**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for 11 (Resident #53, #56, #58, #47,#46, #4, #73, #32, #15, #72 and #70) of 14 residents reviewed for comprehensive care plans. - The facility failed to develop and implement Resident #53's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #56's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #58's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #47's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #46's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #4's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #73's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #32's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #15's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #72's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #70's care plans to reflect the resident's aggressive behaviors. An Immediate Jeopardy was identified on 5/9/25. The IJ template was provided to the facility on 5/9/25 at 1:05pm. While the IJ was removed on 5/9/25 at 3:00pm, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The failures could affect residents by placing them at risk of having care plans that are not updated/accurate to their current identified needs. Findings include: Resident #53 Record review of Resident #53's face sheet, dated 04/17/2025, revealed Resident #53 was a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (a decline in mental ability, specifically in memory, thinking, and reasoning, that significantly impacts daily life), severe, with other behavioral disturbance (a pattern of actions or reactions that deviates significantly from what is considered typical or appropriate behavior, often causing distress or difficulty for the individual or those around them), anxiety disorder (a mental health condition characterized by persistent and excessive worry, fear, and dread that significantly interfere with daily life), bipolar disorder, current episode mixed, severe with psychotic feature (occurs when someone with bipolar disorder experiences symptoms of psychosis, such as hallucinations or delusions, during a manic or depressive episode). Record review of Resident #53's MDS assessment, dated 01/21/2025, revealed that Resident #53 had a BIMS score of 06 which indicated that Resident #53 was severely cognitively impaired. Resident #53's required moderate assistance with bathing; all care areas are supervision or set-up assistance needed only. Section E-Behaviors of the MDS revealed that resident did have verbal behavioral symptoms towards others, coded as a 1, which indicated resident had exhibited these types of behaviors on an occurrence of 1 to 3 days. Record review of Resident #53's care plan, dated 12/31/2024 revealed the following: Focus o Behaviors: [Resident #53] has potential to demonstrate physical and verbal behaviors r/t Dementia. Has shown anger towards certain staff and will become hostile verbally and physically. Date Initiated: 12/31/2024 Revision on: 12/31/2024 Goal o The resident will not harm self or others through the review date Date Initiated: 12/31/2024 Revision on: 12/31/2024 Target Date: 01/06/2025 Interventions/Tasks o Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 12/31/2024 o Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 12/31/2024 o Give the resident as many choices as possible about care and activities Date Initiated: 12/31/2024 Revision on: 12/31/2024 o When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #53's progress notes revealed Resident #53 had multiple incidents with other residents. The progress notes revealed the following: 01/23/2025 at 04:54am CNA called this nurse (DON) to the unit and Resident #53 smashed another resident's (Resident #71) finger with metal cup. Resident #53 stated, He was touching and trying to grab my cup. Removed resident from sight. PRN Vistaril given as ordered. Resident calm after and CNA able to Resident room. DON notified. 01/23/2025 at 1:37pm Resident #53 was still being combative with staff and 'was attempting' to hit of another resident. Phone call was placed to [Psychiatric MD], Pending call back. 01/30/2025 at 2:11pm Resident is readmit, returning from [psychiatric hospital] in [local city name]. 03/12/2025 at 7:30pm Resident got his shoe and slapped another resident when another resident was walking by and bumped into the bedside table that was next to Resident #53. Called on-call [Psychiatric services] and got an order to send resident to inpatient psychiatric hospital. Resident #56 Record review of Resident #56's face sheet, dated 04/17/2025, revealed an [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of unspecified dementia(a decline in mental ability, specifically in memory, thinking, and reasoning, that significantly impacts daily life), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental health condition characterized by persistent and excessive worry, fear, and dread that significantly interfere with daily life), schizophrenia (a chronic mental illness characterized by disruptions in thinking, perception, emotional expression, and behavior), unspecified, major depressive disorder (a mood disorder characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly affect daily functioning), single episode, unspecified. Record Review of Resident #56's MDS assessment, dated 02/06/2025, revealed that Resident #56 had a BIMS score of 09, which indicated that Resident #56 had moderately impaired cognition. Functionality for ADL's was not determined at time of this assessment. Section E-Behavior did not reveal Resident #56 having any behaviors of aggression. Record review of Resident #56's care plan, dated 02/10/2025, revealed the following: Focus o I have a mood problem Schizophrenia/Schizoaffective Medication: Risperidone Date Initiated: 01/22/2025 Revision on: 01/24/2025 Goal o I will have improved mood state such as: happier, calmer appearance, no s/sx of depression, anxiety or sadness through the review date. Date Initiated: 01/24/2025 Target Date: 02/12/2025 Interventions/Tasks o Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/22/2025 o Assist me with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise and physical activity. Date Initiated: 01/22/2025 o Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 01/22/2025 o Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Date Initiated: 01/22/2025 o Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Date Initiated: 01/22/2025 o Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Date Initiated: 01/22/2025 o Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols Date Initiated: 01/22/2025 o Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons Date Initiated: 01/22/2025 o Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity Date Initiated: 01/22/2025 Record review of Resident #56's progress notes revealed the following: 02/26/2025 at 6:51pm resident in the unit got in a verbal altercation with another resident and hit another resident, the other resident reacted and hit him back, he has an open area to the left eyebrow. Notified [psychiatric NP], new order sent to [psychiatric hospital #1 and #2]. Resident #58 Record review of Resident #58's face sheet, dated 04/16/2025, revealed that Resident #58 was a [AGE] year-old male resident admitted to the facility on [DATE] with the diagnoses of other psychoactive substance abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine), uncomplicated, depression (a subtype of major depressive disorder (MDD) characterized by a milder form of the illness, typically lacking severe symptoms and functional impairment), anxiety disorder(a mental health condition characterized by persistent and excessive worry, fear, and dread that significantly interfere with daily life), unspecified, epilepsy(a diagnosis where a person is known to have epilepsy but the specific type (focal, generalized, etc.) is not known or can't be determined), unspecified, not intractable without status epilepticus(describes a type of epilepsy that is not considered difficult to control (intractable) and does not involve a continuous seizure (status epilepticus)), chronic diastolic (congestive) heart failure (occurs when the heart muscle becomes stiff, hindering its ability to relax and fill with blood during diastole). Record Review of Resident #58's MDS assessment, dated 04/07/2025, revealed that Resident #58 had a BIMS score of 00, which indicated that Resident #58 had severely impaired cognition and was functionally independent. Section E-Behaviors revealed that Resident #58 did have physical behavioral symptoms towards others on an occurrence of 1 to 3 days. Record review of Resident #58's care plan, with no completion date, revealed no mention of inappropriate/aggressive behaviors towards other residents. Record review of Resident #58's progress notes revealed the following: 03/27/2025 at 9:30am this writer (LVN AA) was walking down F hall, this writer (LVN AA) noted Resident #58 leaving wheelchair to stand up and walk; he went walking halfway down the hall and noted there was a female resident (Resident #41) there; he stood up against the side rail and was groping the female resident (Resident #41), he (Resident #58) was touching her (Resident #41) breast and her buttocks, squeezing them; this writer (LVN AA)could not get to female resident (Resident #41) fast enough to prevent this from happening; by the time this writer (LVN AA) reached resident (Resident #58)to sit him in his wheelchair and redirect him , he (Resident #58) had already touched her (Resident #41) multiple times; this writer (LVN AA) informed the nurse in the hallway and notified DON; resident (Resident #58) was assisted back to the memory care unit. 03/29/2025 at 4:53pm [LVN A] Notified by CNA staff that resident was caught in another residents (UR) room. Resident was slapping the other resident (UR) back and forth with both hands. CNA staff assisted the resident out of the residents (UR) room. The resident (Resident #58) glared very manic at staff. Resident caught holding a gait belt. Staff was able to retrieve gait belt from resident. Notified [DON name] DON and [FNP name] FNP. Obtained orders to start resident on risperidone 0.5 MG BID. Resident #47 Record review of Resident #47's face sheet, dated 04/17/2025, revealed that Resident #47 was a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (a decline in mental ability, specifically in memory, thinking, and reasoning, that significantly impacts daily life), unspecified severity, without behavioral disturbance, psychotic disturbance mood disturbance, anxiety(a mental health condition characterized by persistent and excessive worry, fear, and dread that significantly interfere with daily life), bipolar disorder (a prolonged period of abnormally elevated, expansive, or irritable mood accompanied by increased activity or energy), current episode manic without psychotic features, moderate, mild cognitive impairment of uncertain or unknown etiology (a condition where individuals experience greater memory or thinking problems than expected for their age, but these issues are not severe enough to interfere with daily activities), restlessness and agitation, cognitive communication deficit (occurs when communication problems are caused by difficulties with cognitive processes like attention, memory, or executive function, rather than with language or speech production). Record Review of Resident #47's MDS assessment, dated 03/12/2025, revealed Resident #47 had a BIMS score of 09, which indicated Resident #47 had moderately impaired cognition and a functionality of total dependency and maximal assistance was needed for most care areas with exception to partial assistance to oral hygiene and set-up assistance to eat. Section E-Behaviors did not reveal any behaviors. Record review of Resident #47's care plan, dated 02/10/2025, revealed no mention of inappropriate/aggressive behaviors towards other residents. Record review of Resident #47's progress notes revealed the following: 12/16/2024 at 10:49am (LVN A) Notified by staff (CNA M) that resident (Resident #47) went up to another resident (Resident #32) and punched him on the left side of face on cheek. Resident (Resident #47) stated he punched him because the other resident (Resident #32) told him to move. When told to move, [Resident #47] stated to the other resident (Resident #32) that he was watching tv and went up aggressively to him (Resident #32) and punched him (Resident #32) in the face. Resident was separated by two CNAs [CNA M] and [CNA I]. When trying to separate the residents, [Resident #47] scratched one of the CNAs on her right arm. Began one on one with [Resident #47] until further instruction. Notified [psychiatric MD] of residents behaviors. Obtained orders to send resident to [psychiatric hospital #2]. Notified by [psych hospital #2] that they do have beds available. Notified [DON name] DON and [previous ADM name] administrator. Notified guardian [guardian name]. 12/16/2024 at 3:41pm Notified by [staff] from [psych hospital #2] that resident is not accepted into [psych hospital #2] until EDO received from judge from [county name] county. Resident is not allowed to sign form himself due to have legal guardian. [Psych hospital #2] stated that we must go through [local hospital name] and then through the judge. [Local hospital] doctor [MD name] stated that the resident did not qualify to got to [psych hospital #2] and the judge was not going to sign due to going based of [MD name] decision. Notified [DON name] DON and [psych MD]. Obtained orders to try [psych hospital #1] in [local city name]. Notified that resident does not qualify due to the fact they don't accept Medicaid and he does not have Medicare yet. Obtained orders from [psych MD] to increased Depakote to 5 tabs of 125mg and obtain CBC and VA level in one week from today! 12/29/2024 at 10:22pm (LVN II) writer was called into locked unity by CNA. CNA reported that Resident (Resident #47) had struck male peer (Resident #32) in the face because peer had entered his room. 12/29/2024 at 10:49 pm (LVN GG) Writer talked to [staff] with [psych MD]'s office and received order to put resident on 1-on-1 monitoring until Resident is able to be sent out to behavioral hosp for eval. 02/12/2025 at 3:25pm (LVN GG) CNA (CNA K) reported that resident hit residents (UR) with his elbow three times to patient. CNA K broke it up. Then patient went after another patient [Resident name] (Resident #1) with a knife and CNA C intercepted. Patient did not attack no further and has been monitored wctm. 02/12/2025 at 4:08pm patient went and attack CNA and noted. Patient s attacking patients. Police was called and investigated the situation. Doctor ordered to send to [psych hospital #2] psychiatric facility. Patient guardian was notified, and management was notified a well as doctor wctm. Resident #46 Record review of Resident #46's face sheet, dated, 04/17/2025 revealed a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of major depressive disorder (a mood disorder characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly affect daily functioning), recurrent severe without psychotic feature, generalized anxiety disorder (a mental health condition characterized by persistent and excessive worry, fear, and dread that significantly interfere with daily life), disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized speech, behavior, and flat or inappropriate affect), cognitive communication deficit (occurs when communication problems are caused by difficulties with cognitive processes like attention, memory, or executive function, rather than with language or speech production). Record review of Resident #46's MDS assessment, dated 04/07/2025 , revealed Resident #46 had a BIMS score of 10, which indicated that the Resident #46 was moderately impaired cognition, and required touch assistance in all care areas. Section E-Behaviors revealed no behaviors. Record review of Resident #46's care plan, dated 02/10/2025, revealed the following: Focus o The resident has potential to Demonstrate physical behaviors mental Illness (schizophrenia) Date Initiated: 09/01/2024 Revision on: 10/08/2024 Goal o The resident will not harm self or Others through the review date Date Initiated: 09/01/2024 Revision on: 10/08/2024 Target Date: 02/09/2025 Interventions/Tasks o Analyze of key times, places, circumstances, triggers, and what de-escalates Behavior and document Date Initiated: 09/01/2024 o Give the resident as many choices as possible about care activities Date Initiated: 09/01/2024 Revision on: 10/08/2024 o Modify environment: (Adjust room temperature to comfortable level, reduce noise, Dim lights, place familiar objects in room, keep door closed etc.) Date Initiated: 09/01/2024 Revision on: 10/08/2024 o When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress' engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later Date Initiated: 09/01/2024 Revision on: 10/08/2024 Record review of Resident #46's progress notes revealed the following: 10/27/2024 at 10:26pm This nurse (LVN EE) witnessed resident (Resident #46) to resident (Resident #44) push and this resident going into residents' room and other resident said, Get out of my room and pushed resident (Resident #44) down to the floor. Resident (Resident #46) stated, He doesn't belong in my room and that's why I pushed him out. Resident (Resident #46) sat back down on the bed and no other aggression noted. DON, MD, and [family member] notified. Resident #4 Record review of Resident #4's face sheet dated 04/17/2025 revealed that Resident #4 was a [AGE] year-old female resident who was admitted to the facility on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness of unspecified duration (a traumatic brain injury where the damage is widespread and the person does not lose consciousness), sequela (a condition which is the consequence of a previous disease or injury), other symptoms of signs involving cognitive functions and awareness, major depressive disorder, recurrent severe without psychotic features (a serious condition where a person experiences both major depressive symptoms and psychotic symptoms like delusions or hallucinations, often related to themes of guilt or worthlessness), schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms, like hallucinations and delusions, and mood disorder symptoms, such as depression or mania), bipolar type (a mental health condition characterized by significant mood swings, fluctuating between periods of intense happiness and high energy (mania or hypomania) and periods of deep sadness and depression). Record Review of Resident #4's MDS assessment, dated 03/18/2025 , revealed that Resident #4 had a BIMS score of 13 which indicated that Resident #4 did not have any cognitive impairment and required set-up assistance in most care areas with a moderate assist with oral hygiene. Section E-Behaviors of the MDS reveal no behaviors exhibited by Resident #4. Record review of Resident #4's care plan, dated 04/03/2025, revealed the following: Focus o Behaviors: Aggression: [Resident #4 Name] has potential to demonstrate physical and verbal behaviors r/t schizoaffective disorder Calling staff names and yelling Date Initiated: 11/20/2020 Revision on: 10/31/2023 Goal o The resident will not harm self or others through the review date Date Initiated: 11/20/2020 Revision on: 12/05/2024 Target Date: 04/24/2025 o The resident will verbalize understanding of need to control physically aggressive behavior through the review date Date Initiated: 11/20/2020 Revision on: 12/05/2024 Target Date: 04/24/2025 Interventions/Tasks o Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 11/20/2020 o Give the resident as many choices as possible about care and activities Date Initiated: 11/20/2020 Revision on: 11/20/2020 o When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later Date Initiated: 11/20/2020 Revision on: 11/20/2020 Record review of Resident #4's progress notes revealed the following: 02/20/2025 at 5:14pm Staff reported that resident [Resident #4's name] and her roommate (Resident #49) were arguing loudly, when staff arrived at the room [Resident #4] had pushed her (Resident #49) to the floor, [Resident #4] stated that her roommate (Resident #49) was yelling at her and she did not touch her roommate. Assessment completed Risk assessment, nursing notes and behavior note completed, FNP, DON, and family called moved to another room. Resident #73 Record review of Resident #73's face sheet, dated 04/17/2025, revealed that Resident #73 was an [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease with late onset (a progressive neurodegenerative disorder that primarily affects the brain, causing a gradual decline in cognitive function, including memory and thinking skills), dementia in other diseases classified elsewhere (a general term for a decline in mental ability that significantly impacts daily life, encompassing various conditions like Alzheimer's disease and vascular dementia), severe, with other behavioral disturbance, schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms, like hallucinations and delusions, and mood disorder symptoms, such as depression or mania), depressive type. Record review of Resident #73's MDS, dated [DATE], revealed that Resident #73 had a BIMS score of 01, which indicates that Resident #73 had severe cognitive impairment. Resident #73 had a functionality of moderate assistance needed with exception to shower/bathing, which was total assist, and eating required set-up assist only. Section E-Behaviors revealed no noted behaviors for Resident #73. Record review of Resident #73's care plan, dated 02/16/2025, revealed the following: Focus o Behavior: Wandering/Elopement risk: [Resident #73] is an elopement risk/wanderer AEB Impaired safety awareness and Dementia Date Initiated: 01/09/2025 Revision on: 01/09/2025 Goal o The resident's safety will be maintained through the review date Date Initiated: 01/09/2025 Revision on: 01/09/2025 Target Date: 04/01/2025 Interventions/Tasks o Assess for fall risk. Date Initiated: 01/09/2025 o Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 01/09/2025 o Monitor for fatigue and weight loss. Date Initiated: 01/09/2025 Focus o Resident has delirium or an acute confusional episode r/t Change in condition, Change in environment Date Initiated: 01/09/2025 Goal o The resident, will be free of s/sx of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness) through the review date. Date Initiated: 01/09/2025 Target Date: 04/01/2025 Interventions/Tasks o Monitor for/address environmental factors recent change in environment, environmental noise and commotion. Date Initiated: 01/09/2025 o Monitor/record/report to MD new onset s/sx of delirium: changes in behavior, altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness and agitation. Altered sleep cycle, dehydration, infection, delusions, hallucinations. Date Initiated: 01/09/2025 Record review of Resident #73's progress notes revealed the following: 01/04/2025 at 12:26am [CNA name] was in secured wing in room [room number] at 11:30pm doing patient care when resident [Resident #73's name] pushed her out of his way into a dresser drawer inflicting pain in her lower back. Staff reported this to nurse [LVN Name], LVN. 01/10/2025 at 8:21pm Resident was being combative and aggressive towards staff and other residents. Resident threw a cup of water at this CN and chased CN and CNA down the hallway in the unit. Resident banging on door to unit in attempts of elopement. ADON notified as well as NP. N/O to increase Seroquel to 50mg po @ bedtime and Hydroxyzine 50mg po Q6 PRN 02/24/2025 at 5:16pm Resident [family member] to visit facility. Resident became agitated after [family member] left. When speaking to [family member] she stated he showered and then given a snack. Resident attempted to hit x2 staff members and residents that were in his path. Redirected to outside to secured area to calm down and decrease stimulation. Walked with resident and spoke with him for 20mins. At first resident tried to punch writer x2 with a closed fist. Writer moved out of the way and continues to walk with resident and let him walk alone in secured area. Resident then sat next to writer and said he was ready to go in. x1 assist. At this time sitting in main lobby speaking with fellow residents. Notified [family member] [family member] name] and don [DON name] of situation. [Psych MD] to be in facility today will notify of behaviors and redirection 03/04/2025 at 2:17pm around 1:30pm resident was banging his elbow on the door that leads outside the unit and yelling. When CNA tried to calm him down he tried to hit her. He was banging so hard that the pain chips from the wall came down. ADON and LVN AA were called to help. Writer witnessed resident hitting, punching and kicking both nurses. At one point resident had grabbed a hold of LVN AA's shirt and would not let go, leaving an abrasion on her mid right below neck area. ADON with a small cut to her right hand. Both nurses with several kicks and punches to their arms, mid-section, and legs. Writer called [Psych MD] with orders to send to out for inpatient therapy. Writer had to call 911 due to resident too strong for 4 nurses. Resident kept saying we had his money and he wants to get in his care to leave. We continuously tried to calm him down and let him know we do not have his money. Writher called [family member] put her on speaker he listened for 10 seconds to her and then quickly grabbed my phone, I yanked my hand back and jumped back quickly while he swung at me. I let his [family member] know what had just happened and she said it'll take her an hour to arrive, but she is going to try to send her on up here to calm him down. Resident was like this for over an hour 911 arrived and has since been speaking to resident. We had to get all other residents in their rooms and clear out the day area of any chairs and tables due to he was trying to hit other residents. Resident #32 Record review of Resident #32's face sheet dated 005/04/2025 revealed that Resident #32 was a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of unspecified dementia, with severe agitation (a severe form of dementia where the specific cause is not identified, and the individual experiences significant agitation), psychotic disorder with delusions due to known physiological condition (a mental illness where the person experiences delusions (false, fixed beliefs) and other psychotic symptoms (like hallucinations, disorganized thinking, and speech) as a direct result of a physical illness or medical condition affecting the brain), major depressive disorder (a mental disorder characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly affect daily functioning), recurrent severe without psychotic features (persistently low mood, loss of interest in activities, changes in appetite or weight, sleep disturbances, fatigue, feelings of worthlessness, difficulty concentrating, and recurrent thoughts of death or suicide), psychotic disorder with hallucinations due to known physiological condition (a mental health condition where hallucinations and/or delusions are direc[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 9 residents (Resident #7, #10, #15 and #41) reviewed for accidents and hazards. The facility staff failed to store hand sanitizer properly on 04/20/25 at 7:00 AM resulting in Resident #7 observing Resident #10 drinking an unknown amount of hand sanitizer which ended in him going to the hospital. The facility failed to provide adequate supervision for Resident #10 on an unknown date (after 4/20/25) in the dining room where he was able to drink the saliva of another resident (Resident #15) out of her (Resident #15) spit cup. The facility failed to provide adequate supervision for Resident #41 on 05/10/25 in the dining room where she was able to drink saliva of another resident (Resident #15) out of her (Resident #15) spit cup. An IJ was identified on 5/14/25 at 3:50 PM. The IJ template was provided to the facility on 5/14/25 at 4:10 PM. While the IJ was removed on 5/14/25 at 2:48 PM, the facility remained out of compliance at a severity of no actual harm and a scope of pattern because all staff had not been trained on 5/14/25. This failure could place residents at risk of injury/death due to unnecessary access to potentially harmful substances/chemicals. Findings included: Record review of Resident #7's face sheet, dated 5/14/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (mental health disorder). Record review of Resident #7's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #7's progress notes, dated 3/13/25-5/14/25, did not reveal any notes regarding him witnessing Resident #10 ingest hand sanitizer on 4/20/25. During an interview on 05/12/25 at 2:12 PM, Resident #7 stated that he observed Resident #10 drinking hand sanitizer on an unknown date in the dining room. He stated he was unsure of the date and time, but other residents were in the dining room, but he does not remember if staff were present. He stated he observed the resident pick up the bottle of hand sanitizer screw and screw the top off. He stated he observed the resident put the pump straw in his (Resident #10) mouth. He stated he immediately rolled out of the dining room to find help. He stated that he yelled down the hall and saw a nurse. He stated he did not remember her name but could identify her face. He stated the nurse was not in the facility at the time of the interview. He stated that the nurse came immediately and went to the dining room. He stated he did not see anything after that. He stated that he had never observed Resident #10 drink hand sanitizer before but had observed him drink the saliva of another resident (Resident #15) out of her (Resident #15) spit cup about 3 months before the interview. He stated when Resident #10 drank Resident 15's saliva, he told staff but did not remember the staff's name. Record review of Resident #10's face sheet, dated 5/12/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with a diagnosis of diabetes (elevated blood glucose/sugar), dementia (memory loss), psychiatric disorder with delusions(a false belief for judgment about external reality), intermittent explosive disorder(a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand),, other amnesia (a partial or total loss of memory). Record review of Resident #10's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 2, which indicated the resident's cognition was severely impaired. Section E Behavior revealed Resident #10 had the presence of wandering that occurred 1 to 3 days. Record review of Resident #10's care plan, dated 5/12/25, revealed: Focus: Behavior: eating/Drinking inedible items: Resident #10 had a behavior problem r/t eating/drinking inedible items r/t cognitive impairments due to dementia. 4/20/25 Resident #10 drank hand sanitizer and was sent to ER for evaluation. (Date Initiated 4/20/25) Goal: Resident #10 safety will be maintained through the review date. (Date initiated 4/20/25) Interventions/Tasks: Anticipate and meet the resident's needs including hunger and thirst too help ensure he does not consume inedible items. Minimize potential for resident's behavior (eating inedible items) by increasing monitoring especially in the dining room. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. (Date initiated 4/20/25) Record review of Resident #10's progress notes, dated 2/11/25-5/12/25, revealed: The DON documented on 04/07/25 at 12:54 PM: Resident #7 wanders, but his wandering was not goal directed, and did not affect the privacy of others. LVN AA documented on 04/20/25 at 7:07 AM: LVN AA was alerted by another resident (resident was not identified in the progress note) that Resident #10 was drinking hand sanitizer in the dining room, LVN AA ran to the dining room and observed Resident #10 with a small jug of hand sanitizer. Resident #10 had taken the hand pump off and she (LVN AA) observed Resident #10 with the jug tilted towards his mouth and was taking big gulps. LVN AA took the jug away from Resident #10 and immediately called 911 for ER transport. ER transport arrived in 4 minutes. LVN AA attempted to take Resident #10's vitals but he (Resident #10) was combative hindering her (LVN AA) from being able to take Resident #10's vitals. LVN AA notified the DON. LVN AA documented on 04/20/25 at 7:19 AM: Resident #10 was sent to the ER. LVN AA documented on 04/20/25 at 11:26 AM: Resident #10 returned to the facility. LVN AA reviewed hospital paperwork which revealed Resident #10's ethanol level was less than 5% mg. LVN AA documented that ER staff the alcohol consumption level was small, and the hospital staff monitored Resident #10 for the allotted time that poison control suggested (The allotted time not documented in the progress note). LVN AA documented that the ER doctor stated Resident #10 was fine. LVN AA documented on 04/20/25 at 11:33 AM: LVN AA notified the DON of Resident #10's return. Provider X documented on 04/22/25 at 12:00 AM: Provider X conducted a follow up visit after Resident #10 returned from the hospital after drinking hand sanitizer. Provider X documented staff created a care plan and are monitoring Resident #10 closely. Provider X documented that staff determined Resident #10 confused the hand sanitizer with a beverage. Provider X recommended that Resident #10 continue medication regimen and to monitor Resident #10's behavior. Provider X documented that Resident #10 was sleeping during this visit. Provider X documented on 05/06/25 at 9:23 PM: Provider X documented that they discussed with Resident #10 to refrain from drinking hand sanitizer or alcoholic beverages while taking prescribed medications. Provider X documented that Resident #10 verbalized understanding. Record review of the incident accident report, dated from 2/12/25-5/12/25, revealed Resident #10 had a self-inflicted injury/incident on 4/20/25 at 7:07 AM. Record review of Resident #10's hospital record dated 4/20/25 revealed that Resident #10 was seen on 4/20/25 for ingesting a substance, accidental poisoning and unintentional ingestion. The result details revealed ethanol level was less than 5 mg. The result details noted that results ranging from 0-10 mg would be interpreted as negative. During an interview on 05/12/25 at 12:29 PM, Resident #10 initially stated that he did drink hand sanitizer and that he liked the way it tasted. However, he did not remember the day he drank the hand sanitizer or where he got the bottle from. Resident #10 later confirmed that he did not know what hand sanitizer was. Record review of Resident #15's face sheet, dated 05/12/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (kidney disease), metabolic encephalopathy(a chemical imbalance in the blood that causes problems in the brain), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and sequel of other cerebrovascular disease (conditions that arise after the acute phase of a cerebrovascular event that include various neurological deficits, cognitive impairments, and other complications). Record review of Resident #15's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E revealed Resident #15 did not have any other behaviors outside of verbal symptoms. Record review of Resident #15's care plan, dated 04/28/25, revealed: Focus: Behavior: Verbal & Physical Aggression: Resident #15 had potential to demonstrate verbal and physical abusive behavior r/t mental/emotional illness, poor impulse control. Resident will apologize after incidents when acting with aggression. Resident #15 yells, hits, grabs and pushes others. Resident recently fired psychiatric doctor. 1/15/25 Resident #15 grabbed a hoodie of another resident (resident unidentified) and yelled at him. Residents were separated. 4/27/25 Resident #15 pushed another resident causing fracture after a verbal altercation. 15-minute check and referrals will be sent to other facilities for alternative placement. (Initiated 4/28/25) Goal: Resident #15 will demonstrate effective coping skills. (Date initiated 04/28/25) Interventions/Tasks: Analyze key times, places, circumstances, triggers and what deescalates behaviors and document. Give Resident #15 as many choices as possible about care and activities. Check Resident #15 every 15 minutes for behavior and safety. When Resident #15 becomes agitated intervene before agitation escalates. Guide Resident #15 away from the source of distress. Engage Resident #15 calmly in conversation. If Resident #15 responds aggressively then the staff should walk away and approach later. (Date initiated 4/28/25). Record review of Resident #15's progress notes, dated 2/11/25-5/12/25, revealed: LVN Y documented on 04/26/25 at 9:39 PM: Resident #15 displayed aggression toward another resident (resident not identified in the progress note). Resident #15 and the other resident (unidentified) were verbally yelling at each other. The other resident (unidentified) stood up from wheelchair arguing with Resident #15 and the other resident (unidentified) was pushed down to the floor by Resident #15. Resident #15 was separated from the resident (unidentified) and escorted by staff to her (Resident #15) room. Record review of the incident accident report, dated from 2/12/25-5/12/25, revealed Resident #15 was involved in a physical aggression-initiated incident on 4/26/25 at 8:00 PM. During an interview on 05/13/25 at 11:25 AM, Resident #15 stated she spits in cups but disposes of them. She said she had never observed any residents drink her saliva. Record review of Resident #41's face sheet, dated 5/12/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with a diagnosis of cerebral palsy (congenital disorder of movement, muscle tone, or posture), intermittent explosive disorder (a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand), non-suicidal self-harm, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and cognitive communication disorder (difficulty with thinking and how someone uses language). Record review of Resident #41's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was unable to complete the interview. Section E revealed no documented behaviors. Record review of Resident #41's care plan, dated 5/02/25, revealed: Focus: Behaviors: Physical and Verbal Aggression: Resident #41 had potential to demonstrate physical and verbal behaviors r/t yelling out and attempting to kick, scratch and strike others especially during care. If Resident #41 sees someone with drinks (sodas) or snacks Resident #41 will follow them and take the items and becomes aggressive with the other person. Resident #41 will also rip off her (Resident #41's) clothing. 4/19/25 Resident #41 pinched another resident. 4/29/25 Resident #41 squeezed another resident's arm. 15-minute checks to check for behaviors and safety. (initiated on 1/24/25 and revised on 5/2/25) Goal: Resident #41 will not harm self or others. (Initiated 1/26/25 and revised 03/27/25) Interventions/Tasks: Analyze of key times, places, circumstances, triggers, and what deescalates Resident #41's behavior. (Initiated 1/26/24) Assess and address for contributing sensory deficits. (Initiated 1/26/24) Assess and anticipate Resident #41's needs: food, thirst, toilet needs comfort level, body positioning and pain. (Initiated 4/29/25) Give Resident #41 as many choices as possible about care and activities. (Initiated 1/26/24 and revised 1/26/24) Increase staff monitoring for aggressive behavior. (no initiation or revision date) Start 15-minute checks for behavior and safety. (Initiated 4/19/25 and revised 5/02/25) Monitor/document and report danger to self and others to the doctor. (Initiated 1/26/24) Consult psychiatric /psychogeriatric as indicated. (Initiated 4/29/25) When Resident #41 becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. If resident #41 response is aggressive, staff were to walk away calmly and try to approach her again later. (Initiated 1/26/24 and revised 1/26/24) Record review of Resident #41's progress notes, dated 2/11/25-5/12/25, did not reveal any documentation of Resident #41 drinking Resident #15's saliva. Record review of the facility's incident accident report, dated 2/12/25-5/12/25 did not reveal that Resident #41 had an incident of drinking another resident's saliva on 05/10/25. Record review of Resident #41's facility documentation titled 15-minute checks, dated 4/19/25-5/2/25, revealed staff conducted 15-minute checks due to aggressive behaviors. During an interview on 05/12/25 at 2:05 PM, Resident #41 was not cognitively able to engage in an interview regarding the incident between her and Resident #22 on 4/19/25. When asked any questions, she would stare and point out the window that was located in her (Resident #41's) room. During an interview on 5/12/25 at 10:48 AM CNA H stated she had not been trained on what to do if resident consumed inedible items or ingested harmful items. She stated she was an agency staff and only had worked at the facility a few times. She stated she had worked with Resident #10 but did not have any information regarding him drinking hand sanitizer on 04/20/25. During an interview on 5/12/25 at 11:00 AM LVN BB stated she does not remember if she had been trained at the facility regarding what to do if resident consumed inedible items or ingested harmful items. She stated because of her nursing experience she would call 911. She stated hand sanitizer should be in the dispenser or locked in the supply closet. She stated she did not have any additional information regarding Resident #10 drinking hand sanitizer on 04/20/25. During an interview on 5/12/25 at 11:23 AM LVN Z stated she had not been trained regarding what she should do if a resident consumes a harmful substance or ingest chemicals, but she would guess with her nursing experience she would call 911 and she believed there was a book that had a list of all the chemicals that were in the facility. She stated she worked the morning that Resident #10 consumed the hand sanitizer, but she was not in the dining room. She stated LVN AA was the other nurse, but she could not remember which aides were there. She stated Resident #10 was sent out to the ER. She stated she did not know how much he drank. She stated he had never drunk harmful substances before but that when he does drink, he drinks a whole lot. She stated she was unsure where hand sanitizer was kept but was sure that it was kept locked up by housekeeping. During an interview on 5/12/25 at 11:47 AM CNA C stated hand sanitizer should be kept locked up or they keep it in the shower rooms sometimes. She stated she worked the morning (4/20/25) that Resident #10 drank the hand sanitizer. She stated she was rounding and checking on other residents. She stated Resident #7 told the nurse (unidentified) about Resident #10 drinking hand sanitizer. She stated she was not responsible for Resident #10 that day. She stated she could not remember the other staff. She stated Resident #10 was sent out to the hospital. She stated she was not interviewed, nor did she receive additional training about Resident #10 drinking harmful substances. She stated she had been trained in the past on what to do if a resident drinks a harmful substance. She stated she had been trained to take the substance away and report it to the charge nurse. During an interview on 5/12/25 at 12:03 PM CNA CC stated she had not been trained regarding what to do if a resident ingests or consumed a harmful substance or chemicals. She stated she would go to the nurse, and she would know what to do. She stated she did not know where chemicals such as hand sanitizer were stored officially but believed it was stored in the supply rooms. She stated she had observed hand sanitizer in the dispensers on the walls. She stated she did not have any information regarding Resident #10 drinking hand sanitizer, but he had never done anything like that before. An observation was made on 05/12/25 at 12:25 PM Hall D and E of the SDS book (red and yellow located in a yellow tray mounted on the wall). A poster located to the right of the SDS book/sheets titled How to read a Safety Data Sheet. During an interview on 5/12/25 at 12:31 PM CNA DD stated she was responsible for Resident #10 at the time of the interview. She stated she was unaware that he had an incident where he drank hand sanitizer. She stated she was not notified that he had the behavior of drinking harmful substances or chemicals. She stated she had observed since she worked with him that he will remove the napkin from the utensils and attempt to put the napkin in his mouth. She stated she assumed Resident #10 was confused. She stated she did not report this to anyone. She stated she had not received training on what to do if a resident consumes a harmful substance or chemical. During an interview on 5/12/25 at 12:36 PM COTA J stated she was aware that Resident #10 had ingested hand sanitizer but was unsure of the date. She stated she was told by her supervisor (DOR). She said that he mentioned it to her, but no additional instructions were given. She stated she did not have the details of the incident. She stated that she had not received training regarding what the facility expected her to do if a resident consumed a harmful substance or chemical. She stated she was unaware of Resident #10 having the behavior of consuming inedible items, harmful substances, or chemicals. An observation was made on 05/12/25 at 1:54 PM of Hall E shower room (locked with a number keypad). Three bottles of hand sanitizer were observed in the shower room, 2 large bottles with hand pump on the floor and one small bottle of hand sanitizer with hand pump on the sink. During an interview on 5/13/25 at 8:22 AM the DON stated she had been trained and trained staff regarding what to do if a resident ingested a harmful substance or chemicals. She stated the Maintenance Supervisor was responsible for knowing where the chemicals and hand sanitizer was stored. She stated regarding Resident #10 drinking the hand sanitizer it was reported to her by staff (did not identify during the interview) that he had drank hand sanitizer. She stated he did not drink a lot. She stated Resident #10 was sent to the hospital. She stated she was unsure how he obtained the hand sanitizer. She stated the hand sanitizer should not have been accessible to the resident. She stated on 4/20/25 they (management staff) came to the facility and stayed at the facility for a while. She stated they were looking to make sure there was no more hand sanitizer accessible to the residents. During an interview on 5/13/25 at 8:54 AM the ADM stated she had been trained on what to do if a resident consumed harmful substances or chemicals. She stated she had also trained her staff. She stated the staff should refer to the SDS sheets/book, call poison control and call 911 immediately. She said the hand sanitizer should be stored in the supply closet (locked) and in the wall dispensers. She stated regarding Resident #10 she did not know where the hand sanitizer came from. She stated it was not a brand of hand sanitizer that they order for the facility. She stated when she came to the facility on [DATE] she and her management team went through the facility and ensured all hand sanitizer was not accessible to the residents. She stated they looked for anything else that could potentially be dangerous for the residents. She stated Resident #10 had never exhibited the behavior of drinking inedible items or consuming harmful substances before. She stated when he returned from the hospital Resident #10 was placed on 15-minute checks. She stated Resident #10 had become more confused. She stated she had observed him attempt to get his own juice from the juice dispenser after 4/20/25 and Resident #10 allowed the juice to overflow while he watched the juice flow from the dispenser. She stated Resident #10 was confused before 4/20/25. She stated the hand sanitizer in the gallon pump bottle should have been locked in the chemical supply closet inaccessible to Resident #10. She stated residents do have access to the shower rooms. Staff will let them in and out she believed. She stated if the resident were independent, they could shower in the shower room independently if they liked. They would have to let staff know. During an interview on 5/13/25 at 10:07 AM CNA DD stated she had not been trained on what to do regarding what to do if a resident ingested harmful substances or chemicals. She stated she would report it to her chain of command. She stated she believed chemicals such as hand sanitizer were stored in the supply room that was locked. She stated she had not observed any of the hand sanitizers that have the hand pumps around in a while. She stated if they did have them out it was ok for staff to use them. She stated she did not know anything about Resident #10 drinking hand sanitizer on 4/20/25 but only became aware when the investigator mentioned it to her on 04/12/25. She stated if she were unaware, she would not know to watch for the behavior. She stated since he was now on the locked unit, she would watch him closely, but it would be helpful to know if he had the behavior. During an interview on 5/13/25 at 9:58 HK R stated that she was responsible for filling the hand sanitizer dispensers located on the wall at the facility. She stated she had never set out any hand sanitizer jugs with the hand pumps. She stated she had not received any training regarding if a resident consumed harmful substance or chemicals or what they should do if they come across a jug of hand sanitizer that had been left out. She stated she did not have any information regarding Resident #10 drinking hand sanitizer on 4/20/25. During an interview on 5/13/25 at 10:00 AM HK L stated housekeeping was responsible for refilling the hand sanitizer in the dispensers on the walls in the facility. She stated the jugs of sanitizer with the hand pumps were not put out by them. She stated the Maintenance Supervisor was the only person who had access to the gallon jugs with the hand pumps. She stated she was not at the facility when the incident happened on 4/20/25 when Resident #10 drank hand sanitizer but was told by the Maintenance Supervisor if they see them turn them into him. During an interview on 5/13/25 at 10:17 AM HK V stated housekeeping was responsible for ensuring that the hand sanitizer on the walls were filled. HK V stated she had not observed any hand sanitizer jugs with the hand pump since the time of COVID. She stated she had not received training within the past 30 days regarding what to do if a resident consumes a harmful substance or chemical. She stated if she observed the hand sanitizer, she would take it to the Maintenance Supervisor but did not remember if she had been trained to do that. She stated she worked the morning of 4/20/25. She stated it was early around breakfast time. She stated it had to be near 7:00 AM. She stated she was preparing her housekeeping cart to start her day. She said she was asked by a nurse (she did not know her name) if the hand sanitizer was hers. She stated she told the nurse no. Before the nurse asked her about the hand sanitizer, she overheard Resident #10 and the staff arguing over the jug of hand sanitizer. She stated Resident #10 was saying the hand sanitizer was his. She stated she overheard the staff say the ambulance was coming and she (HK V) assumed it was for Resident #10. HK V stated that she did not physically see Resident #10 drink hand sanitizer. She said she had observed Resident #10 in the facility. She had never observed him eat inedible items or consume harmful substances. She stated Resident #10 was always hungry because he would say it all the time in Spanish. During an interview on 5/13/25 at 10:41 AM the Maintenance Supervisor stated he had not been trained on what to do if a resident consumes a harmful substance or chemical. He stated he had not been trained at the facility but had spoken with the vendor which he orders his supplies from. He said he had been trained to go to the SDS sheets/books and the book would tell the staff what steps to take. He stated the vendor encouraged him to read up on the contents of the book. He stated that the management team conducts what was known as angel rounds. He stated they go around daily and check areas and residents around the facility. He stated he was unsure who had the dining room and why the hand sanitizer in the dining room was missed. He stated he was assigned to Hall E and conducted his rounds daily. He stated the hand sanitizer was in his office locked in a closet. He stated on 04/20/25 he was notified by the ADM and DON that Resident #10 had consumed hand sanitizer. He stated he came to the facility immediately. Took a picture of the hand sanitizer gave it to the EMS and then retrieved it from the hospital and kept it locked in the closet for evidence. He stated him and other management staff started walking room to room looking for additional hand sanitizer. He stated they discussed the incident in a morning meeting. Stated he was responsible to ensure that the SDS sheets were up to date. He stated the SDS sheets were located on Hall C and D. He stated he was unsure if training was conducted the day (4/20/25) of the incident. The Maintenance Supervisor stated that he conducted a training with his housekeepers instructing them if they observed unapproved hand sanitizer, they were to bring it to him. He stated he did not have them sign an Inservice but verbally told them. He stated after conducting the sweep on 4/20/25 all hand sanitizer and any other risks were removed. The Maintenance Supervisor stated he did not know how the hand sanitizer was left out. He stated the hand sanitizer should not have been in the facility at all as it was a brand that they did not use. He stated he spoke with the vendor who said they did not bring the hand sanitizer to them. During an interview on 5/13/25 at 11:06 AM the DM stated she was not present the morning of 4/20/25 when Resident #10 when he drank the hand sanitizer. She stated she had never observed the hand sanitizer and could not describe to the investigator how the bottle of sanitizer looked like. She stated she participated in morning meetings and remembered discussing in a morning meeting on an unknown date after the date of 4/20/25 that they would increase management presence in the dining room during mealtimes. She stated Fridays were her day to be monitor mealtimes. She stated she had not seen any other management staff monitor mealtimes to help with supervision. She stated they conduct angel rounds and her hall assignment was Hall B. She stated they go to their assigned areas and see if there were any issues. She stated she was unsure who was assigned to the dining room. She said the angel rounds were not documented. She stated as a result of Resident #10 drinking hand sanitizer on 4/20/25 they did receive training over ANE and on storing hand sanitizer. She stated Resident #10 had never drank hand sanitizer before, but he had consumed the saliva in Resident #15's spit cups before. She stated she reported the saliva incident to the ADM, but it had been a while (at least a week). She stated the ADM did not say anything when she reported the incident. She stated the saliva incident with Resident #10 and #15 occurred after 4/20/25. During an interview on 5/13/25 at 11:10 AM DA Q stated he worked the morning of 4/20/25 when Resident #10 drank the hand sanitizer. He stated he was asked by LVN AA about the hand sanitizer, but he had never observed the hand sanitizer before. He stated he had never observed Resident #10 drink or eat any inedible items. He stated he heard from his DM that he had drank the saliva from Resident #15 and she (DM) allegedly reported the saliva drinking incident to the ADM. He stated he had not observed Resident #10 drink the saliva of Resident #15, but he had observed Resident #41 drink the saliva of Resident #15. He stated it happened on the 05/10/25. He stated he reported the incident to the nurse on duty (did not remember the nurses name), DA U and the DM. He stated he had not observed increased monitoring in the dining room during mealtimes. He stated he was not interviewed about the incident that occurred on 4/10/25 where Resident #10 drank hand sanitizer. He sated he was not interviewed about any resident drinking saliva. During an interview on 5/13/25 at 11:18 AM DA U stated she worked in the kitchen on the morning of 4/20/25 when Resident #10 drank hand sanitizer. She stated the Thursday (4/17/25) or Friday (4/18/25) before the incident she had observed a bottle of hand sanitizer with the hand pump on the table near kitchen door. DA U stated she thought a housekeeper left it there. She stated she asked a housekeeper (name unknown) was the hand sanitizer supposed to be on the table and she was told to leave it there by the housekeeper. She stated that the morning of 4/20/25 she was yelled at by the nurse (LVN AA) asking if she was the person who left the hand sanitizer on the table. She stated she explained that she was not the person who placed the hand sanitizer out. She stated she had not received any training regarding what to do if a resident ingested a harmful substance or chemical. She stated she had not observed increased monitoring in the dining room since 4/20/25. She stated she had not been interviewed regarding the incident on 4/20/25 involving Resident #10. She stated she had heard that Resident #10 had drank the saliva of Resident #15 before but did not observe it. She stated DA Q had told her that Residen