**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 1 of 3 residents (Resident #1) reviewed for abuse.The facility failed to ensure that resident #1 was free of physical abuse when LVN A blocked the resident from propelling into the nurses' station. LVN A then initiated a confrontation with Resident #1 when she became physical with the resident after the resident wheeled away from the nurse's station. LVN A nudged a cell phone to the back of Resident #1's head, when the resident reacted and slapped LVN A's arm, LVN A grabbed the resident's arm firmly. LVN pointed her finger at the resident and left the area. LVN A returned and continued the confrontation and subsequently hit Resident #1 on top of the head with an open hand on 07/07/2025.The noncompliance was identified as PNC. The IJ started on 07/07/2025 at 10:30 AM and ended on 07/08/2025. The facility had corrected noncompliance before the investigation had begun.These failures could place residents at risk for emotional distress, fear, decreased quality of care, and further abuse.Findings included: Record review of Resident #1's face sheet, dated 07/24/2025, indicated an [AGE] year-old female who originally admitted to the facility on [DATE]. Resident #1 had diagnoses that included: Wernicke's Encephalopathy (Damage caused to the brain from poor nutrition or alcoholism), Depression, Psychotic Disorder with delusions due to known physiological condition, Alcohol dependence with alcohol-induced dementia, Restlessness and agitation.Record review of Resident #1's quarterly MDS assessment, dated 06/27/2025, indicated a BIMS score of 99 meaning that the interview was unable to be completed. Resident #1's cognitive skills were noted as moderately impaired (decisions poor; cues/supervision required). Resident #1 was noted to be able to recall Staff names and faces, and she could recall that she was in a nursing home/hospital swing bed.Record review of Resident #1's Care Plan, dated 06/24/2025 indicated Resident #1 had Behavior (verbal): Resident has made Verbally Abusive expressions, threats, or inappropriate verbiage towards self, staff other resident's or visitors. Behavior: [Resident #1 ]is at risk for injury related to resistance to care. the resident is at risk for adverse consequences related to receiving antipsychotic medication. Resident is on Lexapro Seroquel Wellbutrin.Record review of Resident #2's quarterly MDS, dated [DATE] indicated a BIMS score of 12 meaning Resident #2 had moderate cognitive impairment. Resident #1 was indicated to have no Potential Indicators of Psychosis.Record review of the Provider Investigation Report dated 07/08/2025, incident categorized as abuse and incident signed by the ADM on 07/08/2025. PIR indicated the incident occurred on 7/7/2025 at 7:00PM. The PIR indicated that LVN A had hit Resident #1 and it was witnessed by Resident #2 and recorded on facility video. Description of the Allegation: [Resident #1] stated at 6:30 PM on 7/7/2025 that a nurse had hit her. She stated where the incident took place. Security cameras were checked and it did not show the event stated by [Resident #1]. On 7/8/2025 another resident expressed to nurse management that she had witnessed the event stated by [Resident #1]. When cameras for the area were checked it was confirmed. [Resident #1 has a history of being verbally and physically aggressive with staff. The nurse [LVN A] and pushed it into [Resident #1's] head.No injuries noted from assessment conducted on 7/8/2025 at 1:30 PM.Investigation Findings Confirmed.Provider Action Taken Post Investigation, Safe Surveys were done. No other incidents were reported, in-services were held on Aggressive residents and Abuse and Neglect.Review of Resident #1's witness statement, dated 07/07/2025 indicated that Resident #1 expressed to the DON that LVN A had hit her on her head.Review of Resident #2's witness statement, dated 07/08/2025 indicated Resident #2 witnessed LVN A hit Resident #1 intentionally on the head while seated at a dining room table.Record Review of LVN A's personnel file revealed that LVN A had been terminated on 07/08/2025.In an interview on 07/24/2025 at 11:30 AM, CNA B revealed that she recently had in-services on Aggressive Residents and Abuse. She was able to identify the ADM as her ANE Coordinator and she was able to identify 5 types of abuse. She stated that if a resident were to become aggressive with her she would give the Resident some space to let them cool down, or she might offer a snack or activity to re-direct the resident. She stated that she had seen no change in Resident #1's behavior or manner.In an interview on 07/24/2025 at 12:15 PM the ADON revealed that Resident #1 had refused to participate in the BIMS scoring questions. She revealed that Resident #1 was able to recall very well, was alert and oriented to person, place, and time and was generally a very good historian. The ADON revealed that Resident #1 could be verbally aggressive to staff. She stated that when she interviewed LVN A about the incident, LVN A indicated that Resident #1 had kicked at her. The ADON further revealed that after viewing the video of the incident she could not see that Resident #1 had kicked at LVN A but the video clearly showed LVN A pushing a cell phone into Resident #1's head and hitting Resident #1 on top of the head with an open hand. The ADON further indicated that LVN A was immediately terminated before her next shift, safe surveys were conducted with all residents with no negative findings and that Resident #1 and Resident #2 were visited by a psychologist the next day with no negative findings. She stated that Resident #1 displayed no change in her behavior or mannerisms after the incident and that the facility was still continuing to monitor resident/staff interactions.An observation and interview on 07/24/2025 at 12:59 PM with the ADM while reviewing the video, time stamped and dated 07/07/2025 at 3:51 PM of the incident involving Resident #1 and LVN A, revealed the ADM identified LVN A on the phone seated behind the nursing station and identified Resident #1 seated in a wheelchair near the doorway of the same nursing station. Later in the video the ADM identified Resident #1 self-propelling herself to a dining room table in frame of the camera and identified Resident #2 was seated at the same table. She stated that Resident #2 was a good historian and had a BIMS score of 13. The ADM stated that Resident #1 had been assessed with no injuries found. The ADM revealed that LVN A was immediately terminated the next day before her shift started. Observation of the video footage during this time revealed the following:LVN A was observed on video footage at the nurses' station waiving Resident #1 away from coming behind the nurses' station, then LVN appears to use her feet to keep the resident from moving forward (lower extremities are out of view in the video) LVN A braces one hand on the door frame and the other hand, held a cellular phone. Resident #1's wheelchair jerks backwards suddenly when LVN A is holding on to the door frame. Resident #1 then backs out of the doorway and propels in front of the nurses' station, away from the nurse. LVN A then walks around to the front of nurses' station, as she walks behind Resident #1 she nudged/poked Resident #1 with the cellular phone into the back of the resident's head which caused the resident shoulders and head to jerk forward. LVN A continues to walk past Resident #1 and Resident #1 slaps at LVN A's right arm. LVN A turns back around and grabs the resident's arm/hand and leans in toward her. There is no sound to the video, Resident #1 can be seen talking. LVN A turns around and points her finger towards Resident #1 and speaks to her. LVN A then walks toward the dining room and out of the camera's view. Resident #1 then propelled to the dining area and went to a table with another resident. Less than a minute later the LVN A walks past Resident #1 while the resident is seated at the dining room table. LVN A walked behind Resident #1, reaches out and tapped/pushed Resident #1's head forward from the back with an open hand. Resident #1's head can be seen to jerk slightly. Resident #1 responded to the tap on the head and grabbed the back of her head and looked over at LVN A leaving the area. Resident was seen talking to resident at the table, turned slightly and pointing at LVN A.In an interview on 07/24/2025 at 1:24 PM, the DON revealed that Resident #1 told her about the incident with LVN A and that she had initially looked at video from another camera and that did not capture the incident. Later that evening, the DON stated that both Resident #1 and #2 approached her about the incident with LVN A and Resident #2 stated that she had witnessed LVN A hit Resident #1 on the head. The DON then revealed that, with the assistance of the ADON, she then found the correct camera footage and observed LVN A nudge a phone into the back of Resident #1's head and LVN A hitting Resident #1 on top of her head on the video. She stated that she immediately assessed Resident #1 and notified the ADM. The DON further revealed that she, the ADM, and the ADON conducted in-service training for all nursing staff on Abuse, Neglect and Exploitation and Aggressive Residents. She stated they had immediately conducted safe surveys of all residents with no negative findings and that they were actively monitoring staff/resident interactions for another week making 4 weeks of observations in response to the incident.Attempts to interview LVN A were made on 07/24/2025 at 10:00AM, 1:52 PM and 4:48 PM . There was no way to leave a message ,and LVN A never attempted to call back.In an interview on 07/25/2025 at 10:00 AM with CNA C, she revealed that she had received in-services on Abuse and Aggressive Residents. CNA C was able to identify the ADM as the ANE Coordinator and stated that if she suspected or saw abuse she would report to the ADM or her nurse immediately. She revealed that she had seen no change in Resident #1's behavior since the incident with LVN A and Resident #1. She stated that the ADON, DON and ADM had been monitoring staff/resident interactions and that she had not heard of or seen any other incidents about LVN A.In an interview on 07/25/2025 at 10:22 AM with LVN D, he reveled that he had received recent in-services on ANE and What to do with Aggressive Residents. He stated that he had worked with Resident #1 many times and that she was generally very nice. He stated that he had seen no change in her mannerisms or behavior since the incident with Resident #1 and that the ADON, DON and Administrator had been monitoring resident/staff interactions and asking residents about abuse. In an interview on 07/25/2025 at 10:36 AM with LVN E, she stated that she had worked with Resident #1 and had heard about the incident with Resident #1 and LVN A. She stated that she had no knowledge of any similar incidents involving LVN A or any other incidents of possible abuse. She stated that she had seen no changes in Resident #1's behavior or mannerisms since the incident. She stated that she had recently attended in-services on ANE and Aggressive Residents. In an interview on 07/25/2025 at 10:58 AM, CNA F revealed that she had worked with Resident #1 and LVN A many times. She stated that she had never seen LVN A treat any residents badly before. She stated that if she even thought there had been any abuse in the facility, she would report it immediately to the ADM or her nurse. She was able to identify 5 different types of abuse and she stated that she had recently attended in-services for ANE and Aggressive Residents. She stated that there are many ways to redirect residents, but with Resident #1, she would have just got what she had asked for because Resident #1 could be very focused on what she wanted.In an interview on 07/25/2025 at 11:09 AM, CNA G revealed that she had recently received in-services about ANE and Aggressive Residents. She stated that she would have offered an activity or a snack or brought the resident to another area if she wasn't able to do what the resident wanted immediately. She denied if she had seen or heard of any other instances of abuse in the facility. She identified the ADM as the Abuse Coordinator.In an interview on 07/25/2025 at 11:47 AM, with Resident #1 over the phone, she revealed that she had loved her time at the facility and that the Incident with LVN A was the only time that she had had any problems. She stated that the facility had a psychologist come and visit her the next day, but that she didn't feel she needed that. She stated that the facility was closing down soon or she would not have moved at all, but she liked the new facility she was at so far. She stated that LVN A had not hurt her and that she had been more surprised than anything and that she could take care of herself, and that all LVN A had to do was give her a bag to be able to pack some things because she had to move soon. She stated that she had not seen LVN A since that day but that she had heard she had been fired. She stated that staff had asked her all sorts of questions afterwords but she was just fine.In an interview on 07/25/2025 at 11:58 AM, over the phone, Resident #2 revealed that she had witnessed LVN A hit Resident #1 on top of the head while she was seated with Resident #1 at the dining room table. She stated that she had told the ADON and the DON about it and they had seen it on some video. She stated that even though she thought LVN A was nice she should not have done that. She stated that the psychologist had also come to see her the next day and she had told the psychologist she was just fine.Record Review found that LVN A had received in-services on Abuse and Neglect on 04/28/2025 and on 06/24/2025. The Administrator was notified a past non-compliance IJ situation had been identified due to the above failures.It was determined these failures placed residents in an IJ situation on 07/07/2025 through 07/08/2025.Through record review it was found that the facility had implemented the following interventions:-LVN A was immediately terminated before her next shift started.-Resident #1 was assessed on 07/08/2025 at 1:30 PM with no injuries noted.-Physician, Responsible Party, and Psych Services notified.-Resident #1 assessed by psychologist on 07/08/2025, with no adverse findings.-On 07/09/2025 in-services for all nursing staff were conducted by the ADON for What to do for Aggressive Residents and Abuse, neglect, and Exploitation.-DON, ADON and ADM conducted monitoring by observing resident/staff interactions and interviewing random residents about sign and symptoms of abuse everyday from 07/08/2025 until 07/25/2025 with one week of monitoring to continue.Record review found that on 07/09/2025, the ADON conducted in-services on What to do for Aggressive Residents and Abuse Neglect and Exploitation for 19 staff, 12 of which were direct nursing care staff. The facility had a low census and staffing due to a planned facility closure on 09/04/2025.Interview on 07/24/2025 at 12:59 PM with the ADM revealed LVN A was immediately terminated the next day before her shift started. The ADON and DON immediately started safe surveys, talking to residents to find out if any other instances had occurred, and then monitoring interactions for the next month. She stated she had never had anything like this occur in the facility before or since. The ADM stated Resident #1 was seen by the psychologist the next day, and the psychologist had found no mental harm. The ADM stated that CNAs and nursing staff reported no changes in behaviors after the incident.Interviews were conducted on 07/25/2025 from 10:00 AM to 07/08/2025 5:00 PM with the following staff through various shifts (6am-6PM and 6pm-6AM, via phone or in person) for the following personnel: ADM, ADON, DON, CNA B, CNA C, LVN D, LVN E, CNA F, and CNA G. All staff were able to report that they had received training on ANE and Aggressive Residents, who to report Abuse too, different types of abuse, and interventions to re-direct, de-escalate aggressive residents. All staff reported being observed for staff/resident interactions by management staff.The noncompliance was identified as PNC. The IJ began on 07/07/2025 and ended on 07/08/2025. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for 1 of 18 residents (Resident #284) reviewed for laboratory services. The facility failed to promptly notify Resident #284's physician after the results from a UA C&S, which was ordered on 10/31/23, were received on 11/04/23 showing the resident had bacteria (Escherichia Coli (E.Coli) ESBL and Providencia Stuartii) in her urine. On 11/09/23, the resident experienced a change of condition with lethargy. She was sent to the hospital where she was admitted for sepsis due to a UTI. An Immediate Jeopardy (IJ) was determined to have existed from 10/31/23 to 11/09/23. The IJ was removed on 11/09/23 because there were no other residents affected or concerns with laboratory services. The facility remained out of compliance with a scope isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This deficient practice placed the residents at high risk of, or the likelihood of, serious injury or harm by not receiving treatment, developing complications, and the development of sepsis. Findings included: Record review of Resident #284's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility 06/10/20. Her diagnoses included heart failure, hypertension (high blood pressure), chronic respiratory failure, pressure ulcer of sacral region (a triangular-shaped bone located at the base of the spine, between the lumbar vertebrae (lower back) and the coccyx (tailbone), and presence of urogenital implants (A bulking agent is injected into the walls of the urethra to treat stress incontinence caused by a weak sphincter muscle). Resident #284 had a BIMS score of 11, meaning she had moderate impaired cognition. The resident required total dependence of two staff members for bed mobility, dressing, and transfers. The MDS further reflected the resident had a catheter and was always incontinent of bowel. Resident #284 did not return to the facility after she was sent out to the hospital on [DATE] and family transferred her to another nursing facility. Record review of Resident #284's care plan edited on 05/28/23 reflected the resident was at risk for UTI's related to the foley catheter used for the diagnosis of a wound to sacral area. Approaches included monitor for signs and symptoms of a UTI such as foul odor of urine, visible sediments in urine, fever, dysuria (blood in urine), complaints of abdominal pain and changes in mental status. Other approaches included to monitor labs and the medical doctor orders. Record review of Resident #284's progress note dated 10/31/23 documented by LVN A reflected the following: Resident's [Family] requested for [Resident #284]'s urine sample to be collected for lab due to its color, this nurse called [Physician] and he ordered urine to be collected and sent to lab. Urine sample is pending for lab pick up. Record review of Resident #284's progress note dated 11/05/23 documented by LVN B reflected the following: .upon assessment patient no c/o pain or discomfort. observed urine pink in color. Changed catheter bag today and emptied Record review of Resident #284's progress note dated 11/09/23 documented by LVN C reflected the following: 11/08/23 Resident was lethargic opening eyes for a short moment when aroused but not verbally responding. After a while resident was awake making eye contact and blinking when spoken to but still not speaking. Resident would not open her mouth to drink when offered or take HS medications. B/P-137/85, T-98.3 P-102, R-18 SpO2 95% NC 3Lpm. [Family] at bedside and requested resident be sent to hospital. [Doctor] notified. N/O to send to ER for further evaluation. 2230 Resident transported to [Hospital] via stretcher X2 [by two] EMT accompanied by [family]. Record review of Resident #284's UA results reflected they were collected on 10/31/23, ready to view on 11/03/23, and printed on 11/04/23. The results reflected there were 2 micro-organisms found in the resident's urine: Final: >100,000 CFU/ML of Escherichia Coli (E.Coli) ESBL isolated. (E.coli is a serious type of bacteria that can cause urinary tract infections that make them resistant to a wide range of antibiotics) <25,000 CFU/ML of Providencia Stuartii also isolated. (bacteria that can cause urinary tract infections) Record review of Resident #284's hospital records dated 11/09/23 reflected the following: .Severe sepsis gram negative bacteremia (a life-threatening bloodstream infection that occurs when bacteria enters the bloodstream) related to a UTI Patient is critically ill with sepsis due to gram negative bacteremia. At high risk for deterioration with one or more organ damage, including death Interview on 10/16/24 at 10:41 AM with LVN A revealed Resident #284's family requested a UA because she felt like the resident's urine was dark in color. LVN A said she collected the urine, had it sent to the lab and gave report to the oncoming nurse, LVN J, and she (LVN J) acknowledged she would follow-up. LVN A said she was off for about 4 days and upon returning, she realized the no one had obtained the UA results from the computer system. LVN A did not recall many details after that nor did she recall what was or was not done with Resident #284. LVN A did recall the DON made a big fuss and was upset and called her (LVN A) asking why Resident #284's urine had been collected and was asked to write a statement about what happened and it was turned into the DON. LVN A further stated Resident #284 had been sent to the hospital sometime after she had collected the resident's urine, but could not recall dates. LVN A did not recall if Resident #284 was ever put on antibiotics. LVN A said she spoke to LVN J to ask why she had not followed up on Resident #284's UA, but she did not recall the answer. Attempts to call LVN J on 10/17/24 were unsuccessful. Interview on 10/17/24 at 9:20 AM with LVN C revealed she vaguely recalled the circumstances around the time she sent Resident #284 out to the hospital other than the resident was not alert or as responsive as she usually was. LVN C said she recalled there was a conversation, did not recall with who , about the resident's UA being collected and later they were questioning the results but did not recall any other details. LVN C further stated they had received in-services on the lab processes and following up after Resident #284's incident. Interview on 10/17/24 at 1:29 PM with the DON revealed she did not know Resident #284 had been admitted to the hospital, 11/08/23, for a UTI. The DON said she did not recall much of what happened around the time Resident #284 was sent to the hospital. The DON said she had recently reviewed the resident's labs and the results showed the UA contained some micro-organisms but she was not able to find any evidence the resident was ever on any antibiotics around the time the labs were ordered and obtained and the resident was sent to the emergency room, 10/31/23 - 11/08/23. The DON further stated there were some in-services done on labs around the time Resident #284 was sent out to the hospital, but they were not related to the resident's incident and just general in-services. The DON did not recall having any staff write statements on the incident. Record review of the in-sevices dated 11/09/23 reflected staff were educated on lab procedures from obtaining the labs orders, calling the doctor with the results, documenting in the progress notes, and contacting the family with the results as well. Interview on 10/17/24 at 9:13 AM with the Administrator revealed she did not recall the circumstances around the time Resident #284 was sent to the hospital (11/08/23). The Administrator said it appeared Resident #284's doctor did not get the UA results so the nurses received education on how to order labs, and to call the doctor when the results came in. The Administrator excused herself and upon returning she stated she had misspoke and the lab in-services were not related to Resident #284's incident. The Administrator further stated risks of not following up on lab results could lead to other health issues. Interview on 10/16/24 at 1:14 PM with Resident #284's Physician revealed the resident had a lot of chronic UTI's and they would check her urine at any given time and the results were positive. The Physician said it was the facility staff's responsibility to follow-up on any lab orders but he stated he did not recall if he got UA results for Resident #284 and he would need to check his system and follow-up, but he never did. The Physician read Resident #284's UA results and he stated that most of the time he would have started the resident on an antibiotic and he also said he thought Resident #284 had been sent to the hospital for hypoxia (lack of enough oxygen). Record review of the facility's current, undated Lab and Diagnostic Test Results policy reflected the following: .1. When test results are reported to the facility, a nurse will first review the results. .3. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition Options for Physician Notification .1. A physician can be notified by phone, fax, voicemail, e-mail, pager, or a telephone message .a. Facility staff should document information about when, how, and to whom the information was provided and the response. .b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification .