 500 mg [milligrams] x (for) 7 days .DC xopenex [a medication used in a nebulizer machine to prevent, or relieve wheezing, coughing, shortness of breath, and chest tightness] 1.25/3 ml [milliliters] QID [4 times a day] x 10 days orders put in on wrong patient . Medical record review of the Medication Administration Record (MAR) dated 6/2019 revealed .LEVAQUIN 500 MG TABLET: GIVE 1 TABLET BY MOUTH AT BEDTIME FOR 7 DAYS order date 6/11/19 .Start Date 6/11/19 .Discontinue Date 6/11/19 . Continued review revealed Resident #82 received 1 dose of Levaquin 500 mg on 6/11/19 at 9:00 PM. Further review revealed .XOPENEX 1.25 MG/3 ML SOLUTION GIVE TREATMENT 4 TIMES DAY FOR 10 DAYS Order Date: 6/11/19 START DATE 6/11/19 DISCONTINUE DATE 6/11/19 . Further review of the MAR revealed Resident #82 received 1 dose of Xopenex 1.25 MG/3 ML on 6/11/19 at 5:00 PM. Medical record review of the facility's documentation dated 6/11/19 revealed .resident [Resident #82] received a wrong medication, due to the wrong order put in .the medication order belonged to an other [another] resident . Record review of the facility's documentation, dated 6/13/19, written by Registered Nurse (RN) #1 revealed .On Tuesday an order was received for [Resident #178] for antibiotic and Neb treatments .They were put in under [Resident #82] by accident . Interview with RN #1 on 9/17/19 at 3:27 PM, in the conference room, confirmed Resident #82 and #178 had similar names. Continued interview confirmed RN #1 selected the wrong resident in the computer to receive Levaquin and Xopenex on 6/11/19. Interview with Licensed Practical Nurse (LPN) #1 on 9/17/19 at 3:45 PM, in the conference room, confirmed the LPN administrated Levaquin and Xopenex to Resident #82 on 6/11/19 at 9:00 PM. Interview with the Director of Nursing (DON) on 9/18/19 at 9:34 AM, in the DON's office, confirmed Resident #82 received a dose of Levaquin and Xopenex on 6/11/19 which was ordered for Resident #178.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to refer 1 resident (#47) after the resident was identified with a possible serious mental disorder, to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) of 4 residents reviewed for PASARR. The findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagoses including Sepsis, Diabetes Mellitus, Major Depressive Disorder, Epilepsy, and Hypertension. Medical record review of the Pre-admission Screening and Resident Review (PASARR) form dated 2/27/18 revealed no mental health diagnosis was known or suspected, and the resident had not been prescribed psychoactive medications within the past 6 months. Medical record review of a psychiatric progress note dated 9/13/17 revealed the resident had a diagnosis of Schizoaffective Disorder. Continued review of the psychiatric progress note revealed .Psych [psychiatric] medication management for depression, aggression, crying spells .staff reports he is still having occ [occasional] crying spells .Has received scheduled Ativan [antianxiety medication] and is doing better with his anxiety and restlessness .STM [short term memory] impaired, remote memory impaired, intellectual disability .Current Psychotropic Medications-Lexapro [antidepressant medication] 10 mg. [milligrams] PO [by mouth] Q [every] day-depression .Ativan 0.25 mg. PO @ [at] 2PM [and] HS [hour of sleep] for anxiety and may repeat X [times] 1 in 24 hours .Seroquel [antipsychotic medication] 25 mg. PO Q AM [morning] and 50 mg. PO Q HS . Medical record review of a psychiatric progress note dated 8/9/18 revealed the resident had a diagnosis of Schizoaffective Disorder. Continued review of the psychiatric progress note revealed .staff report more depressed, more crying spells and thoughts that he would be better off dead expressed to one of the CNAs [Certified Nursing Assistant], charge nurse questioned him and he stated he had no plan, no intention of harming himself .his schizoaffective sxs [symptoms] are managed [with] Seroquel and are stable . Interview with Registered Nurse (RN) #1, responsible for completing PASARRs at the facility, on 9/12/18 at 1:05 PM, at the 3rd floor nursing station confirmed the facility had not referred the resident to the state-designated authority for a Level II PASARR evaluation to determine if the resident required specialized services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview the facility failed to ensure a complete medical record by failing to document the administration of anticoagulant medication for 1 resident (#184) of 5 sampled residents reviewed for anticoagulation medication of 53 total sampled residents. The findings include: Review of the facility's policy Medication Administration with revision date 3/16/15 revealed .Record the name, dose, route, and time of medication on the Medication Administration Record .Initial the record after the medication is administered to the resident . Medical record review revealed Resident #184 was admitted to the facility on [DATE] with diagnoses including: Long Term (Current) Use of Anticoagulants, Atrial Fibrillation (abnormal heart beat), and Fracture of Upper End of Left Humerus (arm). Medical record review of Physician's Orders dated 8/13/18 revealed .xarelto [an anticoagulation medication] is for A Fib [atrial fibrillation] - anticoagulation . Medical record review of Physician's Orders dated 9/1/18 revealed .xarelto 20 milligram (mg) tab (tablet) po (by mouth) at bedtime (a fib) . Medical record review of Resident #184's Medication Record (MAR) dated 9/1/18 through 9/30/18 revealed no documentation Xarelto had been administered on 9/1/18-9/9/18 and 9/11/18. Telephone interview with Licensed Practical Nurse (LPN) #2 on 9/12/18 at 4:00 PM, confirmed she had administered Resident #184's Xarelto on 9/1/18 but had failed to sign the medication administration record (MAR). Telephone interview with LPN #3 on 9/12/18 at 4:02 PM, confirmed she had administered Resident #184's Xarelto on 9/2/18, 9/3/18, 9/4/18, 9/5/18, 9/6/18, 9/8/18, and 9/9/18 but had failed to sign the MAR. Telephone interview with LPN #4 on 9/12/18 at 4:13 PM, confirmed she had administered Xarelto to Resident #184 on 9/11/18 but failed to sign the MAR. Telephone interview with LPN #5 on 9/12/18 at 4:15 PM, confirmed she had administered Xarelto to resident #184 on 9/2/18 but failed to sign the MAR.