Based on record review and staff interview, the facility failed to notify the State Ombudsman of a discharge to the hospital. This failed practice was found true for (1) one of (2) two residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifier: #49. Facility Census 58. Findings included: a) Resident #49 A record review on 10/23/24 at 1:30 PM revealed that Resident #49 had been transferred out to the hospital for an extended stay on 08/04/24. Further record review revealed that no notification had been sent to the state Ombudsman. During an interview on 10/23/24 at 2:52 PM, the Licensed Social Worker (LSW) stated, No, I did not send notification to the Ombudsman. I did not know that we had to do that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to promptly develop and update Resident #37's care plan to include hospice-specific interventions and care coordination with the hospice provider. This deficiency led to an incomplete care plan lacking essential guidance for staff on the resident's end-of-life needs, creating a risk for inconsistent care delivery and unmet needs. Resident Identifier: #37. Facility Census: 58. Findings Included: a) Resident #37 During an annual recertification survey on 10/22/24, at 11:50 AM, this surveyor observed Resident #37, who was admitted on [DATE] with a BIMS score of 4, indicating severe cognitive impairment. The resident, currently receiving hospice care, responded only with nonverbal sounds, demonstrating limited capacity to participate in care planning. A review of Resident #37's medical records revealed the individualized care plan did not contain hospice-specific interventions or documentation reflecting coordinated services with the hospice provider. Key elements necessary for thorough care coordination, such as pain management protocols, emotional support resources, and end-of-life preferences, were notably absent from the Medication Administration Record (MAR), Treatment Administration Record (TAR), Continuity of Care Documentation, and the Care Plan. On 10/23/24, at 10:07 AM, the surveyor questioned the Director of Nursing (DON) regarding the tracking and integrating hospice care details. The DON provided a binder containing hospice-related documentation, including the resident's face sheet and treatment notes from the hospice provider. However, this information had not been integrated into the facility's care documentation for Resident #37, and the DON acknowledged that hospice coordination details were maintained exclusively in the binder, not within the resident's facility care plan. The individualized care plan lacked documented hospice services, logistical information, and hospice-specific interventions critical to the resident's end-of-life care. Furthermore, the MAR included only the contact information for the hospice provider, with no further entries addressing coordinated hospice care. The absence of hospice-specific interventions and documentation of care coordination does not meet the standards established under F657, which require prompt and precise updates to the care plan. This oversight presents a risk for inconsistent care delivery, particularly in addressing Resident #37's end-of-life needs, potentially impacting the resident's quality of care and well-being.

. Based on observations and resident council interviews, the facility failed to uphold residents' rights to voice grievances freely, without fear of reprisal, as required by CMS standards. This deficiency poses a potential risk to more than a limited number of who currently reside in the facility by creating an environment where individuals may hesitate to utilize the grievance process. Faiclity Census: 58. Findings Included: a) Resident Council Meeting On 10/22/24 at 2:04 PM, a special resident council meeting was held in the facility's main dining room, attended by the activities coordinator (permitted by the residents) and this surveyor. The meeting followed a standard agenda to review ongoing and new matters. During the meeting, the surveyor asked residents if they understood how to file an official grievance. After a brief pause, only Resident #7, identified as the council president, responded, indicating the location of the grievance folder. Other residents were silent, with several displaying hesitant or reserved body language. The surveyor then posed a follow-up question about whether residents feared reprisal for filing grievances. In response, multiple residents were observed exhibiting signs of apprehension, including crossing arms, nodding affirmatively, or verbally confirming a fear of staff retaliation. This observed reluctance and collective unease suggest that residents may not feel safe or supported in expressing concerns, potentially undermining the efficacy of the facility's grievance process. The residents' visible discomfort and hesitation to voice concerns indicate a potential systemic failure by the facility to maintain an open, supportive environment for grievance reporting, as mandated by CMS guidelines. This omission directly impacts the facility's responsibility to foster a transparent culture for resident feedback, increasing the risk that resident needs or grievances may go unaddressed, thereby compromising overall resident well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview and staff interview, the facility failed to provide an environment free from abuse. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey process. Resident identifiers: Resident #158, #30, #15. Facility census: 58. Findings included: a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident (FRI) revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses: 1. Hallucinations 2. Vascular Dementia with other behavioral disturbance 3. Alzheimer's disease 4. Major depressive disorder recurrent, 5. Delusional disorders 6. Anxiety Medications: 1. Xanax 0.5 milligrams (mg) 1/2 tablet by mouth twice a day 2. Lamictal 200 mg 1 tablet by mouth at bedtime 3. Zyprexa 2.5 mg 1 tablet by mouth once a day 4. Mirtazapine 7.5 mg 1 tablet by mouth at bedtime In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing note read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 am medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase Zyprexa to 5 mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to (Name of local hospital) for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN (LPN name) notified Dr. of continued behaviors and an order was obtained for resident to be transported to (area hospital ED) for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at area hospital facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. Jan Care called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in BARH ER. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for psych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back via BLS and they were pulling out of the facility at 6:23 am. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psych Eval was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 PM and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to TMH ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5 mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Chief Executive Officer (CEO) or designee and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 PM, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurrence on 11/08/23 had not been reported or investigated. b) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. The resident reported LPN #73 made derogatory statements such as calling her fat, telling her we are afraid to leave any food around you, and telling her a list a mile long of people who Resident #15 has been mean to, and threatening to send her up the river. The resident thought LPN #73 was implying she had a rap sheet and she would be sent to another facility. The FRI states, Resident does get her feelings hurt easily and is very child like with how she thinks but that is normal for her. The FRI, also, stated, Victim does not have capacity. (Name of Resident #15) BIMS (Brief Interview for Mental Status) is a 12 which is moderately impaired. No medical intervention was necessary. (Name of Resident #15) has been emotional distress all day and her roommate said she also had cried through the night the night before. (Typed as written.) An interview, with no date or time, during the facility investigation was held with Resident #15's roommate, Resident #45. Resident #45 confirmed the resident and LPN #73 were arguing and she thought they were going to fist fight. Resident #45 stated she couldn't remember details of what was said. The following witness statements were obtained from the staff: An interview was held with Nurse Aide (NA) #67. There was no specific date or time noted on the witness statement. Nurse Aide (NA) #67 stated, LPN #73 wanted to give the resident her breathing treatment. However, the resident was watching TV and did not want to miss it. NA #67 wanted to give Resident #15 her breathing treatment early due to getting off and there would only be one nurse there. NA #67 stated, the resident became upset and started yelling and cussing .calling the staff names. A witness statement with no date or time noted was obtained from NA #40. NA #40 stated, Heard (Name of LPN #73) talking down to (Name of Resident #15) going back to her room. (Name of Resident #15) was testy over what was on TV. (Name of LPN #73) intensified (Name of Resident #15) mood that's how she does. Told (Name of Resident #15) no one cares what (Name of Resident #15) has to say anyway. When NA #40 heard that she went to other end of hall to avoid hearing the rest of the conversation. Feel that if she intervened it would have made things worse for (Name of Resident #15). Treatment of people is unkind. Reminds her of another nurse that was awful she worked with before. Off Sat (Saturday), Friday she worked. (Typed as written.) A witness statement with the date of 09/19/24 but no time noted, NA #7 stated, I was in the dining room when (Name of Resident #15) was crying she said that (Name of LPN #73) .she stated she hated (Name of LPN #73) and when she got up and was leaving the dining room she said to me that she was going to get (Name of LPN #73) fired. A witness statement was obtained from Activities Director #70. The statement is as follows: Resident (Name of Resident #15) came into the activity room on Monday, September 16th at 10:30 AM and ask if she could speak to me about something private. She said Nurse (Name of LPN #73) came in her room fussing at her. She said (Name of LPN #73) really hurt her because she was making fun of her being fat. She said (Name of LPN #73) said she was afraid of leaving food on a plate around her. She said (Name of LPN #73) she was so overweight. She said (Name of LPN #73) was yelling at her and saying mean things to her. I asked (Name of Resident #15) what was said she couldn't remember what all was said. She expressed that (Name of LPN #73) hurt her so badly she would like if I told (Name of LPN #73) not to come in her room anymore. She said (Name of LPN #73) told her she has had enough on her to send her away up the river. She said (Name of LPN #73) speaks to her roommate (Name of Resident #45) nicely but doesn't speak nice to her. I asked why and she said she feels like (Name of LPN #73) hates her. She said (Name of LPN #73) told her she has a wrap sheet a mile long and its enough to get her transferred to another facility. I expressed to (Name of Resident #15) that (Name of LPN #73) didn't have the authority to send her anywhere and (Name of Resident #15) said well according to her she does. (Name of LPN #73) told her she was mean to the other residents, her roommate and staff members. (Name of Resident #15) also was upset that (Name of LPN #73) made her leave the TV lounge to take her breathing treatments. She said (Name of LPN #73) told her she needed to take the treatment but could come back after she finished but (Name of Resident #15) doesn't want to walk to her room and then walk back. I told (Name of Resident #15) she needed to talk to the social worker about what happened and she said she was going to speak to her. (Name of Resident #15) said she just didn't want (Name of LPN #73) to be her nurse anymore. (Typed as written.) An additional witness statement was obtained from the Administrative Assistant #46. The written statement does not include a date or time. The witness statement states the following: (Name of Resident #15) and (Name of Resident #45) both came into the office and wanted to talk to (Name of Social Services #30). At the time, she was busy with someone in her office, so (Name of Resident #15) and (Name of Resident #45) asked if they could talk to me. (Name of Resident #15) appeared visibly upset so I let them sit by my desk and talk. (Name of Resident #15) said that she was upset with how (Name of LPN #73) had treated her and that she didn't want (Name of LPN #73) in her room or around her anymore. (Name of Resident #15) referenced an instance where (Name of LPN #73) either directly or indirectly made an offhand comment about (Name of Resident #15)'s weight, as well as making a comment about not being able to leave food on a plate around (Name of Resident #15). (Name of Resident #45) seemed to corroborate at least some, if not all, of what had happened. (Name of Resident #15) also mentioned that (Name of LPN #73) said she had a rap sheet on her this long. I also recall (Name of Resident #15) mentioning that someone said she was mean to (Name of Resident #45), (Name of Resident #45) refuted. On 10/21/24 at 2:15 PM, the five (5) day follow-up investigation dated 09/20/24 at 9:06 AM, was reviewed. The five (5) day follow-up states,No additional outcomes were found. Initial report was made regarding abuse, due to comments allegedly made by (Name of LPN #73), towards resident regarding her weight and sending her out of the facility. (Name of LPN #73 denies making any of the statements, she stated that she witnessed (Name of Resident #15) kicking her roommates walker and overheard (Name of Resident #15) calling her roommate a bitch when she intervened and explained to (Name of Resident #15) that she can't kick her roommate's walker because she or someone else could get hurt. The charge nurse responsible for oversight was not in the vicinity of the location where the incident allegedly occurred. Multiple staff members reiterated that (Name of Resident #15) can throw tantrums when she doesn't get her way. One staff member mentioned (Name of Resident #15) had mentioned prior to the incident that she was planning to get (Name of LPN #73) fired. Interviews and statements from staff and roommate were inconclusive. Most staff members heard (Name of Resident #15) get upset in the lounge when asked to return to her room and take a breathing treatment, but no staff members were around to see or hear the alleged incident take place. The allegation was inconclusive due to a lack of witnesses and evidence. (Typed as written.) On 10/21/24 at 4:15 PM, Resident #15 was interviewed regarding the allegation of verbal abuse. Resident #15 stated, she hollered at me at the top of her lungs, called me fat, and told me I was going to have to go to another place to live. During the interview, Resident #15 was visibly upset. She began to cry, wring her hands and shake. Resident #15 stated, I hate when I hear her voice .I can't get over it no matter how hard I try. The resident stated her roommate heard everything. She said she has talked with staff members about the incident with LPN #73 but continues to be upset. On 10/21/24 at approximately 5:00 PM, Resident 15's roommate at the time, was interviewed regarding the incident. Resident #45 was asked, do you remember an incident with (Name of Resident #15) and a staff member? Resident #45 stated, the nurse screamed at her .she was loud and was reprimanding her as if she were a child. Resident #45 was asked, do you think this was appropriate for a staff member to do? Resident #45 stated, no it was not appropriate I remember it happened I just can't remember all the exact words that were said. On 10/23/24 at 10:49 AM, an interview was held with Social Services #30 and Activities Coordinator #70. Both staff members were asked about the statements by witnesses and the interview which was held with Resident #15. Social Services #30 stated, Because, of . we went through all of the statements. I was ready to substantiate initially. We also got statements that (Name of Resident #15) says I am going to get her fired. The Social Services #30 was asked, was the resident not believed because of documented behaviors and angry statements the resident made? Social Services #30 stated, the staff was suspended. On 10/23/24 at 10:53 AM, the facility Administrator walked into the conference room. The Administrator was told of the previous conversation with Social Services #30 and Activities Coordinator #70. On 10/23/24 at 10:57 AM, the Administrator stated, The statements were reflective of what the resident stated, not what actually happened. I did feel she (LPN #73) was aggressive toward the resident. But based on the statements, I am not sure what happened. I feel the staff pushed the situation by being to loud. She (LPN #73 ) could not tell me exactly what was said but that she was loud. On 10/23/24 at 10:58 AM, the Administrator stated, I was out at a conference at this event, I was handling things over the phone. On 10/23/24 at 10:59 AM, Social Services #30 stated, This was a really tough one we went back and forth with this one. On 10/23/24 at 11:00 AM, the Administrator stated, I felt as if her escalating the situation required action . I feel that the resident saying she called her fat and the accusation that we could not substantiate. We feel like it is our job to protect residents, APS (Adult Protective Services) told us they were not interested in investigating, this is what helped lead us to our decision. The Administrator was asked, what would have convinced you this allegation of verbal abuse occurred? The Administrator stated, Another witness to collaborate what was said. NA #42 did not collaborate what she said, because she walked away .the resident is known to tell falsehoods and she had threatened to get the LPN fired. At this time, the written statement by NA #42 was reviewed with the Administrator. The Administrator stated, I do not recall her specific statement, but I do agree with you .the LPN was immediately suspended and upon return to work she was given a Last Chance Agreement. The Last Chance Agreement dated 09/20/24 stated, .It has been brought to the facility's attention that (Name of LPN #73) has previously engaged in inappropriate behavior by escalating situations with aggressive or difficult residents. Despite previous education and guidance on managing such situations with tact and professionalism, the issue persists. Effective immediately, this is the final written warning regarding her conduct. Any future incidents where (Name of LPN #73) raises her voice aggressively or acts in a manner that escalates conflict with residents will result in immediate termination of employment . The Administrator was asked, why was LPN #73 given this Last Chance Agreement? Did you feel the alleged verbal abuse occurred? The Administrator stated, I know she was loud .but I could not verify what actually took place. On 10/23/24 at 11:03 AM, Social Services #30 stated, I have talked to her (Resident #15) many times about the situation. But I do not have notes about this particular situation. I am not sure If I have formally talked to them (Resident #15 and Resident #45) about the situation. On 10/23/24 at 11:20 AM, the Administrator was asked, do you realize the resident remains upset regarding this allegation of verbal abuse .the resident continues to be visibly upset, such as crying and wringing her hands. The Administrator stated, She has been referred to our psych doctor. She comes once a week on Tuesdays. I will see if she has seen her. On 10/23/24 at approximately 12:15 PM, the Administrator was asked, why didn't LPN #73 follow the care plan intervention under the focus area of behavioral symptoms .which is when resident becomes physically abusive, STOP and try task later. Do not force task and Maintain a calm environment and approach to the resident. (Typed as written.) The Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to implement the facility Abuse policy and procedure. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey Process. Resident identifiers: Resident #158, Resident #30 and Resident #15. Facility census: 58. Findings include: a) a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses: 1. Hallucinations 2. Vascular Dementia with other behavioral disturbance 3. Alzheimer's disease 4. Major depressive disorder recurrent, 5. Delusional disorders 6. Anxiety Medications: 1. Xanax 0.5 milligrams (mg) 1/2 tablet by mouth twice a day 2.Lamictal 200 mg 1 tablet by mouth at bedtime 3. Zyprexa 2.5 mg 1 tablet by mouth once a day 4. Mirtazapine 7.5mg 1 tablet by mouth at bedtime In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing not read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA/Daughter notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 am medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase zyprexa to 5mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to Barh for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN (LPN name) notified Dr. of continued behaviors and an order was obtained for resident to be transported to (local hospital ED) for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at local hospital facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. Jan Care called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in local hospital ED. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for phsych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back via BLS and they were pulling out of the facility at 6:23 am. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psychiatric Evaluation was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 pm and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to TMH ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitiled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Cheif Executive Officer (CEO) or designee and to other officals in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 pm, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurance on 11/08/23 had not been reported or investigated. b) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. The resident reported LPN #73 made derogatory statements such as calling her fat, telling her we are afraid to leave any food around you, and telling her a list a mile long of people who Resident #15 has been mean to, and threatening to send her up the river. The resident thought LPN #73 was implying she had a rap sheet and she would be sent to another facility. The FRI states, Resident does get her feelings hurt easily and is very child like with how she thinks but that is normal for her. The FRI, also, stated, Victim does not have capacity. (Name of Resident #15) BIMS (Brief Interview for Mental Status) is a 12 which is moderately impaired. No medical intervention was necessary. (Name of Resident #15) has been emotional distress all day and her roommate said she also had cried through the night the night before. (Typed as written.) An interview, with no date or time, during the facility investigation was held with Resident #15's roommate, Resident #45. Resident #45 confirmed the resident and LPN #73 were arguing and she thought they were going to fist fight. Resident #45 stated she couldn't remember details of what was said. The following witness statements were obtained from the staff: An interview was held with Nurse Aide (NA) #67. There was no specific date or time noted on the witness statement. Nurse Aide (NA) #67 stated, LPN #73 wanted to give the resident her breathing treatment. However, the resident was watching TV and did not want to miss it. NA #67 wanted to give Resident #15 her breathing treatment early due to getting off and there would only be one nurse there. NA #67 stated, the resident became upset and started yelling and cussing .calling the staff names. A witness statement with no date or time noted was obtained from NA #40. NA #40 stated, Heard (Name of LPN #73) talking down to (Name of Resident #15) going back to her room. (Name of Resident #15) was testy over what was on TV. (Name of LPN #73) intensified (Name of Resident #15) mood that's how she does. Told (Name of Resident #15) no one cares what (Name of Resident #15) has to say anyway. When NA #40 heard that she went to other end of hall to avoid hearing the rest of the conversation. Feel that if she intervened it would have made things worse for (Name of Resident #15). Treatment of people is unkind. Reminds her of another nurse that was awful she worked with before. Off Sat (Saturday), Friday she worked. (Typed as written.) A witness statement with the date of 09/19/24 but no time noted, NA #7 stated, I was in the dining room when (Name of Resident #15) was crying she said that (Name of LPN #73) .she stated she hated (Name of LPN #73) and when she got up and was leaving the dining room she said to me that she was going to get (Name of LPN #73) fired. A witness statement was obtained from Activities Director #70. The statement is as follows: Resident (Name of Resident #15) came into the activity room on Monday, September 16th at 10:30 AM and ask if she could speak to me about something private. She said Nurse (Name of LPN #73) came in her room fussing at her. She said (Name of LPN #73) really hurt her because she was making fun of her being fat. She said (Name of LPN #73) said she was afraid of leaving food on a plate around her. She said (Name of LPN #73) said she was so overweight. She said (Name of LPN #73) was yelling at her and saying mean things to her. I asked (Name of Resident #15) what was said she couldn't remember what all was said. She expressed that (Name of LPN #73) hurt her so badly she would like if I told (Name of LPN #73) not to come in her room anymore. She said (Name of LPN #73) told her she has had enough on her to send her away up the river. She said (Name of LPN #73) speaks to her roommate (Name of Resident #45) nicely but doesn't speak nice to her. I asked why and she said she feels like (Name of LPN #73) hates her. She said (Name of LPN #73) told her she has a wrap sheet a mile long and its enough to get her transferred to another facility. I expressed to (Name of Resident #15) that (Name of LPN #73) didn't have the authority to send her anywhere and (Name of Resident #15) said well according to her she does. (Name of LPN #73) told her she was mean to the other residents, her roommate and staff members. (Name of Resident #15) also was upset that (Name of LPN #73) made her leave the TV lounge to take her breathing treatments. She said (Name of LPN #73) told her she needed to take the treatment but could come back after she finished but (Name of Resident #15) doesn't want to walk to her room and then walk back. I told (Name of Resident #15) she needed to talk to the social worker about what happened and she said she was going to speak to her. (Name of Resident #15) said she just didn't want (Name of LPN #73) to be her nurse anymore. (Typed as written.) An additional witness statement was obtained from the Administrative Assistant #46. The written statement does not include a date or time. The witness statement states the following: (Name of Resident #15) and (Name of Resident #45) both came into the office and wanted to talk to (Name of Social Services #30). At the time, she was busy with someone in her office, so (Name of Resident #15) and (Name of Resident #45) asked if they could talk to me. (Name of Resident #15) appeared visibly upset so I let them sit by my desk and talk. (Name of Resident #15) said that she was upset with how (Name of LPN #73) had treated her and that she didn't want (Name of LPN #73) in her room or around her anymore. (Name of Resident #15) referenced an instance where (Name of LPN #73) either directly or indirectly made an offhand comment about (Name of Resident #15)'s weight, as well as making a comment about not being able to leave food on a plate around (Name of Resident #15). (Name of Resident #45) seemed to corroborate at least some, if not all, of what had happened. (Name of Resident #15) also mentioned that (Name of LPN #73) said she had a rap sheet on her this long. I also recall (Name of Resident #15) mentioning that someone said she was mean to (Name of Resident #45), (Name of Resident #45) refuted. On 10/21/24 at 2:15 PM, the five (5) day follow-up investigation dated 09/20/24 at 9:06 AM, was reviewed. The five (5) day follow-up states,No additional outcomes were found. Initial report was made regarding abuse, due to comments allegedly made by (Name of LPN #73), towards resident regarding her weight and sending her out of the facility. (Name of LPN #73 denies making any of the statements, she stated that she witnessed (Name of Resident #15) kicking her roommates walker and overheard (Name of Resident #15) calling her roommate a bitch when she intervened and explained to (Name of Resident #15) that she can't kick her roommate's walker because she or someone else could get hurt. The charge nurse responsible for oversight was not in the vicinity of the location where the incident allegedly occurred. Multiple staff members reiterated that (Name of Resident #15) can throw tantrums when she doesn't get her way. One staff member mentioned (Name of Resident #15) had mentioned prior to the incident that she was planning to get (Name of LPN #73) fired. Interviews and statements from staff and roommate were inconclusive. Most staff members heard (Name of Resident #15) get upset in the lounge when asked to return to her room and take a breathing treatment, but no staff members were around to see or hear the alleged incident take place. The allegation was inconclusive due to a lack of witnesses and evidence. (Typed as written.) On 10/21/24 at 4:15 PM, Resident #15 was interviewed regarding the allegation of verbal abuse. Resident #15 stated, she hollered at me at the top of her lungs, called me fat, and told me I was going to have to go to another place to live. During the interview, Resident #15 was visibly upset. She began to cry, wring her hands and shake. Resident #15 stated, I hate when I hear her voice .I can't get over it no matter how hard I try. The resident stated her roommate heard everything. She said she has talked with staff members about the incident with LPN #73 but continues to be upset. On 10/21/24 at approximately 5:00 PM, Resident 15's roommate at the time, was interviewed regarding the incident. Resident #45 was asked, do you remember an incident with (Name of Resident #15) and a staff member? Resident #45 stated, the nurse screamed at her .she was loud and was reprimanding her as if she were a child. Resident #45 was asked, do you think this was appropriate for a staff member to do? Resident #45 stated, no it was not appropriate I remember it happened I just can't remember all the exact words that were said. On 10/23/24 at 10:49 AM, an interview was held with Social Services #30 and Activities Coordinator #70. Both staff members were asked about the statements by witnesses and the interview which was held with Resident #15. Social Services #30 stated, Because, of . we went through all of the statements. I was ready to substantiate initially. We also got statements that (Name of Resident #15) says I am going to get her fired. The Social Services #30 was asked, was the resident not believed because of documented behaviors and angry statements the resident made? Social Services #30 stated, the staff was suspended. On 10/23/24 at 10:53 AM, the facility Administrator walked into the conference room. The Administrator was told of the previous conversation with Social Services #30 and Activities Coordinator #70. On 10/23/24 at 10:57 AM, the Administrator stated, The statements were reflective of what the resident stated, not what actually happened. I did feel she (LPN #73) was aggressive toward the resident. But based on the statements, I am not sure what happened. I feel the staff pushed the situation by being to loud. She (LPN #73 ) could not tell me exactly what was said but that she was loud. On 10/23/24 at 10:58 AM, the Administrator stated, I was out at a conference at this event, I was handling things over the phone. On 10/23/24 at 10:59 AM, Social Services #30 stated, This was a really tough one we went back and forth with this one. On 10/23/24 at 11:00 AM, the Administrator stated, I felt as if her escalating the situation required action . I feel that the resident saying she called her fat and the accusation that we could not substantiate. We feel like it is our job to protect residents, APS (Adult Protective Services) told us they were not interested in investigating, this is what helped lead us to our decision. The Administrator was asked, what would have convinced you this allegation of verbal abuse occurred? The Administrator stated, Another witness to collaborate what was said. NA #42 did not collaborate what she said, because she walked away .the resident is known to tell falsehoods and she had threatened to get the LPN fired. At this time, the written statement by NA #42 was reviewed with the Administrator. The Administrator stated, I do not recall her specific statement, but I do agree with you .the LPN was immediately suspended and upon return to work she was given a Last Chance Agreement. The Last Chance Agreement dated 09/20/24 stated, .It has been brought to the facility's attention that (Name of LPN #73) has previously engaged in inappropriate behavior by escalating situations with aggressive or difficult residents. Despite previous education and guidance on managing such situations with tact and professionalism, the issue persists. Effective immediately, this is the final written warning regarding her conduct. Any future incidents where (Name of LPN #73) raises her voice aggressively or acts in a manner that escalates conflict with residents will result in immediate termination of employment . The Administrator was asked, why was LPN #73 given this Last Chance Agreement? Did you feel the alleged verbal abuse occurred? The Administrator stated, I know she was loud .but I could not verify what actually took place. On 10/23/24 at 11:03 AM, Social Services #30 stated, I have talked to her (Resident #15) many times about the situation. But I do not have notes about this particular situation. I am not sure If I have formally talked to them (Resident #15 and Resident #45) about the situation. On 10/23/24 at 11:20 AM, the Administrator was asked, do you realize the resident remains upset regarding this allegation of verbal abuse .the resident continues to be visibly upset, such as crying and wringing her hands. The Administrator stated, She has been referred to our psych doctor. She comes once a week on Tuesdays. I will see if she has seen her. On 10/23/24 at approximately 12:15 PM, the Administrator was asked, why didn't LPN #73 follow the care plan intervention under the focus area of behavioral symptoms .which is when resident becomes physically abusive, STOP and try task later. Do not force task and Maintain a calm environment and approach to the resident. (Typed as written.) The Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all allegations of abuse and or neglect were reported to appropriate state agencies as required. This was true for two (2) of four (4) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #4 and #158. Facility Census: 58. Findings Include: a) Resident #4 A review of the facilities grievance and concerns on 10/22/24 at 5:38 PM, revealed a concern that reads as follows: (Resident #4 named) wanted put in bed during mealtime and two staff have to put her in bed and most staff were feeding other residents and told her soon as they could put her to bed they would. Resident stated that a nurse said Poor Thing to her because she was ready to go to bed and stated her hips were hurting from the wheelchair. The staff that made the comment received verbal disciplinary action. During an interview on 10/22/24 at 5:41 PM, the Administrator stated, I remember the incident. The original person she said it was, was not who it was. We found it was a (Nurse Aide) NA. The NA said that she did not mean that in a derogatory way, she meant it as a sweet gesture. The administrator additionally stated, We will report it now. b) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses included Hallucinations, Vascular Dementia with other behavioral disturbance, Alzheimer's disease, Major depressive disorder recurrent, Delusional disorders and Anxiety. In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing not read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 AM medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase Zyprexa to 5 mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to (name of local hospital) for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN (Name of LPN) notified Dr. of continued behaviors and an order was obtained for resident to be transported to (name of local hospital) ER for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at (name of local hospital) facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. (Ambulance Company name) called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in (name of local hospital) ER. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for psych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back via BLS and they were pulling out of the facility at 6:23 am. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psychiatric Evaluation was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 PM and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to (local hospital name) ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5 mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Chief Executive Officer (CEO) or designee and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 PM, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurrence on 11/08/23 had not been reported or investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation and staff interview, the facility failed to complete a through and complete investigation regarding allegations of verbal abuse for Resident #15 and physical abuse for Resident #158. This was true for two (2) of four (4) residents reviewed under the care area of abuse. Resident Identifiers: #15 and #158. Facility Census: 58. Findings Include: a) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. The resident reported LPN #73 made derogatory statements such as calling her fat, telling her we are afraid to leave any food around you, and telling her a list a mile long of people who Resident #15 has been mean to, and threatening to send her up the river. The resident thought LPN #73 was implying she had a rap sheet and she would be sent to another facility. The FRI states, Resident does get her feelings hurt easily and is very child like with how she thinks but that is normal for her. The FRI, also, stated, Victim does not have capacity. (Name of Resident #15) BIMS (Brief Interview for Mental Status) is a 12 which is moderately impaired. No medical intervention was necessary. (Name of Resident #15) has been emotional distress all day and her roommate said she also had cried through the night the night before. (Typed as written.) An interview, with no date or time, during the facility investigation was held with Resident #15's roommate, Resident #45. Resident #45 confirmed the resident and LPN #73 were arguing and she thought they were going to fist fight. Resident #45 stated she couldn't remember details of what was said. The following witness statements were obtained from the staff: An interview was held with Nurse Aide (NA) #67. There was no specific date or time noted on the witness statement. Nurse Aide (NA) #67 stated, LPN #73 wanted to give the resident her breathing treatment. However, the resident was watching TV and did not want to miss it. NA #67 wanted to give Resident #15 her breathing treatment early due to getting off and there would only be one nurse there. NA #67 stated, the resident became upset and started yelling and cussing .calling the staff names. A witness statement with no date or time noted was obtained from NA #40. NA #40 stated, Heard (Name of LPN #73) talking down to (Name of Resident #15) going back to her room. (Name of Resident #15) was testy over what was on TV. (Name of LPN #73) intensified (Name of Resident #15) mood that's how she does. Told (Name of Resident #15) no one cares what (Name of Resident #15) has to say anyway. When NA #40 heard that she went to other end of hall to avoid hearing the rest of the conversation. Feel that if she intervened it would have made things worse for (Name of Resident #15). Treatment of people is unkind. Reminds her of another nurse that was awful she worked with before. Off Sat (Saturday), Friday she worked. (Typed as written.) A witness statement with the date of 09/19/24 but no time noted, NA #7 stated, I was in the dining room when (Name of Resident #15) was crying she said that (Name of LPN #73) .she stated she hated (Name of LPN #73) and when she got up and was leaving the dining room she said to me that she was going to get (Name of LPN #73) fired. A witness statement was obtained from Activities Director #70. The statement is as follows: Resident (Name of Resident #15) came into the activity room on Monday, September 16th at 10:30 AM and ask if she could speak to me about something private. She said Nurse (Name of LPN #73) came in her room fussing at her. She said (Name of LPN #73) really hurt her because she was making fun of her being fat. She said (Name of LPN #73) said she was afraid of leaving food on a plate around her. She said (Name of LPN #73) said she was so overweight. She said (Name of LPN #73) was yelling at her and saying mean things to her. I asked (Name of Resident #15) what was said she couldn't remember what all was said. She expressed that (Name of LPN #73) hurt her so badly she would like if I told (Name of LPN #73) not to come in her room anymore. She said (Name of LPN #73) told her she has had enough on her to send her away up the river. She said (Name of LPN #73) speaks to her roommate (Name of Resident #45) nicely but doesn't speak nice to her. I asked why and she said she feels like (Name of LPN #73) hates her. She said (Name of LPN #73) told her she has a wrap sheet a mile long and its enough to get her transferred to another facility. I expressed to (Name of Resident #15) that (Name of LPN #73) didn't have the authority to send her anywhere and (Name of Resident #15) said well according to her she does. (Name of LPN #73) told her she was mean to the other residents, her roommate and staff members. (Name of Resident #15) also was upset that (Name of LPN #73) made her leave the TV lounge to take her breathing treatments. She said (Name of LPN #73) told her she needed to take the treatment but could come back after she finished but (Name of Resident #15) doesn't want to walk to her room and then walk back. I told (Name of Resident #15) she needed to talk to the social worker about what happened and she said she was going to speak to her. (Name of Resident #15) said she just didn't want (Name of LPN #73) to be her nurse anymore. (Typed as written.) An additional witness statement was obtained from the Administrative Assistant #46. The written statement does not include a date or time. The witness statement states the following: (Name of Resident #15) and (Name of Resident #45) both came into the office and wanted to talk to (Name of Social Services #30). At the time, she was busy with someone in her office, so (Name of Resident #15) and (Name of Resident #45) asked if they could talk to me. (Name of Resident #15) appeared visibly upset so I let them sit by my desk and talk. (Name of Resident #15) said that she was upset with how (Name of LPN #73) had treated her and that she didn't want (Name of LPN #73) in her room or around her anymore. (Name of Resident #15) referenced an instance where (Name of LPN #73) either directly or indirectly made an offhand comment about (Name of Resident #15)'s weight, as well as making a comment about not being able to leave food on a plate around (Name of Resident #15). (Name of Resident #45) seemed to corroborate at least some, if not all, of what had happened. (Name of Resident #15) also mentioned that (Name of LPN #73) said she had a rap sheet on her this long. I also recall (Name of Resident #15) mentioning that someone said she was mean to (Name of Resident #45), (Name of Resident #45) refuted. On 10/21/24 at 2:15 PM, the five (5) day follow-up investigation dated 09/20/24 at 9:06 AM, was reviewed. The five (5) day follow-up states,No additional outcomes were found. Initial report was made regarding abuse, due to comments allegedly made by (Name of LPN #73), towards resident regarding her weight and sending her out of the facility. (Name of LPN #73 denies making any of the statements, she stated that she witnessed (Name of Resident #15) kicking her roommates walker and overheard (Name of Resident #15) calling her roommate a bitch when she intervened and explained to (Name of Resident #15) that she can't kick her roommate's walker because she or someone else could get hurt. The charge nurse responsible for oversight was not in the vicinity of the location where the incident allegedly occurred. Multiple staff members reiterated that (Name of Resident #15) can throw tantrums when she doesn't get her way. One staff member mentioned (Name of Resident #15) had mentioned prior to the incident that she was planning to get (Name of LPN #73) fired. Interviews and statements from staff and roommate were inconclusive. Most staff members heard (Name of Resident #15) get upset in the lounge when asked to return to her room and take a breathing treatment, but no staff members were around to see or hear the alleged incident take place. The allegation was inconclusive due to a lack of witnesses and evidence. (Typed as written.) On 10/21/24 at 4:15 PM, Resident #15 was interviewed regarding the allegation of verbal abuse. Resident #15 stated, she hollered at me at the top of her lungs, called me fat, and told me I was going to have to go to another place to live. During the interview, Resident #15 was visibly upset. She began to cry, wring her hands and shake. Resident #15 stated, I hate when I hear her voice .I can't get over it no matter how hard I try. The resident stated her roommate heard everything. She said she has talked with staff members about the incident with LPN #73 but continues to be upset. On 10/21/24 at approximately 5:00 PM, Resident 15's roommate at the time, was interviewed regarding the incident. Resident #45 was asked, do you remember an incident with (Name of Resident #15) and a staff member? Resident #45 stated, the nurse screamed at her .she was loud and was reprimanding her as if she were a child. Resident #45 was asked, do you think this was appropriate for a staff member to do? Resident #45 stated, no it was not appropriate I remember it happened I just can't remember all the exact words that were said. On 10/23/24 at 10:49 AM, an interview was held with Social Services #30 and Activities Coordinator #70. Both staff members were asked about the statements by witnesses and the interview which was held with Resident #15. Social Services #30 stated, Because, of . we went through all of the statements. I was ready to substantiate initially. We also got statements that (Name of Resident #15) says I am going to get her fired. The Social Services #30 was asked, was the resident not believed because of documented behaviors and angry statements the resident made? Social Services #30 stated, the staff was suspended. On 10/23/24 at 10:53 AM, the facility Administrator walked into the conference room. The Administrator was told of the previous conversation with Social Services #30 and Activities Coordinator #70. On 10/23/24 at 10:57 AM, the Administrator stated, The statements were reflective of what the resident stated, not what actually happened. I did feel she (LPN #73) was aggressive toward the resident. But based on the statements, I am not sure what happened. I feel the staff pushed the situation by being to loud. She (LPN #73 ) could not tell me exactly what was said but that she was loud. On 10/23/24 at 10:58 AM, the Administrator stated, I was out at a conference at this event, I was handling things over the phone. On 10/23/24 at 10:59 AM, Social Services #30 stated, This was a really tough one we went back and forth with this one. On 10/23/24 at 11:00 AM, the Administrator stated, I felt as if her escalating the situation required action . I feel that the resident saying she called her fat and the accusation that we could not substantiate. We feel like it is our job to protect residents, APS (Adult Protective Services) told us they were not interested in investigating, this is what helped lead us to our decision. The Administrator was asked, what would have convinced you this allegation of verbal abuse occurred? The Administrator stated, Another witness to collaborate what was said. NA #42 did not collaborate what she said, because she walked away .the resident is known to tell falsehoods and she had threatened to get the LPN fired. At this time, the written statement by NA #42 was reviewed with the Administrator. The Administrator stated, I do not recall her specific statement, but I do agree with you .the LPN was immediately suspended and upon return to work she was given a Last Chance Agreement. The Last Chance Agreement dated 09/20/24 stated, .It has been brought to the facility's attention that (Name of LPN #73) has previously engaged in inappropriate behavior by escalating situations with aggressive or difficult residents. Despite previous education and guidance on managing such situations with tact and professionalism, the issue persists. Effective immediately, this is the final written warning regarding her conduct. Any future incidents where (Name of LPN #73) raises her voice aggressively or acts in a manner that escalates conflict with residents will result in immediate termination of employment . The Administrator was asked, why was LPN #73 given this Last Chance Agreement? Did you feel the alleged verbal abuse occurred? The Administrator stated, I know she was loud .but I could not verify what actually took place. On 10/23/24 at 11:03 AM, Social Services #30 stated, I have talked to her (Resident #15) many times about the situation. But I do not have notes about this particular situation. I am not sure If I have formally talked to them (Resident #15 and Resident #45) about the situation. On 10/23/24 at 11:20 AM, the Administrator was asked, do you realize the resident remains upset regarding this allegation of verbal abuse .the resident continues to be visibly upset, such as crying and wringing her hands. The Administrator stated, She has been referred to our psych doctor. She comes once a week on Tuesdays. I will see if she has seen her. On 10/23/24 at approximately 12:15 PM, the Administrator was asked, why didn't LPN #73 follow the care plan intervention under the focus area of behavioral symptoms .which is when resident becomes physically abusive, STOP and try task later. Do not force task and Maintain a calm environment and approach to the resident. (Typed as written.) The Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior. b) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses included Hallucinations, Vascular Dementia with other behavioral disturbance, Alzheimer's disease, Major depressive disorder recurrent, Delusional disorders, and Anxiety. In addition to the following documentation: On 10/01/23 at 1:52 PM the nursing note read as follows: Resident noted hitting another resident on A Hall after wheel chair entangled with wheel chair of another resident. Residents separated. No apparent injury to either resident. All necessary parties notified. Resident POA notified. Dr notified. On 10/24/23 at 10:26 AM the nursing not read as follows: Calling staff inappropriate names such as hussy and rhyming inappropriate statements such as She's from [NAME] because she's a whore On 10/24/23 at 12:20 PM the nursing not read as follows: Resident grabbed and started hitting another resident in the activities room. Both residents in wheel chairs. The other resident grabbed back. Both residents sustained discolorations to left arms. DR notified. resident POA/Daughter notified. Nursing Home Program reporting of allegations notified. This event occurred at 11:30 am. On 10/26/23 at 3:49 PM the nursing note read as follows: Resident threw water on this recording nurse while giving her 8 am medications. Resident stated You needed a bath. Staff was able to redirect the resident. On 10/28/23 at 12:47 PM the nursing note read as follows: Resident continues to wander halls yelling at other residents, talking to self, hitting and grabbing at staff and or other residents. DR notified. Orders increase Zyprexa to 5 mg po bid. On 10/28/23 at 2:00 PM the nursing note read as follows: Continues with combative behavior with staff and other residents. Wandering halls and into other residents rooms. Grabbing objects in other resident rooms and throwing them. DR notified again. Orders transfer to (name of local hospital) for further evaluation. On 10/28/23 at 2:10 PM the nursing note read as follows: Resident continues to be combative and needs constant redirection. Resident difficult to redirect. Resident physically and verbally aggressive towards staff and other residents during redirection. Resident hitting, kicking, scratching, and throwing things at staff. LPN R. [NAME] notified Dr. of continued behaviors and an order was obtained for resident to be transported to (name of local hospital) ER for evaluation for behaviors. POA was notified. She was reluctant at first and wanted resident to be isolated for behaviors. This recording nurse advised POA that staff was trying to keep resident redirected and away from other residents but she continues to having combative behaviors. POA notified again of MD's orders to transfer. This recording nurse advised POA that she could meet resident at (name of local hospital) facility, but that since she was causing harm to other residents she would have to go for an evaluation. POA voiced understanding and stated I will get ready and meet her up there. (Name of local ambulance service) called for ambulance transport. Discipline Nursing On 10/28/23 at 5:40 PM the nursing note read as follows: This recording nurse spoke with RN in (name of local hospital) ER. She stated that the resident was combative upon arrival and had to be sedated to be evaluated. She stated that labs were obtained along with a urine sample. BUN 27 and urine was normal. Resident is awaiting a CT scan of her head and possible referral for social worker for psych eval and treatment. She stated that POA was at bedside. On 10/29/23 at 6:33 AM the nursing note read as follows: RN (Last name of Nurse from hospital) called from (Name of local hospital) and stated that they are sending resident back and they were pulling out of the facility at 6:23 AM. her last v/s were BP 127/56 pulse 50 resp. 20 O2 96% on 2L NC temp 97.8. He stated that the Psych Eval was denied due to her dementia. He stated she had been non-combative while she was there. She had a UTI that was negative. There were no med changes. Head CT was done which showed degenerative white matter changes that were consistent with her age. It showed no acute changes. She was given oral Presidex when she arrived there yesterday. He stated she did fine with it. He stated she swallowed water fine. The daughters were with her in the ER until 7:30-8:00 PM and he stated she had did fine and had not even tried to get up or anything. They did get a Troponin level on her which was 11. They did not do a follow up level. On 10/29/23 at 10:30 AM the nursing note read as follows: Resident's POA, notified that resident had returned to the facility from (Name of local hospital) and has been resting in bed. POA also notified that Zyprexa has been increased to 5 mg BID and she verbalized her understanding, she stated that she will be here to visit with resident today. Call light and fluids within reach and encouraged. Safety precautions in place. Will continue to monitor. On 11/08/23 at 1:52 PM the nursing note read as follows: Res. has been very aggressive to staff and other residents. She is grabbing and smacking at other residents as they pass by. Resident has had multiple interacts with staff and has been aggressive each time, even when just trying to speak to her. She has thrown her lunch tray, as well as fluids offered as well. Dr. has been notified of res. behaviors. New order to transfer to (name of local hospital) ER for eval d/t behaviors. On 12/11/23 at 9:29 AM a nursing note recorded as Late Entry on 12/12/23 at 3:18 PM read as follows: Res. has had behaviors this AM. Kicking at therapy staff as they walk by in the hallway ambulating another res. Also kicking at other residents as they wheel by her chair in the hallway. Also kicked at a visitors purse(wife visiting her husband). Also does a loud, inaudible yell/growl sound periodically. Denies pain. Not easily redirected from these behaviors. Have offer food, fluids, toileting, and activities, all unsuccessful. On 12/12/23 at 2:19 PM a nursing note read as follows: Resident propelling self throughout facility, attempting to hit and kick at others, redirection not easy. Resident also yelling out randomly. ADLs provided by staff, resident combative at times with care. Denies any discomfort. Dr. reviewed residents medications and behaviors. New order to discontinue Remeron and increase Zyprexa to 5 mg BID. On 10/22/24 at 4:38 PM, the facility administrator stated the facility does not have specific policy and procedures related to dementia care and behavioral monitoring/interventions. On 10/22/24 at approximately 5:00 PM, a review of facility policy and procedure entitled, Suspected Adult and Elderly Abuse/Neglect was completed which revealed all suspected or alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of patient/resident property shall be reported immediately to the administrator/Chief Executive Officer (CEO) or designee and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. On 10/22/24 at 6:15 PM, a review of the facility investigation was completed which revealed no corrective action noted on 5 day follow up of investigation involving the two residents. On 10/22/24 at 6:15 PM, an interview was conducted with the facility Social Worker (SW) and Administrator #78 who acknowledged the investigation into the 10/24/24 allegation of abuse was not thorough, not complete and no true corrective action by the facility can be identified, in addition no statements were obtained from facility staff or witnesses. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed: PROBLEM: Resident has physical and verbal behavioral symptoms (resists care at times and has hallucination/curses). Frequently hears people talking about her, thinks her kids or others are being murdered, talks about things that have not really occurred. Also combative with staff and other residents at times. Recently had a hospitalization due to combative behaviors. GOAL: Resident will not harm self or others secondary to physically abusive behavior. Approach: Avoid over stimulation (e.g. noise, crowding, other physically aggressive residents. Divert resident's behavior by assisting resident to activities or to a quiet area for redirection of conversations. Maintain a calm environment and approach to the resident. Remove from group activities when behavior is unacceptable. On 10/23/24 at approximately 10:00 AM, a review of Resident #158's Behavioral/Intervention Monthly Flow Records revealed the following: October 2023 Behavioral/Intervention Monthly Flow Record: 10/03/23: Intermittent behaviors, interventions ineffective 10/04/23: Intermittent behaviors: interventions ineffective 10/05/23: Intermittent behaviors, interventions ineffective 10/06/23: intermittent behaviors, interventions ineffective 10/07/23: intermittent behaviors, interventions ineffective 10/08/23: Intermittent behaviors, interventions ineffective 10/09/23: intermittent behaviors, interventions ineffective 10/10/23: intermittent behaviors, interventions ineffective 10/11/23: intermittent behaviors, interventions ineffective 10/23/23: intermittent behaviors, interventions ineffective 10/24/23: Intermittent behaviors, interventions ineffective 10/25/23: Intermittent behaviors, interventions ineffective 10/26/23: Intermittent behaviors, interventions ineffective 10/29/23: Intermittent behaviors, interventions ineffective 10/30/23: Intermittent behaviors, interventions ineffective November 2023 Behavioral/Intervention Monthly Flow Record: 11/08/24: No behaviors documented. 11/29/23: Continuous behaviors, interventions ineffective. On 10/23/24 at 12:19 PM an interview was conducted with the facility Assistant Director of Nursing (ADON) who stated the facility nurses complete the Behavioral/Intervention Monthly Flow Records. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At that time, the DON acknowledged on the Behavioral/Intervention Monthly Flow Records: 1. When a behavior was documented, the outcomes of interventions attempted Resident #158's behaviors were unchanged or worsened. 2. Interventions documented were ineffective 3. The facility was unable to provide further documentation of any interventions attempted were performed to keep other residents safe. 4. Interventions of the behavioral care plan were not resident centered. 5. That the occurrence on 11/08/23 had not been reported or investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop the care plan which includes all diagnoses for Resident #54, Resident #15 and Resident #16; and implement the care plan for Resident #15 and Resident #29. This was true for four (4) of 18 residents reviewed during the survey process. Resident Identifiers: #54, #15, #16 and #29. Facility Census: 58. Findings Included: a) Resident #54 On 10/22/24 at 1:00 PM, the care plan was reviewed for Resident #54. The care plan did not include the following diagnoses: --Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. --Pain, unspecified --Shortness of Breath --Hyperlipidemia, unspecified --Hypomagnesemia --Hypokalemia --Other peripheral vertigo, unspecified ear --Hypertensive heart and heart failure --Chronic Kidney Disease --Unspecified Atrial Fibrillation --Gastro-esophageal reflux disease without esophagitis On 10/22/24 at 1:25 PM, Registered Nurse (RN) #66 stated, I don't use big words .it has to be simple and easy to understand .I don't always add the diagnosis usually a description. On 10/22/24 at 3:15 PM, the Administrator was notified regarding the care plan not including specific diagnoses. The Administrator stated, I understand what you are telling me. b1) Resident #15 On 10/22/24 at 1:45 PM, the care plan was reviewed for Resident #15. The care plan did not include the following diagnoses: --Constipation, unspecified --Hypothyroidism, unspecified --Chronic Obstructive Pulmonary Disease (COPD), unspecified --Hyperlipidemia --Unspecified systolic (congestive) heart failure --Obstructive sleep apnea --Methicilin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere (History of ) --Non-ST elevation (NSTEMI) myocardial infarction On 10/22/24 at 3:15 PM, the Administrator was notified regarding the care plan not including specific diagnoses. The Administrator stated, I understand what you are telling me. b2) Resident #15 On 10/22/24 at 1:45 PM, the care plan was reviewed for Resident #15. One (1) of the care plan interventions under the focus area of behavioral symptoms was not followed. A documented event happened between 09/13/24-09/15/24 which was reported to all State agencies on 09/16/24. Resident #15 became upset verbally and physically. Licensed Practical Nurse (LPN) #73 did not follow the interventions of maintain a calm environment and approach to the resident and when the resident becomes physically abusive, STOP and try task later. Do not force to do task. On 10/23/24 at 1:15 PM, the Administrator stated, the nurse should have came back later regarding the breathing treatment .I agree this escalated Resident #15's behavior. c) Resident #16 On 10/22/24 at 2:00 PM, the care plan was reviewed for Resident #16. The care plan did not include the following diagnoses: --Unspecified systolic (congestive) heart failure --Iron deficiency anemia secondary to blood loss (chronic) --Chronic atrial fibrillation, unspecified --Arteriosclerotic heart disease of native coronary artery without angina pectoris --Peripheral vascular disease, unspecified --Chronic Obstructive Pulmonary Disease, unspecified --Hyperlipidemia, unspecified --Hypothyroidism, unspecified --Pain, unspecified --Gastro-esophageal reflux disease without esophagitis --Hypokalemia --Solitary pulmonary nodule --Constipation, unspecified --Methicillin resistant Staphylococcus aureus infection, unspecified site (History of) --Non-ST elevation (NSTEMI) myocardial infarction (History of) On 10/22/24 at 3:15 PM, the Administrator was notified regarding the care plan not including specific diagnoses. The Administrator stated, I understand what you are telling me. d) Resident #29 During the initial observation on 10/21/24 at 12:29 PM, there was found to be a white board in Resident #29's room. Written on the white board was Moon boots on at all times Further observation of Resident #29 lying in bed revealed she did not have her moon boots on. A record review on 10/21/24 at 1:30 PM, revealed a care plan for Resident #29 that read as follows: Focus: At risk for pressure ulcers related to requiring assistance with bed mobility and incontinence of bladder and bowel. [NAME] score shows risk for skin breakdown. History of an unstageable pressure ulcer on right heel. Intervention: Moon boots to be worn at all times. Remove for bathing. An observation of 10/21/24 at 1:55 PM, showed Resident #29 up to a Geri chair, being assisted with lunch. Resident #29 was not wearing moon boots. During an interview on 10/21/24 at 1:57 PM, Nurse Aide (NA) #24 stated, Yes she should have them on. I don't even know where they are. Let me look in her closet.

. Based on record review and staff interview, the facility failed to provide treatment and care in accordance with professional standards of practice. Resident #23 refuses all AM and PM medications and has had no physician intervention since 05/24. In addition the facility failed to offer hospice to Resident #158. This failed practice was found true for (2) two of 18 sample residents reviewed during the long term care survey process. Resident identifier: #23 and #158. Facility Census 58. Finding Included: a) Resident #23 A record review on 10/21/24 at 2:06 PM, revealed Resident #23 had multiple notes from 05/24 to present of refusing AM and PM medications. The notes also revealed Resident #23 was educated on the risk of refusing the medications; however Resident #23's Brief Interview for Mental Status (BIMS) score is 99. Further record review revealed Resident #23 was ordered the following medications: Famotidine 20 Milligrams (mg) one time a day at 9:00 AM. Levothyroxine 112 mcg one time a day at 9:00 AM. Lipitor 10 mg one time a day at 9:00 PM. Metoprolol tartrate 25 mg every 12 hours at 9:00 AM and 9:00 PM. A review of Resident #23's care plan on 10/22/24 at 3:15 PM, revealed the following care plan for refusal of medications: Focus: Wanders in/out of other residents rooms at times. Says Oh Lord frequently. Occasionally will take others' belongings. Also frequently refuses medications and is verbally and physically abusive with care. The only intervention related to refusing medications reads as follows: Encourage to take medications. Explain importance of taking medications. May mask taste in ice cream or applesauce or food/drink if necessary. Implemented on 07/10/2024. An interview on 10/22/24 at 2:45 PM, Licensed Practical Nurse (LPN) #58 stated, I crush her meds in applesauce. She just refuses them. A record review on 10/22/24 at 3:00 PM revealed Resident #23's blood pressure had been high 44 times since 06/01/24. No physician intervention was noted. Further record review revealed the only physician note addressing the refusal of medications is from 05/20/24 reads as follows: (Doctor named) notified of resident refusing medications. He stated to continue to attempt to give medications and to document when resident refuses them. Risk and benefits explained to the resident of the medications and importance of taking them. POA also notified of resident refusing medications. Further record review of Resident #23's Medication Administration Records (MAR) from 06/2024 to present revealed Resident #23 had refused her medications everyday. During an interview on 10/22/24 at 3:56 PM, the Assistant Director of Nursing (ADON) agreed there are no notes in the chart to say what we are doing about resident refusing meds for a long period of time. She then stated, Let me see if I can find anything else. No further evidence was provided by the end of the survey. b) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses included Hallucinations, Vascular Dementia with other behavioral disturbance, Alzheimer's disease, Major depressive disorder recurrent, Delusional disorders, and Anxiety. In addition to the following documentation: 12/18/2023 4:20 PM New order received from Dr. for Roxanol 0.25 mg sublingual Chirrs for pain, medication is currently on order from pharmacy, resident previously taking Tramadol 50 mg BID for pain this does not appear to be controlling residents pain as exhibited by resident hollering out more frequently as well as moaning/facial grimacing when being transferred or repositioned in bed. MPOA made aware and is in agreement with this change in patients plan of care. Tramadol to be discontinued once Roxanol is received from pharmacy. 12/19/2023 4:25 PM Resident continues on Cephalexin for UTI. Resident tolerates the medication without difficulty. no adverse reaction noted at this time. fluids are frequently offered and encouraged. Resident has had no c/o pain or discomfort from recent fall. Resident is currently resting in bed. call light and fluids are within reach. Nursing 12/20/2023 1:55 AM Resident continues on Cephalexin for UTI. No adverse reactions noted this shift. Resident has been yelling out this shift. Has been receiving Roxanol as scheduled is somewhat effective. Spit out most of hs medication. 12/20/2023 7:59 AM Spoke with Dr about increasing Roxanol from Q4 to Q2, Dr . agreed POA notified 12/21/2023 9:16 AM Res. unable to take her medications. Dr. notified. New order to d/c meds except for Ativan and Roxanol. 12/21/2023 12:17 PM Resident moaning out and restless in bed, family at bedside and spoke with LPN (LPN name) about resident being uncomfortable . Last administration of Morphine Concentrate 0.25 ml less than an hour. Dr. notified and new order to increase dose to 0.5 ml. Family aware of change. 12/22/2023 8:21 PM Resident continues on Roxanol every 2 hours. Resident noted to be restless and sitting up in her bed this morning during 8 am dose. PT/TO in the resident's room with the recording nurse when resident stated she wanted to get up in wheelchair. Prior to getting up in wheelchair resident drank one cup of coffee, one cup of water, and ate a container to applesauce without difficulty. PT/TO assisted the resident up to wheelchair. Resident helped by standing when transferring to wheelchair. Resident self-propelling some while up in wheelchair. Resident place backed to bed after a few hours. Resident rested well after being up. Roxanol seems to be controlling the resident's pain and discomfort. Resident currently resting in bed with family at bedside. 12/22/2023 10:45 PM Resident continues on Roxanol every 2 hours. Resident noted to be restless but calmed after a position change in bed. Roxanol seems to be controlling the resident's pain and discomfort. Resident currently resting in bed with family members at bedside. 12/23/2023 10:38 PM Roxanol 0.5mls continues as ordered q 2 hrs. Resident seems comfortable. Family was at bedside earlier. 12/25/2023 5:02 PM Called to room by family, resident noted to be absent of vital signs, auscultation revealed no breath sounds or heart sounds, Dr. notified, time of death 1658, family remains at bedside. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed which revealed the following care plan: PROBLEM: Code status GOAL: Residents wishes will be followed during stay. INTERVENTIONS: Allergies: ASA, PCN, Sulfa, Cipro, Ciprodex Does not have decision making capacity Limited Additional interventions IVF for defined trail period of 10 days. No tube feeding. No further documentation of a care plan addressing end of life care was identified. On 10/23/24 at 12:56 PM, an interview was conducted with the facility Director of Nursing (DON). At time, the DON acknowledged: 1. The facility has no policy and procedure related to the provision of Hospice services. 2. While the facility does have a contract with a local hospice provider, the facility failed to inform Resident #158 of this service. 3. Resident #158 was not offered hospice services. 4. No further documentation of end of life care was provided.

. Based on record review and staff interview the facility failed to identify, treat, monitor, and manage the resident's pain to the extent possible in accordance with the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences. This is due to the facility ' s failure to implement a formal pain assessment process and develop a comprehensive, individualized pain management plan. This was true for 1 (one) of 2 (two) resident's reviewed for the Long Term Care Survey Process. Resident identifier: Resident #158. Facility census: 58. Findings included: a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident (FRI) was completed which revealed Resident #158 bumped Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 03:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses: 1. Hallucinations 2. Vascular Dementia with other behavioral disturbance 3. Alzheimer's disease 4. Major depressive disorder recurrent, 5. Delusional disorders 6. Anxiety Medications: 1. Xanax 0.5 milligrams (mg) 1/2 tablet by mouth twice a day 2.Lamictal 200 mg 1 tablet by mouth at bedtime 3. Zyprexa 2.5 mg 1 tablet by mouth once a day 4. Mirtazapine 7.5 mg 1 tablet by mouth at bedtime In addition to the following documentation: 12/18/2023 04:20 PM New order received from Dr. for Roxanol 0.25 mg sublingual Q4hrs for pain, medication is currently on order from pharmacy, resident previously taking Tramadol 50 mg BID for pain this does not appear to be controlling residents pain as exhibited by resident hollering out more frequently as well as moaning/facial grimacing when being transferred or repositioned in bed. MPOA made aware and is in agreement with this change in patients plan of care. Tramadol to be discontinued once Roxanol is received from pharmacy. 12/19/2023 04:25 PM Resident continues on cephalexin for UTI. Resident tolerates the medication without difficulty. no adverse reaction noted at this time. fluids are frequently offered and encouraged. Resident has had no c/o pain or discomfort from recent fall. Resident is currently resting in bed. call light and fluids are within reach. Nursing 12/20/2023 01:55 AM Resident continues on cephalexin for UTI. No adverse reactions noted this shift. Resident has been yelling out this shift. Has been receiving Roxanol as scheduled is somewhat effective. Spit out most of hs medication. 12/20/2023 07:59 AM Spoke with Dr about increasing Roxanol from Q4 to Q2, Dr . agreed MPOA notified 12/21/2023 09:16 AM Res. unable to take her medications. Dr. notified. New order to d/c meds except for Ativan and Roxanol. 12/21/2023 12:17 PM Resident moaning out and restless in bed, family at bedside and spoke with LPN (LPN name) about resident being uncomfortable . Last administration of Morphine Concentrate 0.25 ml less than an hour. Dr. notified and new order to increase dose to 0.5 ml. Family aware of change. 12/22/2023 08:21 PM Resident continues on Roxanol every 2 hours. Resident noted to be restless and sitting up in her bed this morning during 8 am dose. PT/OT in the resident's room with the recording nurse when resident stated that she wanted to get up in wheelchair. Prior to getting up in wheelchair resident drank one cup of coffee, one cup of water, and ate a container to applesauce without difficulty. PT/OT assisted the resident up to wheelchair. Resident helped by standing when transferring to wheelchair. Resident self-propelling some while up in wheelchair. Resident place backed to bed after a few hours. Resident rested well after being up. Roxanol seems to be controlling the resident's pain and discomfort. Resident currently resting in bed with family at bedside. 12/22/2023 10:45 PM Resident continues on Roxanol every 2 hours. Resident noted to be restless but calmed after a position change in bed. Roxanol seems to be controlling the resident's pain and discomfort. Resident currently resting in bed with family members at bedside. 12/23/2023 10:38 PM Roxanol 0.5mls continues as ordered q 2 hrs. Resident seems comfortable. Family was at bedside earlier. 12/25/2023 05:02 PM Called to room by family, resident noted to be absent of vital signs, auscultation revealed no breath sounds or heart sounds, Dr. notified, time of death 1658, family remains at bedside. On 10/23/24 at approximately 9:00 AM, a review of Resident #158's care plan was completed which revealed the following care plan: PROBLEM: Pain. Resident states/exhibits pain related to arthritis, as evidenced by yelling out at times, grimacing at times, and will make verbal statements of pain at times. GOAL: Resident will state/exhibit relief of pain with interventions offered through next review. INTERVENTIONS: Pain med (Roxanol) as ordered for pain. Document effectiveness. Monitor for side effects. Assess pain relief techniques from resident/family and implement non-pharmaceutical measures when possible (gentle rubbing, massage, warm bath, soothing music) Position resident for comfort and reposition as needed. Review of policy and procedure entitled, Pain Management was then completed, which revealed that all patients shall be assessed upon admission and at regular intervals when they voice complaints of pain or non-verbal signs of pain are noted. Assessment of pain should include location, duration, radiation, precipitating and alleviating factors. The physician, primary/charge inures and patient and/or significant others shall collaborate to develop the plan of pain management and the ongoing reassessment of plan. In addition, this policy and procedure reviews Methods of Pain Control and lists them as the following: A. Comfort Measure 1. repositioning 2. massage 3. application of cold or heat B. Behavioral Interventions 1. relaxation 2. distraction 3. imagery C. Medication Alternatives 1. non-steroidal 2. anti-inflammatory 3. narcotics (topical, by mouth, intramuscularly and intravenously) On 10/23/24 at 11:00 AM, a review of Resident #158's Medication Administration Record was conducted which revealed no documentation of pain levels. On 10/23/24 at approximately 12:18 AM, an interview was conducted with the Director of Nursing (DON). At that time, the DON states We only document pain if the resident is getting and as needed pain medication. If the pain medication is scheduled, we don't ask the resident's their pain levels. At that time, this Surveyor asked if non-pharmacological interventions were attempted with resident's prior to using pain medication. The DON responded, Yes. This Surveyor reviewed Resident #158's documentation with the DON who acknowledged no use of non-pharmacological interventions for Resident #158 was documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #15's Physician's Orders for Scope of Treatment (POST) form, Resident #54's activity participation record, Resident #16's administration of the pneumococcal vaccination, and Resident #37's POST form. This was true for four (4) of 18 residents reviewed during the survey process. Resident Identifiers: #15, #54, #16, and #37. Facility Census: 58. Findings Included: a) Resident #15 On [DATE] at 11:00 AM, a record review was completed for Resident #15. The review found the POST form did not include the Preparer's signature and date. On [DATE] at 11:50 AM, the Administrator was notified and confirmed the POST form was incomplete. b) Resident #54 On [DATE] at 4:15 PM, a record review was completed for Resident #54. The review found the Activity Participation record dated 08/24 indicated the Resident was actively participating on the dates of [DATE] through [DATE]. Also, the date of [DATE] had expired written in. The resident was actively dying from [DATE] and expired on [DATE]. On [DATE] at 4:30 PM, an interview was held with the Activities Director #70. The Activities Director was asked, what does the A stand for? The Activities Director #70 stated, A means active. The Activities Director #70 was asked, do you think this document is correct regarding active participation when the resident was actively dying? The Activities Director #70 stated, I can't explain it. On [DATE] at 4:36 PM, the Administrator was notified and confirmed the documentation was incorrect. c) Resident #16 On [DATE] at 3:00 PM, a record review was completed for Resident #16. The review found no indication the resident had received a pneumococcal vaccination. Further review of the record, found under the documents tab, a document labeled Pneumococcal Vaccination and Temperature Record. This document included a signed physician's order to administer the pneumococcal vaccination. This document, also, included the lot number, expiration date, date and time of administration, site, temperature and the signature of the Nurse who administered the vaccination. However, this information was not documented under the immunization tab in the electronic medical record. On [DATE] at 3:30 PM, the Director of Nursing (DON) was notified and confirmed the information was not documented under the immunization tab. The DON stated, no one updated it, I'll fix it now. d) Resident #37 On [DATE] at 11:50 AM, this surveyor evaluated Resident #37 as part of the annual recertification survey. The resident, who is under hospice care, exhibited limited verbal communication, responding only with indistinct sounds. admission records show an entry date of [DATE] and a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. During a review of the resident's chart, the surveyor noted that a signed Provider Orders for Scope of Treatment (POST) form was absent. Documentation of the resident's advance directive was limited to a general notation within the Continuity of Care Documentation, without a formalized directive. At approximately 12:00 PM, in response to a request for the completed POST form, the facility administrator provided a copy signed by the resident's Medical Power of Attorney (MPOA) on [DATE]. However, this form lacked a signature and date from the advising healthcare provider. The administrator confirmed that this was the only advance directive available on file, acknowledging the document's incomplete status. The absence of a healthcare provider's signature on Resident #37's POST form limits the facility's ability to fully honor the resident's healthcare preferences, potentially impacting the delivery of end-of-life care. This deficiency underscores the facility's obligation to maintain complete, accurate, and accessible resident records, as required by CMS standards, to safeguard the integrity of care for residents with cognitive impairments and end-of-life needs. d) Resident #37 On [DATE] at 11:50 AM, this surveyor evaluated Resident #37 as part of the annual recertification survey. The resident, who is under hospice care, exhibited limited verbal communication, responding only with indistinct sounds. admission records show an entry date of [DATE] and a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. During a review of the resident's chart, the surveyor noted that a signed Provider Orders for Scope of Treatment (POST) form was absent. Documentation of the resident's advance directive was limited to a general notation within the Continuity of Care Documentation, without a formalized directive. At approximately 12:00 PM, in response to a request for the completed POST form, the facility administrator provided a copy signed by the resident's Medical Power of Attorney (MPOA) on [DATE]. However, this form lacked a signature and date from the advising healthcare provider. The administrator confirmed that this was the only advance directive available on file, acknowledging the document's incomplete status. The absence of a healthcare provider's signature on Resident #37's POST form limits the facility's ability to fully honor the resident's healthcare preferences, potentially impacting the delivery of end-of-life care. This deficiency underscores the facility's obligation to maintain complete, accurate, and accessible resident records, as required by CMS standards, to safeguard the integrity of care for residents with cognitive impairments and end-of-life needs.

Based on record review and staff interview, the facility failed to ensure incidents of resident to resident abuse were reported to the required State officials (The State Survey Agency, Adult Protective Services and the Ombudsman) for three (3) of three (3) residents reviewed for the care area of abuse/neglect. Resident identifiers: #6, #50 and #10. Facility census: 58. Findings included: a) Resident #6 Record review found the following progress note: 01/15/23 at 4:18 PM, Resident was propelling himself in the service hallway near the kitchen and laundry when resident (room number) touched the back of his wheelchair. (Name of Resident #6) then hit (room number of other Resident #50) on the right side of her body with his left fist proceeded to chase after her trying to knock her down twice. He ran over her right foot causing injury while doing this. He continued to follow her as she was trying to get away from him. This event was witnessed by (Name of nurse aide) Incident was reviewed on camera. This event happened at 3:44 PM. On call APS (adult protective service worker) called to send message to (Name of APS worker) social worker about resident's transfer to (name of hospital) for incident. Doctor provided orders to send to (name of hospital) for psychiatric evaluation. Wound vac disconnected and threatening to pull his g-tube out. b) Resident #50 Progress note from Resident #50's chart on 01/15/23: Resident was ambulating in the hallway and touched the back of male resident's wheelchair. Male resident then hit this resident with his fist and hit her with his wheelchair twice, running over her right foot in the process. Resident observed to have broken skin and redness to top outer side of right foot. No swelling noted at this time, however resident was limping immediately following injury. Resident is currently ambulating in hallway without difficulty at this time, no limping observed. Physician and (Name of power of attorney) POA, notified. Will continue to monitor. On 05/30/23 at 11:42 AM, the facility Social Worker (SW) was asked if the incident regarding Resident #6 and Resident #50 was reported to the required State officials. The SW said, Oh that wasn't Resident #6 that was Resident #5. The SW reviewed the progress notes in Resident #6's chart and then said, you are correct, well then it wasn't reported. b-1) Resident #50 On 04/21/23 at 11:18 AM, a fax copy of the immediate fax reporting of allegations to the nursing home program found the following reportable: Date of incident: 04/20/23, Time: 5:15 PM, Location of incident: Dining room. While having dinner in the dining room, both residents were sitting at the same table being assisted by staff. Resident #50 smacked Resident #10 on her left arm. Staff redirected and separated Residents. (Name of physician) notified. POA's (powers of attorneys) notified. No injury noted . At 2:07 PM on 05/30/23 the SW confirmed the 5 day follow-up report required for the incident involving Resident #50 and Resident #10 was not faxed to the required State officials.

Based on resident interview, staff interview and record review the facility failed to ensure a resident had an activity program that supported the resident's choice of activities. This was a random opportunity for discovery during a complaint survey. Resident identifier: #6. Facility census: 58. Findings included: a) Resident #6 An interview with the resident at 12:45 PM on 05/30/23, found he was in his room, in bed. The blinds were drawn and the lights were out. The resident said he doesn't have anything to do here. He said he occasionally goes outside or will get up in his wheelchair to go out and about the facility. He says if he was at home he would probably play video games and he would like to have an X-Box. He says he likes to watch TV but the, higher ups, have taken his remote control for the television. He said he got mad and threw the last remote at the TV and broke it. He said he got a new TV with his own money but he isn't allowed to have the control so he can't turn it on. He said he likes to socialize with others but most of the residents here can't talk to him. He said the lady across the hallway comes over to talk with him almost daily, She is a sweetheart. He is aggravated with the wandering residents who come into his room. He said, I try to be good to them but it makes me very angry when they start messing with my stuff. If you mess with my stuff, I get really mad. The resident said he once had a cell phone but either it's broken or the, higher ups, took it also. So now he can't use it to call anyone. The resident said he doesn't want to play games like they do here. The activity director is really nice but I'm 43 and most of these people are old and I don't like to do what they do. The resident said he is paralyzed from the waist down but he has use of his arms and can get around the facility once he gets up. Once in a while he goes down for an activity. He said he prefers to stay in bed most of the time because his back hurts if he is up for long periods. I get pain pills and they work but not if I stay up all the time it's too hard on me. I also have leg spasms and it's hard to stay up. Review of the medical record found a progress annual note, dated 04/14/23. The resident has a BIMS (Brief Interview for Mental Status) score of 12. A score of 12 indicates the resident's cognition is moderately impaired. Review of the current care plan found the problem: Resident adjustment to long term care placement. The goal associated with the problem: Resident will exhibit adjustment to long term care placement as evidenced by participation in care and daily routine. Approaches included: Resident will be encouraged to participate in resident council to promote his interests. Resident will be visited by the activity director for activity preferences which will enhance resident satisfaction, whether these are group or in room activities. A second care plan problem: Resident has behavioral symptoms toward others (e.g., throwing things at others, cursing at staff and other residents). Also refuses various care (feeding, turning and repositioning, appts., (appointments) care at times). Has made statements of going to kill himself, was sent for eval (evaluation) and treatment, tells psych that he didn't say that and tells staff that he didn't mean it. Has been known to make sexually inappropriate comments. The goal associated with the problem: Resident will not harm self or others secondary to physically abusive behavior. Approaches included: Is not to have anything within reach that can be used as a weapon. Have call light within reach so that he can call for assistance when he needs something. May not have TV remote or cell phone within reach (these items must be used with supervision and then taken back from him when he is done). Also may not have a soda can. Drink must be poured into a plastic cup. Keep curtain pulled in the center of the room between the two residents. Avoid over-stimulation (e.g., noise, other wandering residents when they enter into room- redirect them). The activity director (AD) was interviewed at 3:00 PM on 05/30/23, to determine the Resident's interests. He's young, always on his cell phone. He likes to watch TV and has his own TV. The AD provided an activity calendar for the month of May 2023, which already had TV in room coded as being watched for 05/30/23. Observation and interview with the Resident found the television has not been on. She said she wasn't aware the Resident did not have his remote control for his television. Review of the activity calendar found the individual activity coded, according to the AD, was talking on his phone or coloring pictures. The surveyor told the AD, the Resident said he doesn't know where his cell phone is because the staff have taken it away. He also said he would be interested in getting an X-Box so he could play video games in his room. The AD said she thought he had money to purchase his own. At approximately 3:20 PM on 05/30/23, the Resident's two (2) nursing assistants (#9 and #16) were interviewed after leaving the Resident's room. Neither of the NA's knew where the remote control for the television or the cell phone was located. They said the resident uses them to throw at staff and he actually broke his own television when he threw the remote control at the TV screen. At 4:05 PM on 05/30/23, the author of the care plan, Minimum Data Set Coordinator, Registered Nurse (RN) #17 said the cell phone and the remote control for the television are in a drawer across from the Resident's bed. He can't get them himself because he can't get out of bed on his own. If he wishes to use them, staff have to get them for him and provide supervision for use of them because he uses them as weapons to hit others with. They should know where they are. At 11:15 AM on 05/31/23, RN #17, the author of the entire care plan was asked what activities Resident #6 would enjoy doing. RN #17 said they had actually talked about getting video games for the Resident, but no one probably documented anything about it.

Based on record review and staff interview, the facility failed to ensure a Resident diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Resident #50 was struck by another resident after wandering into his room. Resident #50 also slapped another Resident on the arm. In addition, the facility failed to follow the psychiatrist's recommendation after the Resident was sent for an evaluation. Resident identifier: #50. Facility census: 58. Findings included: a) Resident #50 Review of the progress notes found the following note, dated 01/15/23: Resident was ambulating in the hallway and touched the back of male resident's wheelchair. Male resident then hit this resident with his fist and hit her with his wheelchair twice, running over her right foot in the process. Resident observed to have broken skin and redness to top outer side of right foot. No swelling noted at this time, however resident was limping immediately following injury. Resident is currently ambulating in hallway without difficulty at this time, no limping observed. Physician and (Name of power of attorney) POA, notified. Will continue to monitor. Progress note from 03/19/23: Resident has been up wandering in facility this shift, redirection required for wandering into other resident's rooms. Resident confused and argumentative with other residents and staff at this time. Resident talking and yelling at others when she is alone. Resident took medication crushed in applesauce. Resident continues Cefdinir for UTI (urinary tract infection) with no adverse reactions noted at this time. Resident took medications crushed in applesauce. Resident is currently resting in bed with call light and fluids within reach and encouraged. Will continue to monitor. A progress note written on 04/20/23: Resident up in dining room during dinner while staff was feeding the resident dinner resident smacked (Resident's room number) on her left arm. Staff redirected resident several times during dinner. resident hard to redirect at times. Resident has also been hitting staff during care and times of redirection. This recording nurse attempted to call POA (Name of POA) but had to leave a message for him to call the facility back. (Name of physician) notified and order a UA C&S. Resident was recently seen by psych. Will call and notify Psych tomorrow during business hours. Progress note from 05/28/23: Resident wandering in and out of rooms . On 03/02/23 the resident was sent for a consultation with a Psychiatrist. The reason for the visit: Has delusions/hallucinations. Screams and yells out at the imaginary people she's talking to. Also screams violently and has combative/resistive behaviors during care. The Psychiatrist increased the Resident's antipsychotic medication to Seroquel to 25 mg's (milligram)in the morning, 25 mg.'s in the afternoon and 75 mg.'s at night. The psychiatrist wrote, We may need to increase this dose further depending on her clinical response . The antidepressant, Remeron 15 mg at bedtime was also added. The psychiatrist directed, I have asked staff at treating facility to give me a status update in 2 weeks regarding these medication changes. The Psychiatrist documented the resident has Dementia, behavioral problems and combativeness. The facility attending physician noted in the initial history and physical the Resident has a diagnosis of Dementia with the onset date of 04/12/21. Review of the care plan found the problem: Resident has physical behavioral symptoms toward others (e.g., hitting, pushing) resists care. Yells out at times. Has delusions and hallucinations. The goal associated with the Problem: Resident will not harm self or others secondary to physically abusive behavior. Approaches included: Provide two 1:1 sessions with resident per week. Avoid over-stimulation Divert resident's behavior by talking with resident, try soothing voice or even singing during care. Maintain a calm environment and approach to the resident. When resident becomes physically abusive, stop and try task later. Do no force task. A second care plan for wandering was: At risk for injury related to potential for wandering. Need for secure guard bracelet to alert staff if resident tries to leave unattended. The goal associated with the problem: Resident will be free from injury related to attempts to exit facility without assistance. Interventions included: Has successfully eloped out of ambulance door before. If seen near any exit doors, redirect. Encourage to sit for rest periods. Wanders throughout the building constantly and has had a weight loss. Does wander around facility and into other resident rooms. Will lie in other resident beds. Redirect when seen wandering into others' rooms. Usually easily redirected. Secure guard bracelet at all times. Check function weekly. At 3:00 PM on 05/30/23, the activity director was asked why types of activities the resident participates in? She stated, It is hard to hold her attention. Review of the activity participation log found the resident was coded as walking in the hallways daily. When asked about the 1 on 1 activities, the activity director provided the following 1 on 1 activity: 05/2/23 walked and chatted 05/05/23 Chatted and walked 05/09/23 Walked, chatted 05/11/23 Walked, chatted 05/16/23 Chatted, walked, looked outside at Courtyard 05/18/23 chatted, walked 05/23/23 Walked, chatted On 5/30/23 at 1:47 PM, the Director of Nursing (DON) said she was unable to find any evidence the Psychiatrist was contacted when the Resident continued to have behaviors. She confirmed the Psychiatrist had asked facility staff to call within 2 weeks to provide a status update. In addition, the Psychiatrist was not contacted after the 04/20/23 incident when the nurse documented a call would be made during normal business hours. The DON was unable to state how the facility works with the Resident to prevent the wandering behaviors. The DON said, Redirection is provided when the Resident wanders.

. Based on record review and staff interview the facility failed to ensure resident to resident altercations resulting in falls and an elopement were reported to the appropriate state agencies within the required time frame. These were random opportunities for discovery during the long-term care survey. Resident Identifiers: Resident #49, Resident # 31, and Resident #27. Facility Census: 58 Findings Included: a) A review of a facility policy titled Resident Abuse/Neglect read as follows: I. POLICY: .to ensure that residents are not subjected to abuse by staff, other residents, consultants, volunteers, staff or other individuals. II. PURPOSE: It is the purpose of this policy to define forms of abuse and neglect in order to facilitate education, recognition and reporting III. DEFINITIONS: Abuse- willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish . Sexual Abuse-includes, but limited to sexual harassment, sexual coercion, or sexual assault. Physical Abuse-includes hitting, slapping, pinching, kicking, pushing, pulling hair, handling rough, angry manner and other related acts against a person. Mental Abuse- includes such actions as humiliation, harassment, threats of punishment or deprivation and so on. .V. Reporting -It is the responsibility of the facility to ensure that all staff are aware of the reporting requirements and support an environment in which covered individuals report a reasonable suspicion of a crime and staff and others report all alleged violations of mistreatment, exploitation, neglect or abuse, including injuries of unknown source, and misappropriate of resident property. -If the events that caused the allegation involved abuse, neglect or result in serious bodily injury, a report is made not later two (2) hours after the center is notified of the allegation VI. Resident to Resident altercations-resident to resident altercations must be reported in accordance with regulations include any willful action that results in a physical injury, mental anguish or pain. VII. Investigation upon the report or discovery of any circumstance noted above the facility, under the direction of the administrator will investigate the concern including observation, interviews, document reviews and all means to determine the events and credibility of the report. The facility will protect residents from harm during the investigation. b) Resident #49 Elopement During a review on 12/13/22, Resident #49's medical records revealed an event report which occurred 06/11/22 at 6:26 PM. Typed as written: Resident exited the facility via ambulance door. Resident pushing on exit door and then hit door with her hip at which time the door opened. Secure guard was working appropriately and staff responded to alarm but was not able to reach resident before she went outside. Upon finding resident outside she was observed sitting on the sidewalk outside of the ambulance door. Resident assisted back into the building by staff. During a further review on 12/13/22 of the reportable grievance/concerns log this event was not reported to the appropriate state agencies. During an interview on 12/14/22 at 10:14 AM, the Director of Nursing (DON) stated, We did not see her elope, we had to watch the video to see what actually happened. During an interview on 12/14/22 at 10:15 AM the Administrator stated, Yes, we were not with her, she was sitting outside but she is fast. She acknowledged, the elopement should have been reported to the appropriate state agencies. During an interview on 12/14/22 at 10:14 AM, the Social Worker (SW) acknowledged the elopement should have been reported to the appropriate state agencies. c) Resident #31 During a review on 12/13/22 at 4:20 PM, Resident #31's medical records revealed a fall on 10/06/22. The event report on 10/06/22 at 8:40 PM type as written read: At approximately 8:5mg, resident let out a shout and began hollering for help. (Name of Nurse Aide) informed this nurse that resident was in the floor on A hall. Resident was found laying on left side and holding her head on the left side. Red knot noted to top of residents head on left side. Pupils round and reactive. Alert with confusion per baseline. ROM (range of motion) x (times) 4 WNL (within normal limits), but has been holding left hip and c/o (complaints of) pain to area. Resident assisted to WC (Wheelchair). Cameras replayed, resident got up from WC attempting to get away from resident in room A7-2 and lost balance, hitting left side of head directly against wall. Resident then landed on left side of body. Ice pack applied to bump on head x20 mins. Dr notified. Orders to send to (Name of local hospital) for evaluation. POA (Power of Attorney) notified. A review of the local hospital discharge summary on 10/06/22 revealed Resident #31 had a closed head injury and contusion of the scalp. During a further review on 12/13/22 of the reportable grievance/concerns log found, this event was not reported to the appropriate state agencies. During an interview on 12/14/22 at 10:14 AM the Director of Nursing (DON) stated, We did not see her fall, we had to watch the video to see what actually happened. During an interview on 12/14/22 at 10:15 AM the Administrator stated, Resident #49 who caused Resident #31 to fall is demented and combative. She acknowledged the fall should have been reported to the appropriate State agencies. During an interview on 12/14/22 at 10:14 AM the Social Worker (SW) acknowledged the fall should have been reported to the appropriate State agencies. d) Resident #27 During a review on 12/13/22 Resident #27's medical record revealed a fall on 09/18/22 at 9:14 PM. The event report on 09/18/22 typed as written read as follows: (Name of Nurse Aide (NA)) reported that (Name of Resident #27) was in the floor of another resident's room, she stated that she was in a room across the hall and observed resident lying on her back in the floor. Upon entering the room resident was observed still lying on her back on the floor. Resident reports that she hit her head and c/o pain in the back of her head, no bumps or knots noted at this time. Resident initially c/o back pain as well but then denied back pain prior to going to the ER (Emergency Room) for evaluation. Resident VS(vital Signs) - BP (blood pressure): 138/78, R (respirations): 18, O2 (Oxygen): 97% on RA (Room Air), T(temperature): 97.3. (Name of Resident #27) reports that another resident had come into her room and took her belongings, she then followed her into another resident's room where (Name of Resident #27) states the (Resident #49) threw me in the floor;. Resident transferred to (Name of Local Hospital) for evaluation d/t (due to)hitting her head and c/o pain. No visible signs of injury observed at this time Dr.(doctor) and representative notified. A review of the local hospital discharge summary on 09/18/22 revealed an acute cervical myofascial strain, acute thoracic myofascial strain and acute lumbar myofascial strain. The CT (Computerized Tomography Scan) of the head, neck, thoracic spine and lumbar spine and bony pelvis did not show any acute fractures or dislocations. On 12/13/22 the reportable grievance/concerns logs were reviewed and found, this event was not reported to the appropriate state agencies. During an interview on 12/14/22 at 10:14 AM the Director of Nursing (DON) stated, We did not see her fall, the Resident said another Resident threw her on the floor. During an interview on 12/14/22 at 10:15 AM the Administrator stated, Resident #49 who may have caused the injury is demented and combative. She acknowledged the fall should have been reported to the appropriate State agencies. During an interview on 12/14/22 at 10:14 AM the Social Worker (SW) acknowledged the fall should have been reported to the appropriate State agencies. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interviews, and the guidance of the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure Resident #50, received pressure ulcer care, consistent with professional standards of practice. Specifically, the facility failed to monitor and access the existing pressure ulcers weekly. This was true for one (1) of one (1) resident investigated for pressure ulcers. Resident Identifier: #50. Facility census was 58. Findings included: a) Resident #50 Review of Resident #50's medical records found the resident was admitted to the facility on [DATE] at 6:25 p.m., diagnoses included pressure ulcer to right buttocks, bipolar disorder, intellectual disabilities, seizure disorder, paraplegia from a fall from a cliff resulting in a fracture of the thoracic and the cervical spine with surgical intervention. Review of the admission Minimum Data Set (MDS) assessment, dated 04/04/22, revealed a Brief Interview for Mental Status (BIMS) for Resident #50, the score was eleven (11) out of 15, which indicated moderately impaired cognition. The resident's functional status for bed mobility was extensive assistance. The MDS assessment documented Resident #50 had a stage IV (4) pressure ulcer on the coccyx and the resident was high risk for the development of new pressure ulcers. Review of Resident #50's Clinical admission Documentation including admission Body Observation, which revealed a stage IV (4) pressure ulcer on the coccyx area with a wound vacuum in place, excoriation to the groin area, two (2) blisters noted to inner right heel, and a scab to the outer right ankle. Nurses note dated 03/25/22 at 8:24 pm read: .Resident has a stage 4 pressure ulcer to coccyx area tunnelling approximately 10 centimeters (cm) to the upper right, 2 open areas that tunnel to meet, 3-4 cm deep.excoriation to groin area . No documentation was found for the two (2) blisters on inner right heel and the scab on the outer right ankle. Pressure ulcer documentation completed by Employee #83, Registered Nurse (RN) on 03/29/22 at 6:23 pm, found stage 4 pressure ulcer coccyx/buttocks area with tunneling, a moderate amount of serosanguinous drainage noted with no odor. Wound bed is beefy red, some white tissue noted, area has two surface openings. Upper opening is approximately 15 cm and lower opening is approximately 3 cm. Area tunnels together with tunneling upward towards the back of the wound approximately 4 cm. Depth is approximately 3.5 cm in lower opening and 2.5 cm in upper opening. Wound edges are intact with pink tissue noted. Wound vacuum applied as ordered. Review of Pressure Ulcer Documentation forms from 04/01/22 through 12/12/22 found the following: --04/13/22-Stage 4 pressure ulcer to coccyx/buttocks. --04/27/22- Stage 4 pressure ulcer to coccyx/buttocks. --05/13/22- Stage 4 pressure ulcer to coccyx/buttocks. --05/25/22- Stage 4 pressure ulcer to coccyx/buttocks. --06/21/22- Stage 2 pressure ulcer to left outer ankle- scab and black tissue gone. Wound bed shows granulation tissue. -- 06/22/22- Stage 4 pressure ulcer to coccyx/buttocks. -- 06/29/22- Stage 4 pressure ulcer to coccyx/buttocks. --06/29/22- Unstageable pressure ulcer left heel- area was blistered and now hardened black eschar tissue. --06/29/22- Unstageable pressure ulcer right heel- area was blistered and now hardened black eschar tissue. --06/29/22- Stage 2 pressure ulcer to right outer ankle- scab and black tissue gone. Wound bed shows granulation tissue. --07/19/22- Stage 4 pressure ulcer to coccyx/buttocks. --08/09/22- Stage 4 pressure ulcer to coccyx/buttocks. --08/09/22- Unstageable pressure ulcer right heel- area was blistered and now hardened black eschar tissue. --08/09/22- Unstageable pressure ulcer left heel- black eschar tissue gone. --08/09/22- Stage 2 pressure ulcer to right outer ankle- scab and black tissue gone. Wound bed shows granulation tissue. --08/17/22- Stage 4 pressure ulcer to coccyx/buttocks. --08/17/22- stage 2 pressure ulcer right heel- hardened black eschar tissue gone. --08/17/22- Unstageable pressure ulcer left heel- --08/17/22- Stage 2 left ankle --08/17/22- Stage 2 pressure ulcer to right outer ankle- scab and black tissue gone. Wound bed shows granulation tissue. --08/26/22- stage 2 pressure ulcer right ankle. --09/20/22- Stage 2 pressure ulcer right outer ankle. --09/20/22- Stage 2 pressure ulcer left ankle. --09/20/22- Stage 2 pressure ulcer right heel. --09/20/22- Stage 2 pressure ulcer left buttocks. --09/20/22- Stage 4 pressure ulcer to coccyx/buttocks. --09/20/22- Stage 2 pressure ulcer to back of left lower leg. --10/20/22- Stage 2 left buttocks --10/25/22- Stage 2 back of left lower leg. --10/25/22- Stage 2 right heel --Out of facility from 11/04/22 through 11/14/22 The above-mentioned Pressure Ulcer Documentation forms does not contain the width, length, and depth of the pressure ulcers. Review of the Weekly Pressure Injury/Ulcer Record found these forms were initiated on 09/25/22: --09/25/22- Left outer ankle-Stage 2 measures 2 cm in length and 1.8 cm in width and 0.1 cm in depth. --09/25/22- Sacrum-Stage 4 measures 6 cm in length and 4.5 cm in width and 1.2 cm in depth. --09/25/22- Left Buttocks-Stage 2 measures 1.2 cm in length and 1 cm in width and 0.1 cm in depth --09/25/22- Right Heel-Stage 2 measures 2.8 cm in length and 2 cm in width and 0.1 cm in depth --09/25/22-- Left lower leg-Stage 2 measures 11 cm in length and 2.4 cm in width and 0.1 cm in depth. --09/25/22- Right Ankle-Stage 2 measures 2 cm in length and 2 cm in width and 0.1 cm in depth --10/06/22- Left outer ankle-Stage 2 measures 1 cm in length and 1 cm in width and 0.1 cm in depth. --10/06/22- Sacrum-Stage 4 measures 5.8 cm in length and 4.2 cm in width and 1 cm in depth. --10/06/22- Left Buttocks-Stage 2 measures 1 cm in length and 0.4 cm in width and 0.1 cm in depth --10/06/22- Right Heel-Stage 2 measures 2.4 cm in length and 1.6 cm in width and 0.1 cm in depth --10/06/22-- Left lower leg-Stage 2 measures 10 cm in length and 2.2 cm in width and 0.1 cm in depth. --10/06/22- Right Ankle-Stage 2 measures 1 cm in length and 1 cm in width and 0.1 cm in depth --10/11/22- Left outer ankle-Stage 2 pressure ulcer healed. --10/11/22- Sacrum-Stage 4 measures 6 cm in length and 4.5 cm in width and 1.2 cm in depth. --10/11/22- Left Buttocks-Stage 2 measures 0.1 cm in length and 0.1 cm in width and 0.1 cm in depth --10/11/22- Right Heel-Stage 2 measures 2.2 cm in length and 1.8 cm in width and 0.1 cm in depth --10/11/22-- Left lower leg-Stage 2 measures 8 cm in length and 2 cm in width and 0.1 cm in depth. --10/11/22- Right Ankle-Stage 2 pressure ulcer healed --10/20/22-- Left lower leg-Stage 2 measures 4.8 cm in length and 1.2 cm in width and 0.1 cm in depth. --10/20/22- Sacrum-Stage 4 measures 6 cm in length and 5 cm in width and 1 cm in depth. --10/20/22- Right Heel-Stage 2 measures 2 cm in length and 1.8 cm in width and 0.1 cm in depth. --10/20/22- Left Buttocks-Stage 2 pressure ulcer healed. --10/25/22-- Left lower leg-Stage 2 measures 2 cm in length and 2.2 cm in width and 0.1 cm in depth. --10/25/22- Sacrum-Stage 4 measures 6 cm in length and 4.2 cm in width and 1 cm in depth. --10/25/22- Right Heel-Stage 2 measures 2 cm in length and 1.8 cm in width and 0.1 cm in depth. --11/03/22-- Left lower leg-Stage 2 measures 2 cm in length and 2.2 cm in width and 0.1 cm in depth. --11/03/22- Sacrum-Stage 4 measures 4.2 cm in length and 4 cm in width and 0.1 cm in depth. --11/03/22- Right Heel-Stage 2 measures 1.2 cm in length and 1 cm in width and 0.1 cm in depth. --11/15/22-- Left lower leg-Stage 2 measures 2 cm in length and 1.5 cm in width and 0.1 cm in depth. --11/15/22- Sacrum-Stage 4 measures 2.2 cm in length and 2 cm in width and 0.1 cm in depth. --11/15/22- Right Heel-Stage 2 pressure ulcer healed. --11/22/22-- Left lower leg-Stage 2 measures 2 cm in length and 1.2 cm in width and 0.1 cm in depth. --11/22/22- Sacrum-Stage 4 measures 2.2 cm in length and 2 cm in width and 0.1 cm in depth. --12/01/22-- Left lower leg-Stage 2 measures 2 cm in length and 1.5 cm in width and 0.1 cm in depth. --12/01/22- Sacrum-Stage 4 measures 2.1 cm in length and 2.1 cm in width and 0.1 cm in depth. --12/08/22-- Left lower leg-Stage 2 measures 1.8 cm in length and 1 cm in width and 0.1 cm in depth. --12/08/22- Sacrum-Stage 4 measures 2. cm in length and 2 cm in width and 0.1 cm in depth. Interview with the Director of Nursing (DON) on 12/13/22 at 1:46 pm, verified the documentation on the pressure ulcer documentation did not contain the measurements (length, width and depth) also did not contain the onset date. She acknowledged the resident had developed multiple pressure ulcers since admission. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview and resident interview the facility failed to address Resident #49's dementia care needs, resulting in the resident's inability to achieve her highest level of functioning and maintain her psychosocial well-being. Resident identifiers: #49. Facility census: 58. Findings Included: a) Progress Notes regarding Resident #49's behaviors affecting other residents. During a record review on 12/13/22 Resident #49 medical record revealed the following progress notes: -10/18/2022 at 6:57 AM Typed as writtenResident went into room A11-2. Scratched resident in bed 11-2 on arm. Resident redirected back into own room. -10/13/22 at 2:33 PM typed as written Resident has been going in resident rooms on b hall. These residents have yelled at her to get out. Some resident's are scared of her. Resident is very difficult to redirect -10/09/22 at 3:43 PM typed as written RESIDENT WAS ROAMING FROM ROOM TO ROOM , PICKING UP PERSONAL BELONGINGS, COMBATIVE WHILE TRYING TO REDIRECT , RESIDENT WAS PUSHING ANOTHER RESIDENT IN ROOMA12/1 AND RESIDENT WAS YELLING BECAUSE SHE WAS SCARED OF HER, CNA (Name Redacted to ensure privacy) INTERVENED TRIED TO GET HER TO STOP -10/07/2022 at 12:11 AM Typed as WrittenResident has been very combative and noncompliant this shift. Has been wandering in and out of numerous residents rooms and taking their belongings- in doing so, multiple residents have become upset and making complaints. Resident becomes combative and yells at staff when redirection is attempted. Resident attempted to pull resident from A17-1 out of bed- resident A17-1 began hollering for help. When this nurse attempted to intervene, resident (Last name of Resident #49) hit nurse in face with a stolen shoe. At another time, resident was trying to push resident B19-1 in her WC, resident was trying to get away but could not. Resident B19-1 then stood up from WC to get away, lost balance, and hit her head against the wall- nurses sent resident B19-1 to local ER for evaluation. (Resident #49's name) was attempting to get resident B19-1 up from ground when she fell- resident B19-1 began yelling for help and yelling at resident (Name of Resident #49) to go away. Event caught on camera. -09/16/22 at 6:20 PM typed as written resident took coke from another resident and threw it on the other resident resident was not easy to redirect was hitting cna. -08/16/2022 at 6:30 PM typed as written Resident took the drink cart at suppertime from the end of the B hall at supper time. Resident was pushing it towards the back of a resident sitting in the hallway. Recording nurse attempted to redirect the resident who had a hard grip on the cart. Let go of the cart and walked by recording nurse then turned around and beat recording nurse on the back several times open palmed. -08/16/22 at 11:57 PM typed as written Resident had found a dirty brief out of a trash bag and was rubbing it on A15-2. Resident gave dirty brief with encouragement began pushing recording nurse who had the trash bag into the soiled room. Resident was taking the thermometer off of the vital machine. Took hand sanitizer off of the med cart. -07/01/22 at 3:30 AM typed as written Resident smacked resident A12-2 in face. This occurred because, Resident A12-2 didn't want to be pushed in wheel chair and told this resident to stop. Redirected resident. -05/23/22 at 6:49 PM typed as written Resident hit resident A17-2 in the face during activities this evening. Resident was trying to take A17-2 resident's walker and bag. Staff separated the residents. Resident was redirected by staff. resident is currently up walking facility. safety precautions are in place. will continue to monitor. -05/16/22 at 11:38 PM typed as written This nurse and CNA responded to yelling from (resident #35's name). Upon entry we see (resident #49's name) ripping blankets off the bed and throwing items from the bedside tables. (Resident # 49's name) was hitting and kicking staff. We escorted (Resident #49's name) out of the room. In the hallway resident lifted her feet and this nurse and CNA had to sit resident into the floor. Resident then began to crawl around whispering to the floor. Currently up roaming the facility. Will continue to monitor behaviors. -04/27/22 at 6:22 PM typed as written Resident hit resident room A12-1 upside the head for being in her way. Staff quickly redirected residents. Will continue to monitor. -04/15/22 at 9:45 PM typed as written Resident was found in room A1 above resident in bed B ( a Male Resident) of that room completely nude, touching and grabbing on resident. When CNA tried to redirect resident out of room and get resident dressed resident became combative with staff. Staff finally got resident dressed and assisted her out of the room. Resident then wandered around facility going in and out of other residents room. Redirection was used as needed. Will continue to monitor and inform on coming nurse of this situation. b) Progress notes regarding Resident #49's causing other residents to react negatively toward her. -- 05/23/22 at 2:44 PM- . Resident was cussing and saying he was going to gut her like a deer and if she comes back in here, someone better call 911 cause I'm going to kill her resident was talking about (Name of Resident #49) who had come in his room over the weekend . - 05/30/22 at 4:56 PM-(Name of Resident #49) was wandering into his room and he threw a can of soda at her and when asked why he threw it at her, he said he was tired of people coming in his room. --09/13/22 at 10:18 PM- (Name of Resident #49) was coming out of this resident's room dripping wet with a sticky liquid. Hair, face, and clothes were all dripping wet. This resident's bed, sheets, and floor were all wet. This resident stated he threw 2 cups of tea all over her. Resident is smiling and laughing when he talks about what he did. --09/17/22 at 10:37 PM- Resident threw water on (Name of Resident #49). He stated, I didn't want her in my room, and she wouldn't leave when I told her. c) Resident Interviews During an interview on 12/14/22 at 10:50 AM, Resident #54 stated, (Name of Resident #49) came into the room and took my roommates tissues and she chased after her. Then she was pushed by (Name of Resident #49). She hit her head and had to go to the hospital. I am afraid she will hit me, she comes into our room all the time. You just have to keep your distance to feel safe. During an interview on 12/14/22 at 10:55 AM, Resident #52 stated I am afraid of (Name of Resident #49) hitting me. During an interview on 12/14/22 at 10:56, AM, Resident #16 stated (Name of Resident #49) has grabbed me before, I am afraid of her. During an interview on 12/14/22 at 10:57 AM, Resident #20 stated (Name of Resident #49) will grab people, I am afraid she is going to hurt someone. During an interview on 12/14/22 at 10:58 AM, Resident #44 stated I am not afraid of (Name of Resident #49), if she ever hits me then I hit her back. I don't think she should be there, people don't feel safe. d) Resident Council Meeting During the Resident Council meeting held 12/13/22 at 10:10 AM the group as a whole was asked the following question: Do you have anyone wandering in your rooms? Their responses included: -We have a few that wander into our room and run the hall ways all hours of the night. -We have one that steals your stuff (Resident #49's name). -(Resident #49's name) will get in bed with you , pull all the covers off your bed in the middle of the night while you are trying to sleep. - (Resident #49's name) I am afraid of her, she will hit people and slap them. -I am afraid of being hit by (Resident #49's Name). -I have never been hit or slapped by (Resident #49's Name), but I'm very afraid. I just try to stay my distance. - I am so scared of her, she has grabbed my arm. e) Psychiatrist Consults During a review on 12/13/22 Resident #49's medical record revealed psychiatric consults for the follow days: -On 04/25/22 the consult had the following medications suggestions ~lower Citalopram 10mg daily ~increase Klonopin 0. 5mg three times a day (TID) ~increase Seroquel 50mg TID ~Add Aircept 5mg daily ~Add Depakote 250 mg twice a day (BID) During a review of Resident #49's physician orders revealed no order for the Aircept. -On 08/31/22 the telehealth visits note typed as written Telehealth completed with Dr. [NAME]. Medications and behaviors reviewed. Dr. [NAME] discussed increasing frequency of klonopin, explained that klonopin was decreased due to resident sleeping so much and having decreased food intake while taking klonopin TID. No changes to medications ordered at this time. Will continue to monitor and redirect as needed. f) Social Services Notes During a review on 12/13/22 Resident #49's medical record revealed a Social Services note dated 08/25/22 at 1:21 PM. The Annual Note: is typed as written .Numerous behaviors such as in other people rooms, pushing people in there wheelchair and not wanted. Combative with care and redirection is getting harder. g) Staff Interviews During an interview on 12/14/22 at 10:18 AM the Administrator stated, we have sent Resident #49 to the Psychiatrist, we have had 1:1 with her. We don't know what to do with her. When asked why they did not follow the Psychiatrist recommendations for medication changes on 12/13/22, the Administrator was unaware of the recommendation was not being followed. An interview on 12/14/22 at 12:36 PM, with the consulting Pharmacist, found he is in the facility monthly. I send my recommendations within a week or two. I meet with the Administrator, Director of Nursing and we review anyone that has behaviors. Resident #49's name has not came up in the last month. I look at the Psychiatrist consult if they are scanned into the chart. I look at Psychiatrist recommendations and talk to our facility physician about the recommendation and see why he think its not needed. The doctor does not want the residents on Aircept due to side effects like weight loss. No further information was provided from facility regarding nonpharmalogical interventions to address and/or attempt to prevent Resident #49's behaviors which infringe on the rights of others and for her protection from other residents as a result of her behaviors toward others. .

. Based on medical record review and staff interview, the facility failed to ensure a resident's Physician's Order for Scope of Treatment (POST) form conveying end of life wishes was complete. This was true for one (1) of 16 residents reviewed during the long-term care survey process. Resident identifier: #40. Facility census: 58. Findings included: a) Resident #40 Review of Resident #40's medical records revealed a Physician's Order for Scope of Treatment (POST) form dated 09/10/20. The responsible party completed the POST form and checked the box indicating intravenous (IV) fluids were desired. The POST form required a specific time period to be completed regarding how long IV fluids would be provided. The time period was not specified on the POST form. The area was blank. On 09/08/21 at 12:39 PM, the Director of Nursing (DON) verified the POST form did not contain any direction for the time frame for which IV fluids would be administered. The DON stated the POST form had been completed at another facility. No further information was provided through the completion of the survey. .

. Based on record review and staff interview, the facility failed to ensure residents received dialysis treatment and care in accordance with professional standards of practice. Two (2) of two (2) residents reviewed for the care area of dialysis did not have physician's orders to receive dialysis. Resident Identifiers: Resident #105 and #36. Census: 58 Findings included: a.) Resident #105 A record review noted a progress note, dated 09/07/21, showing Resident #105 attended dialysis three times a week on Monday , Wednesday and Friday. Further review of physician's orders showed no physician's order for the dialysis treatment. An interview, with the Assistant Director of Nursing (ADON), on 09/08/21 at 09:38 AM, verified Resident #105 was going to dialysis on Monday, Wednesday and Friday but confirmed there was no physician's order for the dialysis treatment. b) Resident #36 Review of Resident #36's progress notes revealed the resident received dialysis treatments. However, the physician's orders did not contain an order for dialysis. During an interview on 09/08/21 at 12:35 PM, the Director of Nursing (DON) confirmed Resident #36 was receiving dialysis treatments but did not have a written physician's order for dialysis services. On 09/08/21 at 3:30 PM, the DON presented evidence that a physician's order for dialysis services had been written for Resident #36. .

. Based on observation, facility documentation review and interview, the facility failed to provide menu items to meet the resident's choices including nutritional needs and preferences for one (1) of 16 residents reviewed during the long term care process. Resident Identifier: Resident #105 Findings included: a) Resident #105 During a resident interview, on 09/07/21 at 11:26 AM, Resident #105 expressed a concern the facility served items on the meal trays that was not in accordance with the renal diet the resident adhered to. Resident #105 stated potatoes were not permitted on his diet and were often served and placed on the tray. It was also stated, this had been discussed with the facility but potatoes continued to be served. A meal observation, on 09/07/21 at 12:12 PM, revealed Resident #105 had potatoes served for the lunch meal. Resident #105 showed the surveyor the potatoes that were served and stated I am not supposed to have them and left the potatoes uneaten. A review of the tray card for Resident #105 , on 09/08/21 at 11:40 AM, noted Resident #105 was not to receive tomatoes, potatoes, bananas, or orange juice. An interview with the Director of Nursing (DON) on 09/08/21 at 11:50 AM , confirmed Resident #105 should not have received potatoes on the meal tray. .

. Based on observation and staff interview the facility failed to store and prepare foods in a safe and sanitary manner. During the kitchen tour it was discovered, food was not dated after opening and a mop bucket had not been stored improperly after usage. These failed practices had the potential to affect a limited number of residents. Facility census: 58 Findings included: a) Kitchen tour During the kitchen tour on 09/07/21 at 11:10 AM, it was discovered in the walk-in freezer, three (3) single opened packages of corn dogs, broccoli, and mozzarella cheese sticks, which were not dated after opening. In addition, clean dishware was air drying near an industrial mop bucket, which had not been stored properly after using. These failed practices did not ensure food was being prepared in a safe and sanitary manner. On 09/07/21 at 11:10 AM, the Dietary Manager, verified the corn dogs, broccoli, and cheese sticks were not dated after opening. He also agreed the dishware had been air drying too close to the mop bucket, which had not been stored properly after using. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide advanced notice of beneficiary protection notifications when the facility determined that the residents no longer qualified for Medicare Part A services and Medicare benefit days remained for three (3) of three (3) residents and/or resident representatives reviewed during a recertification survey. Resident's #255, #52, and #53 did not receive advanced notices of termination of services. Two (2) residents received the notice on the day of termination. The third resident received notice four (4) days after being terminated from services. Resident Identifiers #255, #52 and #53. Facility census 58. Findings Included: a) Resident #255 A record review of Beneficiary Protection Notification revealed, Resident #255 had a Medicare Part A service with last covered day on 06/04/21, the NOMNC ( Notice of Medicare Non-Coverage) was signed 06/04/21 by the Resident Representative. Resident #255 discharged home on [DATE]. b) Resident #52 A record review of Beneficiary Protection Notification revealed, Resident #52 had a Medicare Part A service with last covered day on 05/21/21, the NOMNC was signed 05/26/21 by the Resident Representative. Resident #52 remains in the facility. c) Resident #53 A record review of Beneficiary Protection Notification revealed, Resident #53 had a Medicare Part A service with last covered day on 05/05/21, the NOMNC was signed 05/05/21 by the Resident Representative. Resident #53 remains in the facility. During an Interview on 09/08/21 at 11:30 AM the Social Service Director (SWD) #47 stated that the facility was unable to provide any documentation that the NOMNC was issued in advance to the identified residents or the resident representatives for Resident's #255, #52, or #53. The SWD #47 also stated that she used to send a return receipt, but it was costing $7.00 a letter. She stated that she was told by the facility it was too expensive and was told to stop doing the return receipts for the NOMNC's. .

. Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed or obtained. This practice affected three (3) of sixteen (16) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier's #45, #26 and #54. Facility census: 58. Findings Included: a) Resident #45 A medical record review revealed, Resident #45 was receiving Hospice Services starting on 04/24/21. A continued record review of physician's orders revealed, Resident #45 had no active order for Hospice Service. During an interview with the Director of Nursing (DON) on 09/08/21 at 03:15 PM, she verified that Resident #45 was receiving Hospice Services and had no current order. She stated that she will enter an order now. The DON provided me a copy of the new Hospice order entered on 09/08/21. b) Resident #26 An observation on 09/08/21 at 11:23 AM, found Resident #26 (R #26) sitting in a wheelchair (w/c) in activities with a seat belt alarm around her waist and a tab alarm hooked to her shirt. A review of the Resident #26's physician orders revealed three (3) safety alarm orders: --May sit in w/c with E-Z belt, with a start date 07/21/21. --Tab alarm at all times except in w/c with E-Z belt, with start date 07/21/21. --Pressure sensitive alarm at all times except when in w/c with E-Z belt, with start date 07/21/21. A second observation on 09/09/21 at 09:45 AM, found Resident #26 up in her w/c in group activities. She had a seat belt alarm around her waist and a tab alarm hooked to her shirt. An interview on 09/09/21 at 09:50 AM with nursing assistant (NA) #72 verified, resident #26 was wearing a E-Z seat belt and a tab alarm at this time and the seat belt and tab alarm were actively working at this time. On 09/09/21 at 10:02 AM, the findings were discussed with the DON. She verified Resident #26 should only have the E-Z belt in place when she is up in her W/C. She stated that she was going to take the tab alarm off at this time. No further information was provided to the surveyor prior to the exit of the annual survey on 09/09/21 at 1:45 PM. c) Resident #54 An observation, on 09/08/21 at 09:45 AM, revealed Resident #54 ambulating with a walker down the hallway past the nurses desk with a therapy aide walking with the resident and pulling the resident's wheelchair. A seat alarm was observed in the chair. A record review, on 09/08/21 at 09:45 AM , showed no order for Resident #54 to have a seat alarm. At this time, the Assistant Director of Nursing (ADON) was interviewed, and verified the seat alarm present in the chair and verified there was no order. During the interview, it was revealed by the ADON, the staff thought Resident #54 had an order for the alarm to be used. An interview, on 09/09/21 at 10:06 AM, with the Director of Nursing (DON), confirmed no order was written for Resident #54 to have an alarm in the chair. .

. Based on medical record review, and staff interview, the facility failed to ensure medications were stored in accordance with currently accepted professional principles. This failed practice had the potential to affect residents receiving items from the medication storage room. Facility census: 58. Findings included: a) Medication storage and labeling facility task On 09/09/21 at 11:09 AM, inspection of the first-floor medication room was made. Registered Nurse (RN) #45 was in attendance. During inspection, two (2) tubs of silver sulfadiazine medication ointment were found to be stored under the sink to the right of entering the room. Needles, lancets to obtain blood for glucose monitoring, and individual packets of lid scrub cleaning pads were found to be stored under the sink to the left of entering the room. RN #45 was informed medication and equipment could not be stored in the cabinet area under the sink. This area is not considered a dry, clean storage area due to possible leaks or condensation from the sink pipes. RN #45 stated she would ensure the items were removed from under the sinks. No further information was provided through the completion of the survey. .

. Based on observation and staff interview the facility failed to ensure the ice machine was in safe operating condition. It was discovered during the kitchen tour, the ice machine had no air gap between the drainage pipe and the floor drain This failed practice had the potential to affect any resident receiving ice from the machine. Facility census: 58 Findings included: a) Kitchen tour During the kitchen tour on 09/07/21 at 11:10 AM, it was discovered the drainage pipe to the ice machine was in direct contact with the floor sewage drain. There was no visible evidence of one (1) to three (3) inch air gap between the drainage pipe and the floor drain. No air gap between the drainage pipe and the floor sewage drain did not allow for the prevention of possible back flow from the sewage drain. This failed practice could not ensure any ice being produced by this machine was sanitary. In an interview and observation with the Nursing Home Administrator (NHA) on 09/08/21 at 11:15 AM, verified the drain pipe was in direct contact with the floor drain and there was no visible air gap. It was also discussed how not having the proper air gap could allow for back flow from the sewage drain. .