Ralls Nursing Home

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, interviews and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #1), reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when MA B administered Tegretol 200mg (prescribed for seizures, bipolar disorder, and nerve pain), Lipitor 40mg (prescribed to lower cholesterol), Baclofen10mg (muscle relaxer), Metoprolol 25mg (prescribed to lower blood pressure), Neurontin 300mg (prescribed for seizures and nerve pain), Quetiapine Fumarate 200mg (medication prescribed for bipolar disorder and schizophrenia) to Resident #1 on 10/13/25, when these medications were prescribed to another resident. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.Findings Included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease with early onset (loss of cognitive functioning), essential hypertension (high blood pressure), cognitive communication deficit (inability to communicate clearly), Intermittent Explosive Disorder (mental health condition characterized by sudden, intense episodes of anger or aggression), psychotic disorder with hallucinations due to known physiological condition (mental health disorder), dry eye syndrome of bilateral lacrimal glands (dry eyes), acute atopic conjunctivitis, right eye (infection in the eye), and muscle weakness . Record review of Resident #1's annual MDS, dated [DATE] revealed a BIMS score of 99, which indicated the resident's cognitive status could not be determined using the BIMS assessment. Record review of Resident #1's physician orders dated 10/16/25, did not reveal orders for Tegretol 200mg, Lipitor 40mg, Baclofen10mg, Metoprolol 25mg, Neurontin 300mg, Quetiapine Fumarate 200mg. Record review of physician orders did not reveal any new orders regarding the medication error. Record review of Resident #1's Medication Administration Record, dated 10/01/25-10/31/25, did not reveal physician ordered medications for Tegretol 200mg, Lipitor 40mg, Baclofen10mg, Metoprolol 25mg, Neurontin 300mg, Quetiapine Fumarate 200mg. Record review of Resident #1's Medication Error Report, dated 10/13/25, revealed Resident #1 was given the wrong medication on 10/13/25 at 15:20 (3:30 PM). Record review of Progress notes dated 10/13/25, revealed in part, on 10/13/25 the ADON noted she was advised by MA B that he had given Resident #1 the wrong medications at 15:20 (3:30PM). Record review of Progress notes dated 10/13/25, revealed in part, on 10/13/25 the LVN A noted she was instructed to contact emergency medical services to have Resident #1 transferred to the local hospital at 21:45 (9:45PM). Record review of hospital records, dated 10/14/25, revealed Resident #1 was admitted into the hospital for close monitoring. During an interview on 10/16/25 at 09:30 AM, the ADM said MA B gave Resident #1 the wrong medications. The ADM said the MD was notified and instructed staff to monitor the resident but later instructed staff to send Resident #1 to the hospital. The ADM said Resident #1's vitals were stable when EMS arrived, however Resident #1 was transferred to the hospital as per physician orders. The ADM said Resident #1 returned to the facility on [DATE] with no additional orders. During an observation and interview on 10/16/25 at 11:40 AM, Resident #1 was observed rolling up and down the facility hallways holding a shirt. She said she was doing good. She said she needed a shirt for work and then she rolled away. Resident #1 was active and alert. During an observation and interview on 10/16/25 at 2:48 PM, Resident #1 was observed at the nurse station talking with staff. During an interview on 10/16/25 at 3:45 PM, MA B said Resident #1 was having behaviors and hollering in the dining room when he was passing out medications. He said he was parked with the medication cart in front in the nurses station when the ADON brought Resident #1 by the nurse station. MA B said he became irritated as he had verbalized before that he did not like when they set the residents around him when he prepared medications because it caused him to become distracted. He said he mistakenly gave Resident #1 the wrong medications. He immediately realized the mistake and reported it to the ADON and the DON. During an interview on 10/16/25 at 4:26 PM, the ADON said she was in the medication room when she heard Resident #1 hollering. She said Resident #1 indicated she wanted to be moved to the area by where the medication cart was by pointing her finger in that direction when she parked her there, then she went back to the office to continue working. She said MA B was at the medication cart passing out medications. She said MA B told her he gave Resident #1 the wrong medication. She said the MD instructed staff to monitor Resident #1. She said she had received training on and in-services on medications pass. She said staff were provided in-services and completed competency checklists after the incident. The ADON said she did not know what system was implemented to prevent medications errors from happening. She said the MA and nurses were responsible to ensure the medications were given to residents. She said she expected staff do what they knew they were supposed to do, check blood pressures if required, and notify the nurse of any issues. She said MAs went to school and should know how to pass out medications correctly. She said a potential negative outcome of taking the wrong medication was that a resident could end up in the hospital or could experience anaphylaxis- a severe, immediate, potential fatal systemic allergic reaction. During an interview on 10/16/25 at 5:06 PM, the MD said he was notified of the medication error and instructed staff to observe the resident, check vitals, and to send her to the hospital if she was lethargic. He said her vitals were stable and they were monitoring for changes but he then sent her to the hospital for closer observation. He said staff followed the facility protocol. He said an error was an error and the significance of an error did not matter and that he expected staff to follow the medication error protocol. He said errors happened all the time. He said an adverse outcome of an error of one dose was lower. He said a potential negative outcome was the resident could get sleepy, they could have an allergic reaction, or they could die. He said the important thing was to determine how it happened, check the patient, and to do what you could to tend to the patient. During an observation and interview on 10/16/25 at 5:22 PM, Resident #1 was observed rolling down the hallways. She said she was sick in the hospital. She said she was better. During an observation and interview on 10/17/25 at 10:05 AM, Resident #1 was observed in her bedroom dressed as she went through clothes in her dresser. She said she was at the hospital but could not verbalize the reason. During an interview on 10/17/25 at 10:50 AM, the DON said the policy for medication errors was to suspend staff, complete an investigation, complete the medication error form, monitor the resident, and to ensure all medications were given correctly to other residents. She said she became aware of the medication error after the incident occurred via text message from staff. She said the resident's allergies were verified. She said the MD ordered continued monitoring but later ordered staff to contact EMS to transport Resident #1 to the hospital. She said the system in place to prevent medication errors was to re-educate staff and provide them with in-services on medication pass. She said the nurse on duty was responsible to ensure medications were given to residents correctly. She said she expected staff to follow the six rights of residents which were to ensure the dose, person, route, medication, time and documentation were all correct and to make sure they were passing medications correctly. She said she could not speculate what could happen if a person received the wrong medication, they must call the doctor, inform him, take vital signs, follow his orders, and provide close supervision to the resident. During an interview on 10/17/25 at 11:27 AM, the ADM said the policy for when a medication error occurred was to complete notifications and all were done. He said staff completed competencies and were in-serviced on medication pass afterwards. He said he was notified of the medication error immediately after it occurred and the MD ordered staff to monitor the resident. He said staff continued to monitor Resident #1 until the MD ordered the resident to be transferred to the hospital for monitoring. He said the resident was admitted to the hospital for observations and monitoring for 48 hours. He said there had been no issues since she returned to the facility and she was discharged with no new orders. He said the system the facility had in place to prevent medication errors was to provide in-services to staff, educate them, and review competencies. The ADM said the previous DON and ADM provided staff with in-services on medication pass in August 2025. He said the DON and nurse on shift were responsible to ensure medications were passed out correctly, and ultimately he was responsible as well. He said he expected staff to follow the six medication rights when passing out medications, which were the to ensure the dose, person, route, medication, time, and documentation were all correct. He said he could not speculate potential negative outcomes to residents when taking the wrong medications as it was determined on a case-by-case basis, and the outcome could be serious or not be serious. Record review of facility policy titled, Administering Medications, revised in April 2019, revealed in part: Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3. Medications must be administered in accordance with the orders, including any required time frame.6. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:a. Checking identification band;b. Checking photograph attached to medical record; andc. If necessary, verifying resident identification with other facility personnel.7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of facility policy titled, Medication Errors and Drug Reactions, undated, revealed in part: Purpose: Establish uniform guidelines for reporting and recording of medications errors and drug reactions. Definitions:Medication Error means the observed or identified preparation or administration of medications or biologicals which is not In accordance with:1. The prescriber's order;2. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological or3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. Criteria for judging significant medication errors as well as examples are provided below. Significance may be subjective or relative depending on the individual situation and duration, e.g., constipation that Is unrelieved because an ordered laxative is omitted for one day, resulting in a medication error, may cause a resident slight discomfort or perhaps no discomfort at all. However, If this omission leads to constipation that persists for greater than three days, the medication error may be deemed significant since constipation that causes an obstruction or fecal impaction can directly jeopardize the resident's health and safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 residents (Residents #1) reviewed for abuse and neglect. <BR/>The facility Staff (Administrator) failed to report the incident that occurred on 03/30/2024 and 04/04/2024 between Resident #1 and Resident #2 to the governing state agency. <BR/>CNA H &I failed to report allegations of abuse to the abuse coordinator within 2 hours of incident.<BR/>These failures could place the residents in the facility at risk of lacking timely reporting of incidents, risk of abuse, neglect, exploitation, or misappropriation of their property by staff members and contribute to further resident abuse.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread, and uneasiness), cognitive communication deficit (difficulty understanding and communicating). <BR/>Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #1 had slurred speech, could make himself understood and usually understood others. <BR/>Record review of Resident #1 Care Plan, dated 02/29/24, revealed that he is a max assist, depends on staff for meeting his needs, requires tube feeding, has depression (impaired ability to remember), is on antianxiety medications, and that he was pulled from the bed on 04/25/24.<BR/>Record review of Resident #1's progress notes revealed the following:<BR/>04/25/24 at 05:08 PM LVN A documented:<BR/>Resident #1 was found on the floor was pulled out of bed by another resident (unidentified) assist Resident #1 back to bed did assessment no injures noted<BR/>03/30/24 at 12:49 AM LVN B documented:<BR/>Other resident (unidentified) tried to pull Resident #1 out of his bed. other resident (unidentified) scratched Resident #1 across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Other resident (unidentified) was taken to his own room. <BR/>Record review of Resident #2's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was readmitted to the facility on [DATE] with diagnosis to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. <BR/>Record review of Resident #2 care plan, dated 04/30/24 revealed the following: <BR/>Focus (Date initiated:04/26/24 Date revised:04/26/24)<BR/>4-25-24-I pulled another resident out of bed.<BR/>Goal<BR/>I will have no further episodes of aggression through review date.<BR/>Interventions<BR/>Placed 1:1 Sent to a behavior support center. <BR/>Focus (Date initiated:01/22/24 Date revised: 01/22/24)<BR/>I am an elopement risk/wanderer. Wander risk<BR/>Goal<BR/>I will not leave facility unattended through the review date.<BR/>Interventions <BR/>Distract me from wandering by offering pleasant diversions. I prefer having snacks.<BR/>followed by psychiatric services. notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications.<BR/>Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log.<BR/>Focus (Date initiated: 01/22/24 Date revised:01/22/24)<BR/>I have episodes of verbal and physical aggression r/t dementia.<BR/>Goal<BR/>I will not harm self or others through the review date.<BR/>Interventions <BR/>Give me as many choices as possible about care and activities.<BR/>Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. <BR/>Monitor/document/report PRN any s/sx of me posing danger to self and others.<BR/>When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Focus (Date initiated:01/22/24 Date revised:01/22/24)<BR/>I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye.<BR/>Goal<BR/>I will show no decline in visual function through the review date.<BR/>Interventions <BR/>Arrange consultation with eye care practitioner as required.<BR/>Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Place frequently used items on my left side so I may see them<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>04/25/24 at 04:55 PM LVN A documented:<BR/>Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room.<BR/>04/24/24 at 08:25 PM the DON documented:<BR/>7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and laid down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. <BR/>04/23/24 at 11:34 AM the DON documented:<BR/>Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. <BR/>04/23/24 at 1:06 AM LVN A documented:<BR/>Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2<BR/>04/15/24 at 4:16 AM LVN B documented:<BR/>Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room.<BR/>04/04/24 at 05:11 PM LVN B documented:<BR/>Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking<BR/>cane from rt hands and redirect to room. Admin notified.<BR/>03/30/24 at 12:26 AM LVN B documented:<BR/>Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room.<BR/>03/30/24 at 05:27 PM LVN D documented:<BR/>Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go<BR/>into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room.<BR/>Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision.<BR/>Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1.<BR/>Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every 30 minutes on 05/08/24-05/10/24.<BR/>During an interview on 05/08/24 at 11:42 AM, the DON stated Resident #2 had advanced dementia. The DON said she, as the DON, had been trained on what to do regarding reporting ANE. She said their system for monitoring ANE was to educate staff through in-services. The DON said all staff had been trained on reporting ANE. The DON said staff were trained upon hire, annually, and when an incident arose. The DON said staff had been trained to report abuse immediately to the abuse coordinator, and she expected her staff to do so. The DON said she was unaware why CNA H and I did not report the allegations of verbal abuse immediately. She said all staff were responsible for reporting ANE immediately to the abuse coordinator. The DON said the ADM was the abuse coordinator. <BR/>During an interview on 05/08/24 at 11:42 AM, the ADM stated she was unsure of the date and exact time, but CNA G came to her and told her that he needed to tell her something. The ADM said CNA G told her that he was told by CNA H & I that LVN A was ugly to Resident #2. The ADM said that she immediately suspended LVN A upon being notified of the situation. She stated she immediately suspended CNA H & I. The ADM stated she reported the incident to the state. She said they conducted safe surveys. She said Resident #2 could not recall the incident. The ADM stated they reported the incident to the sheriff's department.<BR/> During her investigation, the ADM said CNA H admitted that she witnessed LVN A yelling at Resident #2. CNA I also admitted that LVN A yelled at Resident #2. The ADM stated she immediately educated CNA H & I that she was supposed to report it immediately. The ADM said she was unaware why the staff did not report the incident because she was physically in the facility the night of the incident (04/25/24). She said The CNAs did not give her a reason why they did not report it immediately. She said she was never notified until the next morning. The ADM stated that CNA H was an agency staff member but that they had an understanding that all ANEs should be reported immediately. The ADM stated when she spoke with LVN A that LVN A denied the allegations of verbal abuse but that LVN A did tell Resident #2 to get out of bed, which was not his. She said LVN A did admit that she was loud. After consulting with her corporate office, the ADM decided to terminate LVN A based on interviews and her past involvement in other incidents. The ADM stated that she did not terminate the CNAs because they had never had issues with their performance and had reeducated them on ANE. The ADM stated they also considered that CNA H & I did report the incident to another coworker even though they should have reported it to the abuse coordinator as trained. She said the potential negative outcome of not reporting allegations of abuse immediately to the abuse coordinator could place residents and staff in harm's way. The ADM stated they were at the facility to protect the residents. The ADM stated her system to monitor that the abuse policy was being followed implemented, and staff was reporting allegations of abuse was that they trained staff through inservices. The ADM stated policies and signs were posted with the ADM's name and number on the wall. She said she had been trained on the abuse policy, and all staff had been trained. She said she expected to be notified of ANE immediately when and if it happened. She said all staff were responsible for reporting and following the abuse policy. She said she did not know why CNA H and I did not report the allegations immediately. The ADM stated it was reported to her that on 04/25/24, around 7:30 PM. The ADM said that Resident #2 went into Resident #1's room. The ADM stated Resident #1 and Resident #2's rooms are next to each other. She stated staff heard yelling but was unsure where the yelling was coming from. She stated when staff entered the room, they observed Resident #1 on the floor, and Resident #2 was in Resident #1's bed. The ADM stated staff redirected Resident #2 to his room, assessed Resident #1 and did not identify any injuries on either resident. The ADM stated she was notified and physically came to the facility to attempt to get additional support from a local behavior support center for Resident #2's behavior. She said Resident #2 was transported to a behavior support center the same night. The ADM stated that Resident #2 had never done this to Resident #1 before. She stated Resident #1 had a history of aggressive behavior with staff. The ADM said as a result of this incident, on 04/25/24, they conducted training with staff over resident rights, ANE, and that they had consulted with the local behavior support center to conduct training on dealing with aggressive behaviors, but no official date had been set.<BR/>During an interview on 05/08/24 at 12:37 PM, CNA G stated he did not remember the exact date but he had come in at the beginning of his shift. CNA G stated he was getting a report from the night-time CNAs, and it was passed on that Resident #2 had pulled Resident #1 out of bed. CNA G said he was told by CNA H &I that when Resident #2 refused to leave Resident #1's bed, LVN A yelled loudly for Resident #2 to get the fuck out of the bed. CNA G said he was told it was so loud that everyone in the facility could hear it. CNA G said that CNA H & I appeared concerned with how LVN A approached the situation. CNA G stated he immediately reported it to LVN D, and the ADM. CNA G stated as a result of his report of LVN A's verbal abuse immediately that the ADM started getting witness statements but was unaware of what was done with LVN A. CNA G stated he had not seen LVN A back at the facility since the incident. He stated he reported the incident immediately because he had been trained to report all allegations of ANE immediately to the abuse coordinator. <BR/>During an interview on 05/08/24 at 01:34 PM, Resident #2 said he did not recall staff yelling at him, felt safe, had difficulty seeing things, and had no physical incidents with staff or other residents. Resident #2 said he knew where his room was but could not recall a specific room number. He said he did not have any additional concerns. <BR/>During an interview on 05/08/24 at 1:50 PM, Family Member J stated on 04/25/24, she was notified that Resident #2 had thrown Resident #1 on the floor. Family Member J said she was notified that Resident #1 was assessed, received x-rays, and had no injuries. Family Member J said she spoke with Resident #1 and was told he was not hurting too badly.<BR/>During an interview on 05/08/24 at 2:02 PM, Resident #1 stated via telephone that Resident #2 had pulled him off the bed, and he did not want it to happen again.<BR/>During an interview on 05/08/24 at 2:03 PM, Family Member K stated via telephone that she was physically with Resident #1 but that he had a hard time talking because of his stroke. Family Member K said there was an incident where LVN A walked into the room (unsure of the date), and Resident #1 was sideways, hanging onto the bed with one arm. She said she believed there was another incident where Resident #1 tried to protect his feeding tube site. She said she was concerned that this was happening when Resident #1 was sleeping, and that Resident #1 could not defend himself. Family Member K said the staff knew about the incidents and needed to do something. Family Member K said that she had not physically told anyone but was told by Family Member J that she had. <BR/>During an interview on 05/08/24 at 2:18 PM, CNA F stated she was unsure of the exact dates, but about a month before the interview, She and CNA E had caught Resident #2 in Resident #1 room. CNA F said Resident #2 was confused and had difficulty seeing. CNA F said she did not believe Resident #2 was being mean or awful to Resident #1, but he thought he was in his (Resident #2) room. CNA F stated Resident #1 was yelling. CNA F said when they got to Resident #1's room (she and CNA E), they observed the door closed and the lights off. CNA F said when they turned on the lights, they observed Resident #2 trying to pull Resident #1 off the bed. CNA F stated water was on the floor, and Resident #1 Head was on the bed rail. She observed the side table turned over, and Resident #1 was protecting his feeding tube site and crying. CNA F attempted to redirect Resident #2, but he refused to leave. CNA F stated this incident was reported to LVN B. CNA F stated LVN B said she reported the incident to the appropriate parties. CNA F stated a week after that incident (unsure of the exact date), Resident #2 was back in Resident #1's room. CNA F stated that Resident #1 had pushed his call light, and Resident #2 was standing in Resident #1's room when they got to him. CNA F stated that when they attempted to redirect him out of Resident #1's room, Resident #2 stated he wanted his jacket, and they grabbed his hand. Finally, Resident #2 went with them. CNA F stated that there had been a lot of changes in the facility as far as room changes and believed that the separation by gender may have contributed to Resident #2 being confused about where he was going and, in addition, his difficulty being blind. CNA F stated Resident #2 had been moved three or four times. CNA F stated the difficulty they had been having with Resident #2 had been reported to LVN A and LVN B (unsure of the exact time and date). She stated she was under the impression that, as the CNA, she was to report to her charge nurse and that they would proceed further if needed. She said her charge nurses had told her that the incidents with Resident #2 had been reported to higher people. CNA F stated they had wondered when something would be done. CNA F stated she was frustrated with all the incidents that had occurred with Resident #2. She stated that although Resident #2 was not evil and was sweet, his behaviors had worsened, and he had become more confused. CNA F stated that outside of the incidents with Resident #1, Resident #2 had become aggressive with her, and CNA G. CNA F stated that if something had been done, some of the incidents with Resident #2 could have been prevented.<BR/>During an interview on 05/08/24 at 2:58 PM, CNA E stated she could not remember exact dates and times. CNA E stated the first incident between Resident #1 and #2 might have occurred four months ago. CNA E stated that she and CNA F were doing rounds and heard Resident #1 scream aloud. CNA E stated Resident #2 was in Resident #1 room. CNA E stated she observed Resident #1 halfway off the bed. CNA E stated that Resident #1 had his family member in the room. CNA E stated Resident #1 was halfway off of the bed, and she observed the lower half of Resident #1's body off the bed. CNA E said Resident #1 was holding onto the bed rail with his right arm. CNA E stated the incident where Resident #1 was hanging off the bed was the first incident she had ever seen. She said she reported the incident to the charge nurse but could not remember who it was as they have many charge nurses. CNA E stated there was another incident (unsure of the date and time) where Resident #1 screamed. CNA E stated that Resident #2 scratched Resident #1 during this incident. CNA E stated it happened possibly two months ago. CNA E stated Resident #2 had scratches on his chest and right side. CNA E stated this was reported to LVN B. CNA E stated that she had to scream for assistance during this incident. She stated CNA F came to assist her. CNA E stated that this incident scared her and that things were worsening with Resident #2's behaviors. CNA E stated that Resident #2 was telling her that Resident #1's room was his room and yelling at her. CNA E said she kept telling him it was not his room. CNA E said that after they told LVN B, she (LVN B) would notify the appropriate parties. She said Resident #1 appeared scared and had water in his eyes. She said Resident #1 said it was scary. CNA E said Resident #1 used minimal words such as scary, hurt, and oh man to describe what had happened. CNA E said there was another incident where Resident #2 had become agitated and aggressive with staff; this was when she messaged the DON. CNA E said she did not like what was happening, and it made her sad about what had happened to Resident #1. <BR/>During an interview on 05/08/24 at 3:29 PM, LVN A stated that she no longer worked at the facility. LVN A stated on 04/25/24 that she did not witness Resident #2 pulling Resident #1 out of the bed. LVN A stated that she had heard Resident #1 scream and thought it was another resident. LVN A said that when she walked down the hallway, one of the CNAs came running towards her. LVN A stated she could not remember the CNAs name. LVN A when she went into Resident #1's room and observed Resident #2 in Resident #1's bed and Resident #1 was on the floor. LVN A said this was not the first interaction between Resident #1 and Resident #2. LVN A stated this was the second time this had happened. LVN A said that during the incident on 04/25/24, Resident #2 yelled at the staff. LVN A stated she raised her voice for Resident #2 to get out of Resident #1's bed. LVN A said that they were finally able to get Resident #2 out of Resident #1 room. LVN A said she notified the DON of the incident. LVN A stated the DON said that she told the ADM and that the ADM was on the way to the facility to send Resident #2 out for behavior support. LVN A said she had experienced Resident #2 becoming agitated with staff on 04/18/24. She stated that the FNP, PCP, DON, and ADM knew about the incident. She said she had been told by other staff that Resident #2 had attempted to pull Resident #1 out of bed before. She said she was unaware of any interventions that had been put in place. <BR/>During an interview on 05/08/24 at 10:25 PM, CNA I stated on 04/25/24, it was around 7 PM or 9 PM when the residents that smoke go out. CNA I said she observed Resident #1 on the floor. CNA I said she went to get LVN A, and that was when she (LVN A) told Resident #2 to get the fuck out. CNA I said she redirected Resident #2 to his room. CNA I stated she and CNA H placed Resident #1 back in bed. CNA I said their shift was over at 6:00 AM the next morning, and LVN A worked the remainder of her shift. CNA I stated that she did not report the verbal incident because the LVN A knew about it as she was there and had said the words to Resident #2. CNA I stated she reported the incident to the oncoming shift the next morning. CNA I said the ADM and DON reeducated her. CNA I said that she had never heard LVN A curse at the residents but had observed her be loud. CNA I said she and her coworker (CNA H) did discuss that the interaction between Resident #2 and LVN A was aggressive and abrasive. CNA I said she was more focused and glad that Resident #1 was not hurt. CNA I said after that incident and Resident #2 received a shot of Ativan he came back out and was trying to throw a shoe at Resident #1. CNA I said that most of the time when she worked with Resident #2, he would always try to go into Resident #1's room. CNA I said this occurred at least three times a week. Before the incident on 04/25/24, CNA I said that Resident #2 never made physical contact with Resident #1 on her shift. CNA I said there was nothing ever done that she could recall to alleviate the situation, but the staff had placed gloves on the outer door at one point. She stated she could not provide a picture of the gloves on the door to the HHSC worker. CNA I said that she had been trained to report allegations of ANE immediately. <BR/>During an interview on 05/08/24 at 10:51 PM, LVN D stated that the incident on 04/25/24 was the second time that Resident #2 had attempted to pull Resident #1 out of bed. She stated she was not present but had received the information in the report as she typically worked the day shift. LVN D said that they had to redirect Resident #2 consistently. LVN D stated that she did not feel that Resident #2 was explicitly targeting Resident #1 but that he was confused as to where his room was. <BR/>An attempt to contact LVN B was made on 05/08/24 at 10:57 PM. LVN B said she would contact her DON and ADM and return the call. Additional attempts to speak with LVN B were made on 05/09/24 at 10:29 AM. LVN B did not answer. <BR/>During an interview on 05/09/24 at 10:52 AM, the Activity Director stated that she participated in Resident #1's care plan. The Activity Director stated that Family Member J expressed that Resident #2 had wandered into Resident #1's room once or twice. <BR/>During an interview on 05/09/24 at 11:27 AM, Resident #1 stated that Resident #1 had been in his room [ROOM NUMBER]-5 times. Resident #1 said out of those 4-5 times, Resident #2 had become physical with him. Resident #1 stated no one had come to him and interviewed him about the incident outside of the HHSC investigator. Resident #2 said that he was afraid when he had to hang onto the bed. Resident #1 said he had told multiple CNAs and nurses that he did not want Resident #2 in his room. Resident #2 said he could not remember the names of the staff he told. Resident #2 said he felt like his problem was never solved. Resident #1 said that three times when Resident #2 came into his room, it got physical; he was pulled off the bed, scratched, and pulled halfway off the bed. Resident #1 said he could not remember the date and time when the incidents happened but that staff knew about it because they had to help him.<BR/>During an interview on 05/09/24 at 1:07 PM, the ADM clarified that during the initial interview, she stated the incident between Resident #2 and Resident #1 had never happened was because three weeks prior, staff had reported that Resident #2 had gone into the room and scratched Resident #1 and LVN B had redirected Resident #2 out. The ADM stated she was unsure where the scratch was. The ADM stated this type of information was typically reported to the DON. The ADM stated she did not report the incident to the state agency because the nurse had intervened and redirected Resident #2 out of the room. The ADM said she was unaware that Resident #2 had encountered Resident #1 multiple times. The ADM said she was unaware that Resident #2 had attempted to pull Resident #1 out of the bed before the incident on 04/25/24. The ADM said they were monitoring Resident #2's behavior through psychiatric services and medication adjustments. The ADM stated that the staff had expressed concerns about them getting hurt, but she was unaware of the ongoing issues with Resident #1. She said she was only aware of one incident where Resident #2 had become aggressive with staff. She said she was unaware of any other incidents. The ADM said she knew that most of Resident #2's incidents or behaviors occurred at night. The ADM said she did not implement any other interventions outside of the medication adjustments and monitoring from psychiatric services and notifying the family, PCP, and FNP. The ADM said she had never interviewed Resident #1 to see if this had happened. The ADM had never delegated to interview Resident #1. The ADM said the night of the incident (04/25/24), she was more concerned with his well-being and what happened. The ADM said part of the investigation process was interviewing key witnesses and residents and finding out what happened. The ADM said the potential negative outcome of not reporting allegations of abuse to the state governing agency was that resident harm or the resident's safety could be compromised. The ADM said she was unaware of the additional incidents outside of the incident on 04/25/24 between Resident #1 and Resident #2. The ADM said her system for monitoring ANE was that signs were posted that instructed staff to contact her regarding ANE concerns. The ADM said they educate staff to report allegations of abuse immediately, and the ANE policy was attached to those inservices. The ADM said she expected the staff to report immediately if they witnessed or suspected abuse. The ADM said she and the staff had also been trained to report allegations of ANE immediately. The ADM said everyone was responsible for following the abuse policy and reporting ANE immediately.<BR/> During an interview on 05/09/24 at 2:17 PM, the DON stated that the only other incident she knew of between Resident #1 and Resident #2 was where Resident #2 scratched Resident #1. The DON said she was unsure of the date and time when this incident occurred. The DON said that Resident #2 was redirected out of the room. The DON said she was unaware of any other incidents. The DON said that she could not think of any other interventions put in place outside of psychiatric medication adjustments and close monitoring. The DON stated she never interviewed Resident #1. The DON said once an incident was reported to the ADM, she would relinquish the investigation process to the ADM because she had so much on her plate. The DON said the potential negative outcome of not reporting allegations of abuse was that abuse could continue to happen. The DON said she was aware of two incidents between Resident #1 and Resident #2 and was unaware that this was an ongoing situation. The DON said their system for monitoring ANE reporting and following the ANE policy was to educate staff through inservices. The DON said she had never observed Resident #2 enter Resident #1's room. The DON said she expected staff to report all incidents of abuse to the abuse coordinator.<BR/> Record review of salesforce (tulip) revealed from January 2024 until May 2024 date no other reports have been made to state in regard to Resident #1 and Resident #2 other then the incident that has us in the facility. <BR/>Record review of the facility's policy, Abuse, Neglect, Exploitation General Policy, Filing, undated revealed the following:<BR/>PROCEDURE :<BR/>Investigation<BR/> All facility employees, family members and volunteers and educated that alleged or suspected [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 residents (Resident #1) reviewed for abuse. <BR/>The facility failed to report a reasonable suspicion of Abuse for Resident #1 after allegations were made by staff members to Administrator and Resident #1 suffered a spiral fracture to his upper left arm. <BR/>This failure could place all residents at risk of further potential injuries or Abuse. <BR/>Findings included: <BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, <BR/>Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) listed as 3, meaning severe cognitive impairment.<BR/>Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. <BR/>Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words.<BR/> Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. <BR/>Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. <BR/>Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. <BR/>Under C0700 labeled long-term memory is left blank and not completed. <BR/>Under C0800 labeled Memory/Recall Ability is left blank and not completed. <BR/>Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. <BR/>Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. <BR/>Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. <BR/>Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. <BR/>Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under <BR/>B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. <BR/>Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. <BR/>Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. <BR/>Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance.<BR/>Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). <BR/>Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. <BR/>Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. <BR/>Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. <BR/>Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. <BR/>Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. <BR/>Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). <BR/>Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. <BR/>Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. <BR/>Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. <BR/>During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. <BR/>During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. <BR/>During an Interview on 04/13/2023 at 1:16 pm with CNA D, stated that he has worked in the facility for approximately six months. CNA D stated that he had just barely had to meet with the police to give a statement. CNA D stated that he did not know before this that there was a problem. CNA D stated that the facility had not called him to let him know that there was an issue. CNA D stated that when the police called to question him and now being interviewed by State let him know that there was a problem. CNA D stated that he had three interactions with Resident #1 that night that he worked. CNA D stated that the first two interactions with Resident #1 was just to redirect him back to his room. CNA D stated that the last interaction that he had with Resident #1 is when Resident #1 was found by the Monitor Tech in another resident room in an empty bed. CNA D stated that the Monitor Tech L stated that she needed help to transfer Resident #1. CNA D stated that he offered to help. CNA D stated that he tapped Resident #1 on the shoulder a few times to wake him up. CNA D stated that immediately Resident #1 was aggravated when he was awakened. CNA D stated that Resident #1 was telling him to leave him alone. CNA D stated that he walked out of the room for approximately 10 minutes to allow Resident #1 to calm down. CNA D stated that he returned into the room and tapped on the shoulder of Resident #1 again. CNA D stated that Resident #1 was having a hard time standing up so CNA D stated that he grabbed Resident #1 in both of the arm pit areas to pick him up with his (CNA D) thumbs on the outside of the armpits. CNA D stated that Resident #1 began to punch him several times in the CNA D stomach. CNA D stated that it did not bother him that Resident #1 was hitting him because he is not a big guy. CNA D stated, I am a big guy, and I can handle it. CNA D stated that he escorted Resident #1 to his room with no problems. CNA D stated that he escorted Resident #1 by getting behind Resident #1 and grabbing his arms and directing him to go towards his room. CNA D stated that when he was redirecting Resident #1 that he kept trying to pull away from him (CNA D), so CNA D stated he had to grab firmly to keep Resident #1 from trying to pull away while CNA D redirected him. CNA D gave a witness statement that Resident #1 does not like him (CNA D) and he does not know why. CNA D stated that the incident happened on 04/11/2023 on his night shift. CNA D stated, Now as of 04/13/2023, I am probably being suspended since State is in the building). CNA D stated that the administrator didn't tell him anything about the incident or question him yet still until State came in the building. CNA D stated that the Administrator told him that when he is done giving a statement to State then she needed to question him. CNA D stated that he did have another complaint with another resident and had been written up for that one before. CNA D stated that the resident that made that complaint didn't like him either and tried to make accusations that CNA D was rough with him (Resident #2). CNA D stated that is all he is going to say unless he has an attorney. Surveyor ended Interview and thanked CNA D for taking the time to interview. CNA D stated to Surveyor, I'm sure I will have 3 days to be pissed off about all this, I'm sure that's what I am going to do. I can't afford to get suspended again.<BR/>Record Review of the Disciplinary Action for CNA D, provided on 04/13/2023, labeled, Counseling Notice, dated on 03/13/2023, revealed: CNA D had been suspended for three days and a 30-day probation period for a previous accusation of being too rough with a different resident which was used as a sample resident for this investigation. <BR/>Suspension: 3 days<BR/>Reason for Counseling Notice: Complaint from Resident #2 family, See Report on back.<BR/>Report on Back: 03/13/2023, HR counseled with CNA D, discussed his approach to patient care. He apologized and stated he didn't realize he was being too rough. He has been suspended for 3 days. After counseling CNA D agreed to a 30-day probation period and would not be allowed any reports from family or residents. CNA D stated he loved his job and would be agreeable to the 30-probation period, and then would review. <BR/>Supervisor Statement: I have discussed the counseling notice with the employee CNA D. Signatures included Administrator, CNA D, and BOM<BR/>Record Review of the Disciplinary Action for CNA D, provided on 04/14/2023, labeled, Counseling Notice, dated on 04/14/2023 at 12:30 pm revealed: CNA 4 had been terminated on 04/14/2023 via phone with no signature from employee provided. <BR/>Termination-Effective Date: 04/14/2023 at 12:30 pm<BR/>Reason for Counseling Notice: Termination due to employee allegations of Abuse and Neglect. <BR/>Signed by: Administrator, BOM, No Employee signature provided. <BR/>During an interview on 04/13/2023 at 4:20 p.m. with CNA C, stated that she worked with CNA D on the shift of 04/11/2023 going into 04/12/2023 from 7p.m. top 7 a.m. night shift. CNA C stated that she thought the incident was on 04/10/2023 going into 04/11/2023 but could check camera to make sure. CNA C stated that at about 2:30 a.m. the monitoring tech asked her and CNA D if they could help to get Resident #1 out of another room because she had found him asleep in an empty bed that was not his. CNA C stated that she was busy with another resident at the time that the monitoring tech had asked so CNA D stated that he would go help. CNA C stated that the monitoring tech was fully capable of doing it herself and she is unsure why the monitoring tech needed help to walk Resident #1 back to his bed, but she still wanted assistance. CNA C stated that when she was done tending to her resident, she overheard LVN A ask CNA D, What did you do to Resident #1?, CNA C stated that she also heard LVN A ask CNA D, Why is Resident #1 yelling in pain right when you walk out of his room? CNA C stated that she then heard CNA D tell LVN A that he had just grabbed Resident #1 under both of his arms and pulled him up out of the bed to transfer him. CNA C stated that she then witnessed CNA D say that he was all of a sudden feeling sick and she saw him go outside. CNA C stated that when CNA D came back inside the facility he asked if anyone cared if he went home because he did not feel good. CNA C stated that she was surprised because up to that point CNA D had not acted as though he was sick, she stated, He was fine all night. CNA C stated to CNA D that she did not care if he went home and that she could handle the workload, and then he left. CNA C stated that LVN A asked her if she would go with her to Resident #1 room to ask him what happened because he was crying out in pain since CNA D had left his room. CNA C stated that she would go with LVN A to Resident #1s room to find out what happened. CNA C stated that she asked Resident #1 in Spanish what happened and why is he in pain and CNA C stated that Resident #1 stated, He hit me, TWICE (DOS). CNA C stated that she told Resident #1, Why do you say that? CNA C stated that Resident #1 stated, He wanted to fight me. CNA C stated that she observed Resident #1 in a lot of pain. CNA C stated that Resident #1 was crying and moaning in pain. CNA C stated that she showed Resident #1 with her hand and opened her hand and stated, Did he hit you with open hand like this? CNA C stated that she then made a fist and showed Resident #1 and then asked Resident #1, Or did he hit you with a fist? CNA C stated that Resident #1 then made a fist and stated, He hit me like this. CNA C stated that she observed LVN A assess Resident #1 for injuries and they both saw a big red mark on his upper left arm. CNA C stated that LVN A was slightly feeling Resident #1's arm and stated there is a big lump and a space. CNA C stated that LVN A then stated that she needed to call the administrator and get Resident #1 sent out to the hospital. CNA C stated she did know that CNA D is not allowed to go into some of the residents' rooms alone because of being rough with some of the residents. CNA C stated that she did not know if Resident #1 was one of those residents or not, but she does know that he is not allowed in some of the other resident's rooms alone. CNA C stated that she had been told that by the nursing staff when she first started working there. CNA C stated that she was told that sometimes she may have to help him with certain residents and when she asked why that is what she was told. CNA C stated that she has noticed that CNA D would avoid taking care of Resident #1 and he has stated before that he did not like Resident #1. <BR/>During an interview on 04/13/2023 at 5:26 p.m. with Administrator revealed she was aware of the incident that occurred with Resident #1 and CNA D on 04/12/2023. Administrator stated BOM called her at approximately 3:30 a.m. on 04/12/2023 and told Administrator that LVN A called BOM to report that Resident #1 was punched in the face and there was blood everywhere. Administrator stated that she called the facility and spoke to LVN A and was told that Resident #1 was in pain to the point of moaning and was being sent out to the hospital. Administrator stated that LVN A told her that CNA D was involved, and she did assess the resident for injuries. Administrator stated, In my thinking that since Resident #1 was already being sent out to the hospital, that everything was taken care of. I was thinking that since CNA D had gone home sick and Resident #1 was sent out to the hospital, that everything was calm and taken care of. Administrator stated that LVN A stated that CNA D was involved with the incident with Resident #1, but she was thinking now that CNA D went home not feeling well and the resident was sent to the hospital everything is okay for now. Administrator stated that her next plan of action was to make sure the family was notified and that everyone was okay. Administrator stated that she was told by the BOM that she had contacted the Medical Director after the incident happened. Administrator stated that when she came into work that morning around 8 am or 8:30 am, she notified the police, and the police made a report. (Surveyor contacted chief police and informed that in the investigation process and report is not ready to view at this point on 04/14/2023). Administrator stated that she had not interviewed CNA D yet until after surveyor had interviewed him on 04/13/2023 sometime after 2:00 p.m. Administrator stated that when she asked CNA D what happened on 04/13/2023 sometime after 2:00 p.m., he stated that he had transferred Resident #1 to the room and that it. Administrator stated that CNA D had already been written up for a different incident for allegations of abuse, with Resident #2 and now he will be written up for Resident #1. Administrator stated that CNA D is not supposed to be in the room with Resident #2 due to the allegations that was made against him by family member and Resident #2. Administrator stated that he is supposed to have a partner to make sure that nothing happens. Administrator stated that she has had to partner CNA D up with a partner with certain residents due to allegations being made but she does not have the staff to just exclude him from working with certain residents because of the allegations. Administrator stated that her way of monitoring CNA D to make sure that he was using a partner to enter certain residents' rooms was that she wouldn't get any more complaints and that is how she would know. Administrator stated that she had not suspended CNA D at this time but that she is going to suspend him. Administrator stated that CNA D went home because he felt sick during his shift on 04/12/2023 and was not scheduled to work on 04/13/2023 but Administrator stated that she was going to suspend him when he came in to work next. Administrator stated that she does have CNA D phone number and could contact him that way but has not done that. Administrator stated she was just going to suspend him when he came in. Administrator stated that she does know what the policy says about reporting abuse and neglect. Administrator stated that she was not sure how to fill out the provider investigation report but did report but not until the next day when she came to work. Surveyor pulled out the facility provided policy for abuse and showed the Administrator the protocols for reporting allegations of abuse when there is an injury. Administrator stated that she is aware that she was supposed to report within the 2-hour timeframe but was tired and it was the middle of the morning so she was just going to report when she came into work and did not think that would be a problem. Administrator stated that the incident occurred around 3:00-3:30 a.m. and the incident was reported on 04/12/2023 after Administrator got to work sometime after 8:00 or 8:30 a.m. Administrator stated that her staff has been trained in abuse and neglect. Administrator stated that right now the facility does not have a DON or an ADON and she stated that usually the DON and ADON is responsible for making sure that training is completed. Administrator stated that the negative potential outcome for not preventing abuse is that other residents may get hurt.<BR/>During an interview on 04/16/2023 at 9:57 a.m. Administrator brought in a disciplinary form to Surveyor and had stated that she had herself written up for failing to report in the 2-hour timeframe and failure to report on the online portal for Abuse and Neglect. Surveyor reviewed disciplinary document and noticed it was dated as of 04/12/2023 but was provided on 04/16/2023. It shows the document is a written warning. Signed by Administrator, BOM, and an unidentified signature. <BR/>During an Interview on 04/13/2023 at 6:11 p.m. with LVN A, stated that she worked the night shift and that the night of the incident on 04/11/2023-04/12/2023 Resident #1 came to the nurse station and stated, I fell asleep on my hand. LVN A stated that Resident#1 had been asleep since 10 or 11 p.m. and had come to the nurse station approximately around 12:30 a.m. LVN A stated that she told Resident #1 that it would be fine just to give it a couple of minutes and his hand would wake back up. LVN A stated that Resident #1 then walked away, and she did not see what direction he had went. LVN A stated that she just figured that Resident #1 went to the day room to watch tv because he would do that sometimes. LVN A stated that when the Monitor Tech L went to make rounds, she noticed that Resident #1 was not in his bed and came to ask her if LVN A had seen Resident #1. LVN A stated that she told the Monitor Tech L that she had not seen him since he said his hand fell asleep. LVN A stated that she noticed that Monitor Tech L was going room to room to find Resident #1 and had found Resident #1 in Resident #10s room in the vacant bed, asleep. LVN A stated that a couple of minutes go by and LVN A stated that she hears Monitor Tech L and CNA D talking. LVN A stated that she had heard the Monitor Tech L tell CNA D that Resident #1 was in the vacant bed in Resident #10s room by the door. LVN A stated that she heard CNA D state, I will take care of it. LVN A stated that when she saw CNA D next, he had Resident #1 from behind,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 residents (Residents #32) reviewed for infection control.<BR/>The facility failed to ensure CNA A utilized proper hand hygiene during incontinence care for Resident #32.<BR/>This failure could place residents at risk for infection and cross contamination.<BR/>The findings include: <BR/>Record review of Resident #32's undated face sheet revealed an [AGE] year-old male originally admitted on [DATE]. Resident #32 had a medical history of malignant neoplasm of prostate (an abnormal growth of tissue that can spread into nearby tissues and other parts of the body), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and atrial fibrillation (a common type of irregular heart rhythm). <BR/>Record review of Resident #32's quarterly MDS assessment dated [DATE], revealed a BIMs score of 15 which indicated Resident #32 was cognitively intact. Section H- Bladder and Bowel revealed Resident #32 had an indwelling catheter. <BR/>Record review of Resident #32's care plan last revised on 8/14/2024, revealed Resident #32 had a foley catheter with the following intervention Catheter care every shift to be performed by CNA. Date Initiated: 01/31/2024.<BR/>Record review of Resident #32's physician orders revealed, Catheter care every shift to be performed by CNA every shift, with a start date of 1/19/2024. <BR/>During an observation on 8/19/2024 at approximately 10:15AM, CNA A washed his hands and donned PPE (gloves and gown) outside of the resident's room. CNA A entered the room and assisted Resident #32 with his pants. CNA A unfastened Resident #32's brief and cleaned the resident's foley and front. CNA A assisted Resident #32 to turn onto his right side and tucked the dirty brief under the resident. CNA grabbed the clean brief with contaminated gloves and placed it under Resident #32. CNA A assisted resident to turn to his left side and removed the dirty brief. CNA cleaned Resident #32's bottom with wet wipes. CNA A applied barrier cream onto resident's bottom. CNA A turned Resident #32 onto his back and fastened his brief. CNA A removed his dirty gloves and gown and utilized ABHS. CNA A failed to change gloves and utilize hand hygiene during incontinence care. <BR/>During an interview on 8/19/2024 at 1:15pm with CNA A, he stated the infection preventionist was the DON and ADM. He stated he had been trained on handwashing during incontinence care but did not remember the last one. He stated the potential negative outcomes of not changing gloves and utilizing handwashing during incontinence care could be skin breakdown, bed sores, skin discoloration, or cross contamination between residents. He stated handwashing should be performed before resident care and immediately after. CNA A stated glove changes should occur if the gloves were visibly soiled. He stated during the care he realized he had grabbed the clean brief with dirty gloves, and he had been nervous during the incontinence care. <BR/>During an interview with the DON on 8/20/2024 at 10:52 AM, she stated she was the infection preventionist. She stated handwashing training is done monthly and yearly. She stated handwashing compliance is monitored by the nurses and herself and they track UTI rates. She stated the potential negative outcome of not utilizing proper hand hygiene could be infection. She stated handwashing should be done before they go into the resident's room, when they go from dirty to clean, and when they exit the room. She stated handwashing should always occur between glove changes. She stated handwashing is monitored by observation. <BR/>During an interview with the ADM on 8/20/24 at 12:05 pm, he stated the DON was the infection preventionist. He stated handwashing training is done as needed and yearly. The ADM stated competencies are conducted annually to monitor for compliance. The ADM stated the risk of not utilizing proper hand hygiene during incontinence care is potential for contamination. He stated glove changes should occur after cleaning the soiled area and before switching to a clean area. He stated staff are trained on handwashing or to use ABHS in between glove changes. <BR/>Record review of facility policy titled Handwashing/Hand Hygiene, revealed .<BR/>Indications for Hand Hygiene .<BR/>d. After touching a resident.<BR/>e. after touching the resident's environment. <BR/>f. before moving from work on a soiled body site to a clean body site on the same resident and<BR/>g. immediately after glove removal <BR/> .Applying and removing gloves .<BR/>4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand folding it into the first glove. <BR/>5. perform hand hygiene.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, on facility grounds in 1 of 2 parking lots (front entrance parking lot) in that:<BR/>The facility failed to ensure the trash was emptied into the dumpster for five hours. <BR/>This failure could attract unwanted pests and cause the facility to have an unsightly appearance. <BR/>The findings included:<BR/>On 8/19/24 at 9:45 AM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash.<BR/>On 8/19/24 at 12:29 PM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash.<BR/>On 8/19/24 at 2:45 PM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash.<BR/>On 8/20/24 at 12:57 PM, an interview was conducted with the Maintenance and Housekeeping Supervisor, and he stated he was aware that the trashcan by the front entrance was full. He stated he saw it around 10:00 AM as he walked by it, but he was in the middle of repairing something else and did not take it to the dumpster at that time. He stated trashcans were not supposed to be overflowing with trash that prevent the lid from closing. He stated he has since spoken to the housekeeping staff to include checking trashcan outside and on the patio's every morning. He stated he expected housekeeping staff to throw trash immediately when they notice it was full or overflowing. He stated he expected all other staff to let housekeeping staff know when they see any trashcans were full or overflowing so it can be thrown out. He stated he was responsible for training housekeeping staff about requirements for trash. He stated most of his housekeeping staff were new and were still in the process of being trained. He stated he did not know when the last time housekeeping staff received that training if hired prior to him becoming the Maintenance and Housekeeping Supervisor nine months ago. He stated he did not know of a potential negative outcome that could occur from trashcans being left full and overflowing with trash.<BR/>On 8/20/24 at 1:45 PM, an interview was conducted with the Regional Director/Interim Administrator, and he stated facility policy was that all litter must be disposed of properly and timely. He stated he saw the trashcan by the front entrance was full as he walked a visitor out of the facility, and he told staff to throw it out. He stated there was currently not a system to ensure that trashcan was checked regularly, but he would create a check-off list for housekeeping staff to add checking trashcans in the parking lot, as the current list only included checking trashcans inside the facility. He stated he expected staff to get rid of trash as soon as they had seen it. He stated housekeeping staff were trained; however, he was not sure when each member received the training as it would depend on who their supervisor was when they were hired. He stated potential negative outcomes were that it was unsightly and could invite pests.<BR/>Record review of the facility policy titled Grounds, Revised May 2008, revealed the following documentation, Policy Statement. Facility grounds shall be maintained in a safe and attractive manner. Policy Interpretation and Implementation. <BR/>1. Maintenance shall be responsible for keeping the grounds free of litter.<BR/>2. Lawns shall be mowed on a weekly basis during the grass cutting season. Shrubs shall be trimmed as needed.<BR/>3. Areas around the buildings (i.e., sidewalks, patios, gardens, etc.) shall be maintained in a safe and orderly manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to immediately inform the resident representative when there was an incident that involved the resident's physical, mental, or psychosocial status for 1 resident (Resident #3) of 9 residents reviewed for notifications.<BR/>The facility failed to notify Resident's #3's representative (Family Member C) that Resident #3 had been involved in an incident of inappropriate sexual behavior that occurred on 05/10/24. <BR/>This failure could affect residents by causing the resident's family to be unaware of changes in residents' condition. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness). <BR/>Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. <BR/>Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had the potential for psychosocial well-being related to trauma.<BR/>Record review of Resident #3's progress notes revealed the following:<BR/>05/11/24 at 01:27 AM LVN G documented: Male resident observed in Residents room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries noted upon physical inspection with female CNA present. DON to notify PCP & family.<BR/>During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself, and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself.<BR/>During an interview on 06/05/24 at 3:49 PM, Family Member C stated she had not been notified of any incidents with Resident #2 that involved inappropriate sexual activity. <BR/>During an interview on 06/06/24 at 9:47 AM, CNA H stated the incident between Resident #2 and #3 occurred on 05/10/24 around 11:00 PM. She said she was told to go and check on another resident by LVN G. While doing so, she observed Resident #2 in Resident #3's room. When she got closer, she was able to see that he had his penis out, and Resident #3's hand was cuffed under Resident #2's penis. She said Resident #2 had his hand under hers and was masturbating (rubbing it up and down). CNA H said she told Resident #2 he could not do that. CNA H said Resident #2 did not move. She said she was hesitant to physically redirect Resident #2 because Resident #2 had struck her two weeks prior. CMA H said she told Resident #2 again to stop, but this time, she placed her hands on Resident #2's shoulder, and Resident #2 jerked his shoulder back forcefully. She said she took this action from Resident #2 and needed to leave him alone. She stated that, again, because of her past experiences, she did not want to engage with Resident #2. CNA H said she yelled for help, and LVN G and CNA E assisted her. CNA H said the two male staff could get Resident #2 out of Resident #3's room without any issues. CNA H stated the administration instructed them to watch Resident #2. CNA H said all staff took turns watching Resident #2 every two hours and sat outside his door. CNA H said they told the oncoming shift what happened, and that Resident #2 was on 1:1 supervision. Before the incident on her shift, CNA H said she had not been given any specific instructions regarding Resident #2. <BR/>During an interview on 06/06/24 at 12:25 PM, the DON said the potential negative outcome of not notifying the family was that the family would not be aware of what was going on with their loved one in the facility. The DON stated she was unaware that Family Member C had not been notified of the inappropriate sexual contact. She said normally, the charge nurse would have been responsible for notifying the family. She said she was unsure why LVN G had not notified the family. <BR/>During an interview on 06/06/24 at 2:00 PM, Resident #3 was unable to answer any questions about being inappropriately touched. She was able to confirm she was Resident #3, but when asked more detailed questions, she blinked, and breathed at an increased pace. <BR/>During an interview on 06/06/24 at 1:16 PM, The ADM said she did not know a potential negative outcome for not reporting changes or incidents to family members. The ADM said the only thing she could think of was emotional affect and the family being upset. The ADM said she did expect Family Member C to be notified and was unaware of why she was not notified. The ADM stated that the nursing staff was responsible for notifying family. <BR/>During an interview on 06/07/24 at 11:39 AM, Family Member C stated the facility still had not called her to notify her of the details concerning Resident #3 and inappropriate sexual contact. Family Member C said she would appreciate being informed and that it upset her not to be notified. <BR/>During an interview on 06/09/24 at 1:10 PM, Family Member C stated she was notified of the inappropriate sexual incident. She said she was told the person assigned to may have forgotten. Family Member C said she was still upset about the incident and not being notified.<BR/>Record review of the facility policy Abuse Investigation and Reporting, dated July 2017 revealed:<BR/>Policy Statement<BR/>All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.<BR/>Policy Interpretation and Implementation<BR/>Role of the Administrator:<BR/>The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation.<BR/>Role of the Investigator:<BR/>Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator.<BR/>Reporting <BR/>All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:<BR/>The Resident's Representative (Sponsor) of Record;<BR/>The resident and/or representative will be notified of the outcome immediately upon conclusion of the investigation.<BR/>Record review of the facility policy Resident Rights, dated December 2016 revealed:<BR/>Policy Statement<BR/>Employees shall treat all residents with kindness, respect, and dignity .<BR/>Policy Interpretation and Implementation<BR/>Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the<BR/>resident's right to:<BR/> o. be notified of his or her medical condition and of any changes in his or her condition;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 8 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10), reviewed for abuse. <BR/>The facility failed to ensure a safe environment free from abuse for Resident #1 when can D was suspected to have used unnecessary force causing a spiral fracture to Resident #1 on night shift on 04/12/2023. <BR/>The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 resided in a safe environment after making allegations of abuse toward CNA D and CNA D was continued to allow to work with all resident's even after prior allegations of abuse. <BR/>This failure was determined to be an Immediate Jeopardy situation that was identified on 04/14/2023 at 5:51 p.m. While the IJ was removed on 04/17/2023 , the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death. <BR/>Findings include: <BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, <BR/>Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was a 3/15, meaning severe cognitive impairment.<BR/>Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. <BR/>Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words.<BR/> Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. <BR/>Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. <BR/>Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. <BR/>Under C0700 labeled long-term memory is left blank and not completed. <BR/>Under C0800 labeled Memory/Recall Ability is left blank and not completed. <BR/>Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. <BR/>Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. <BR/>Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. <BR/>Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. <BR/>Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under <BR/>B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. <BR/>Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. <BR/>Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. <BR/>Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance.<BR/>Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). <BR/>Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. <BR/>Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. <BR/>Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. <BR/>Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. <BR/>Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. <BR/>Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). <BR/>Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. <BR/>Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. <BR/>Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. <BR/>During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. <BR/>During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. <BR/>*Resident #2:<BR/>Record Review of Resident #2 face sheet documented he is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis which includes: stroke, seizures, difficulty swallowing, facial weakness, major depressive disorder, anxiety disorder, type 2 diabetes, muscle wasting, cognitive communication deficit, lack of coordination, hyperlipidemia (a condition which there are high levels of fat particles (lipids) in the blood). <BR/>Record review of Resident #2's admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 00 meaning zero points are assigned if the resident didn't repeat words correctly<BR/>Under B0600 for Speech Clarity indicated that Resident #2 scored 1 meaning Unclear Speech-slurred or mumbled words. <BR/>Under B0700 for Makes Self Understood indicated that Resident #2 scored 2 for ability to express ideas and wants. meaning sometimes understood ability is limited to making concrete requests. <BR/>Under B0800 for Ability to Understand Others-understanding verbal content scoring a 2 meaning responds adequately to simple and direct communication only. <BR/>Under G0110 for Activities of Daily Living Assistance indicates: A). Bed Mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) Resident #2 scored a 3 meaning extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist. B). Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), Resident #2 scored a 4 indicating total dependence (full staff performance every time during entire 7-day period). G). Dressing how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas, Resident scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist). Resident #2 scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with one person assist. Toilet Use: how resident uses the toilet room, commode, bedpan, or urinal<BR/>Record review of Resident #2s Care Plan dated on 07/01/2022 indicated the following:<BR/>Resident #2 has an ADL self-care performance deficit with interventions of: ADL self-performance fluctuates with confusion but usually requires assistance as follows: Bed mobility-self-performance (Total Dependence), Bed mobility: support provided with 2-person physical assist, Transfer: self-performance (total dependence), Transfer-support provided with 2 person physical assist, walk in room- self-performance (activity did not occur), walk in room- support provided ADL activity did not occur, Walk in corridor- self-performance (Activity did not occur), walk in corridor-support provided ADL activity itself did not occur, Locomotion on unit-self performance (total dependence), Locomotion on unit- support provided one person physical assist, Locomotion off unit- self-performance (total dependence), locomotion off unit- support provided with one person physical assist, Dressing: self-performance (Extensive assistance), Dressing: support provided with two person physical assist, Eating: self-performance (Supervision), Eating: support provided with one person physical assist, Toilet use: self-performance (Total dependence), Toilet use: support provided with two person physical assist, <BR/>Personal hygiene: self-performance (Total dependence), Personal hygiene: support provided with two-person physical assist, Nurse aides to document Resident #2s most dependence self-performance per shift. Monitor for signs and symptoms of ADL decline and notify family, MD, identifying causes and solutions. Monitor/document/report to MD as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. <BR/>Record Review of Resident #2's Progress notes dated 04/15/2023 at 10:57 am, signed by Social Worker revealed: Social worker spoke with Family Member #12 to let her know about the new reporting guidelines for abuse and neglect. She (Family Member #12) asked that it be mailed. She (Family Member #12) may also pick it up today when she is here. The form is also placed in Resident #2's room. <BR/>During an Observation on 04/13/2023 at 12:08 pm with Sampled Resident #2 revealed: Observed Resident #2 laying in his bed visiting with family member. Observed Resident #2 free from distress. <BR/>During an Interview with Resident #2 on 04/13/2023 at 12:07 pm. Resident #2 was able to slowly reveal the complaint that he had against CNA D with the help of family member. Resident #2 stated that during care he went to grab side bars and CNA D pushed him hard and motioned to Surveyor where his head was hit on the side bars. Resident #2 stated, He hits me, hard. (CNA D). Resident #2 put his fingers on top of his head and stated, Devil. Surveyor stated who is the Devil, Resident #2 called CNA D by name. Observed Resident #2 began to show signs of anxiety just talking about it and began to tear up in his eyes. Family member #11 had to console Resident #2 to get him to calm down. <BR/>During an interview on 04/13/2023 at 12:17 p.m., with Family member 12 via telephone for Resident #2, Family Member #11 used her own personal cell phone to reach out to Family member #12 and was happy to share some concerns. Family Member #12 stated that she does have some concerns with CNA D and that she did not have a lot of time because she had to get back to work but would like the opportunity to write down all the concerns and get back with Surveyor in a couple of days. Family Member #12 stated that she was told by Resident #2's old roommate (Resident #9) that he witnessed CNA D tell Resident #2 to stop using the call light so much or the next time he puts him in the Hoyer lift he (CNA D) will leave him there. Family Member #12 stated that the Administrator and BOM both knew that these things were going on and did nothing about it. Family Member #12 stated that she had stressed out so much from worrying about Resident #2 being in the facility when CNA D is working. Family Member #12 stated that she would like to make a written statement to provide to Surveyor about all the things that CNA D did to Resident #2. <BR/>Record Review of a written Statement provided on 04/15/2023 at 8:00 am, from Family member #12, revealed:<BR/>To Whom it May Concern:<BR/>I (Family Member #12) just want to say thank you, my name is (Family Member #12), stated it is unfortunate that they are in the situation that they are in with the facility. Family Member #12 stated that she is willing to share Resident #2 journey at the facility in hopes that something or someone will finally do something to help these residents. Family Member #12 stated that everything had gone fine until the facility had hired CNA D (nights). Family Member #12 stated that she finally became concerned when CNA D had acted in a manner in front of another family member like he didn't like Resident #2 (talking rude to him). Family Member #12 stated that CNA D had a demeanor that he did not have a very caring personality and acted like he didn't want to be there most times. Family Member #12 stated that she had witnessed one of the times that CNA D had been rough with Resident #2 when she walked in when he was providing care and she told CNA D, Hey be easy with him. Family Member #12 stated that it seemed to upset CNA D when she told him because he got an upset look on his face. Family Member #12 stated that as time passed by it got to a point when Resident #2 didn't want family to leave him there alone when CNA D was working. Family Member #12 stated that she finally reported her concerns to the DON and Administrator at the time on October 2022 and she was told that the facility was investigating the situation but nothing ever changed. Family Member #12 stated that she asked weeks later and was still told that it was being investigated and still nothing changed. Family Member #12 stated that she got so frustrated because the facility is supposed to protect the resident's and did nothing to protect. Family Member #12 stated that about the second week of November 2022 she was approached by the DON and stated that the DON told her that there was an incident that the CNA D had Resident #2 up in the Hoyer and CNA D told Resident #2 that if he didn't stop, bitching, and pushing the call light that he (CNA D) would leave him up there. Family Member #12 stated that she was told by DON at the time that CNA D had left Resident #2 in midair in his brief that was soiled and wet for a good period of time. Family member #12 stated that she was told that the situation is being investigated, and again nothing happened. Family Member #12 stated that she went to the DON after days of hearing nothing and asked what was going to be done and DON stated that other residents had to be questioned. Family Member #12 stated that she asked at this time for CNA D not to be allowed to go into the room or care for Resident #2. Family Member #12 stated that she was told by the administrator that the facility could not do that and that is when she knew that there was going to be a problem with this place. Family Member #12 stated that it got to a point that family members would try to go as much as possible in hopes that the situation would stop. Family Member #12 stated that most times she was there that Resident #2 would show anxiety anytime CNA D would work. Family Member #12 stated that another incident happened in December 2022 with CNA D and Resident #2. Family Member #12 stated she was there at the facility with Resident #2, and she pushed the call light because Resident #2 was soaking wet and had, poop in his brief. Family Member #12 stated that Resident #2 started getting really anxious and scared. Family Member #12 stated that CNA D came in the room and told Family Member #12 that she had to leave the room for the privacy of Resident #2. Family Member #12 told CNA D that she would not leave the room. Family Member #12 stated that CNA D then told her that he would not change Resident #2 then. Family Member #12 stated that she told CNA D that she was going to report him to the administrator. Family Member #12 stated when she threatened to report CNA D, he then changed Resident #2, but CNA D was very rough and when he pushed Resident #2 to the side CNA D pushed him so hard that Resident #2 hit his head on the side pull bars. Family Member #12 stated that Resident #2 would cry sometimes and say that he was scared to go to sleep because of CNA D. Family member #12 stated that she did report this to the administrator and again, nothing, just investigating. Family Member #12 stated that she finally got to the point with the administrator that she said, What is it going to take, CNA D seriously hurting someone or killing them? Family Member #12 stated that she was scared daily, and this stressed her out because she was constantly worried about Resident #2. Family member #12 stated that things got worse with CNA D and Resident #2 began telling her that CNA D would twist his arm really hard and yell at him. Family Member #12 stated that she had went to the facility on March 10th, 2023, and already had Resident #2 up and in the wheelchair. Family Member #12 stated that Resident #2 was crying and very scared with his fists clenched. Family Member #12 stated, What's wrong, what happened, to Resident #2. Family Member #12 stated that Resident #2 had told her that CNA D was pulling and hitting him in his bad arm and leg. Family Member #12 stated that she had never been so scared before for Resident #2 because it was getting worse. Family Member #12 stated that she would have to go out of town that day due to her daughter having cancer. Family Member #12 stated that she told the current Administrator and was told by the Administrator that she would have to report this to Human Services, and she would question CNA D to see what happened. Family member #12 stated that when she came back from out of town that the Administrator told her that CNA D was on a 30-probation and was suspended. Family Member #12 stated that she told the Administrator not put CNA D to care for Resident #2 and she was told that this could not happen due to lack of staff that the facility had. <BR/>Resident #3:<BR/>Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: stroke, anorexia, muscle wasting and atrophy (decrease in size of a body part), dementia, lack of coordination, atherosclerotic heart disease (buildup of fats, cholesterol, and other substances on the artery walls), unsteadiness on feet, schizoaffective disorder, depression, anxiety, seizures, insomnia, high blood pressure, abnormalities of gait and mobility. <BR/>Record review of Resident #3 admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 12 meaning cognitively moderately impaired.<BR/>Under B0200-Hearing: Resident #3 was listed as 0 meaning: Adequate- no difficulty in normal conversation, social interaction, listening to tv. <BR/>Under B0600-Speech Clarity: Resident #3 was listed as 0 meaning: distinct intelligible words.<BR/>Under B0700-Makes Self Understood: Resident #3 was listed as 1 meaning: Usually Understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800-Understands Verbal Content however able: Resident #3 is listed as a 1 meaning: Usually understands-misses some part/intent of message but comprehends most conversation. <BR/>Under C1310-Delirium- Resident #3 was listed as a 0 meaning there is no delirium. <BR/>Under G0110-Functional Status: Bed mobility-Resident #3 was listed as extensive assistance with 2 person assist, Transfer-Resident #3 is listed as total dependence with 2 person assist, walk in room- Resident #3 was listed as activity did not occur, Walk in corridor- Resident #3 was listed as activity occurred only once or twice with 1 person assist, Locomotion on Unit- Resident #3 was listed as extensive assistance with one person assist, Locomotion off Unit- Resident #3 w[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 residents (Residents #1) reviewed for abuse and neglect. <BR/>The facility Staff (Administrator) failed to report the incident that occurred on 03/30/2024 and 04/04/2024 between Resident #1 and Resident #2 to the governing state agency. <BR/>CNA H &I failed to report allegations of abuse to the abuse coordinator within 2 hours of incident.<BR/>These failures could place the residents in the facility at risk of lacking timely reporting of incidents, risk of abuse, neglect, exploitation, or misappropriation of their property by staff members and contribute to further resident abuse.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread, and uneasiness), cognitive communication deficit (difficulty understanding and communicating). <BR/>Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #1 had slurred speech, could make himself understood and usually understood others. <BR/>Record review of Resident #1 Care Plan, dated 02/29/24, revealed that he is a max assist, depends on staff for meeting his needs, requires tube feeding, has depression (impaired ability to remember), is on antianxiety medications, and that he was pulled from the bed on 04/25/24.<BR/>Record review of Resident #1's progress notes revealed the following:<BR/>04/25/24 at 05:08 PM LVN A documented:<BR/>Resident #1 was found on the floor was pulled out of bed by another resident (unidentified) assist Resident #1 back to bed did assessment no injures noted<BR/>03/30/24 at 12:49 AM LVN B documented:<BR/>Other resident (unidentified) tried to pull Resident #1 out of his bed. other resident (unidentified) scratched Resident #1 across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Other resident (unidentified) was taken to his own room. <BR/>Record review of Resident #2's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was readmitted to the facility on [DATE] with diagnosis to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. <BR/>Record review of Resident #2 care plan, dated 04/30/24 revealed the following: <BR/>Focus (Date initiated:04/26/24 Date revised:04/26/24)<BR/>4-25-24-I pulled another resident out of bed.<BR/>Goal<BR/>I will have no further episodes of aggression through review date.<BR/>Interventions<BR/>Placed 1:1 Sent to a behavior support center. <BR/>Focus (Date initiated:01/22/24 Date revised: 01/22/24)<BR/>I am an elopement risk/wanderer. Wander risk<BR/>Goal<BR/>I will not leave facility unattended through the review date.<BR/>Interventions <BR/>Distract me from wandering by offering pleasant diversions. I prefer having snacks.<BR/>followed by psychiatric services. notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications.<BR/>Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log.<BR/>Focus (Date initiated: 01/22/24 Date revised:01/22/24)<BR/>I have episodes of verbal and physical aggression r/t dementia.<BR/>Goal<BR/>I will not harm self or others through the review date.<BR/>Interventions <BR/>Give me as many choices as possible about care and activities.<BR/>Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. <BR/>Monitor/document/report PRN any s/sx of me posing danger to self and others.<BR/>When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Focus (Date initiated:01/22/24 Date revised:01/22/24)<BR/>I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye.<BR/>Goal<BR/>I will show no decline in visual function through the review date.<BR/>Interventions <BR/>Arrange consultation with eye care practitioner as required.<BR/>Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Place frequently used items on my left side so I may see them<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>04/25/24 at 04:55 PM LVN A documented:<BR/>Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room.<BR/>04/24/24 at 08:25 PM the DON documented:<BR/>7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and laid down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. <BR/>04/23/24 at 11:34 AM the DON documented:<BR/>Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. <BR/>04/23/24 at 1:06 AM LVN A documented:<BR/>Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2<BR/>04/15/24 at 4:16 AM LVN B documented:<BR/>Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room.<BR/>04/04/24 at 05:11 PM LVN B documented:<BR/>Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking<BR/>cane from rt hands and redirect to room. Admin notified.<BR/>03/30/24 at 12:26 AM LVN B documented:<BR/>Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room.<BR/>03/30/24 at 05:27 PM LVN D documented:<BR/>Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go<BR/>into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room.<BR/>Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision.<BR/>Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1.<BR/>Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every 30 minutes on 05/08/24-05/10/24.<BR/>During an interview on 05/08/24 at 11:42 AM, the DON stated Resident #2 had advanced dementia. The DON said she, as the DON, had been trained on what to do regarding reporting ANE. She said their system for monitoring ANE was to educate staff through in-services. The DON said all staff had been trained on reporting ANE. The DON said staff were trained upon hire, annually, and when an incident arose. The DON said staff had been trained to report abuse immediately to the abuse coordinator, and she expected her staff to do so. The DON said she was unaware why CNA H and I did not report the allegations of verbal abuse immediately. She said all staff were responsible for reporting ANE immediately to the abuse coordinator. The DON said the ADM was the abuse coordinator. <BR/>During an interview on 05/08/24 at 11:42 AM, the ADM stated she was unsure of the date and exact time, but CNA G came to her and told her that he needed to tell her something. The ADM said CNA G told her that he was told by CNA H & I that LVN A was ugly to Resident #2. The ADM said that she immediately suspended LVN A upon being notified of the situation. She stated she immediately suspended CNA H & I. The ADM stated she reported the incident to the state. She said they conducted safe surveys. She said Resident #2 could not recall the incident. The ADM stated they reported the incident to the sheriff's department.<BR/> During her investigation, the ADM said CNA H admitted that she witnessed LVN A yelling at Resident #2. CNA I also admitted that LVN A yelled at Resident #2. The ADM stated she immediately educated CNA H & I that she was supposed to report it immediately. The ADM said she was unaware why the staff did not report the incident because she was physically in the facility the night of the incident (04/25/24). She said The CNAs did not give her a reason why they did not report it immediately. She said she was never notified until the next morning. The ADM stated that CNA H was an agency staff member but that they had an understanding that all ANEs should be reported immediately. The ADM stated when she spoke with LVN A that LVN A denied the allegations of verbal abuse but that LVN A did tell Resident #2 to get out of bed, which was not his. She said LVN A did admit that she was loud. After consulting with her corporate office, the ADM decided to terminate LVN A based on interviews and her past involvement in other incidents. The ADM stated that she did not terminate the CNAs because they had never had issues with their performance and had reeducated them on ANE. The ADM stated they also considered that CNA H & I did report the incident to another coworker even though they should have reported it to the abuse coordinator as trained. She said the potential negative outcome of not reporting allegations of abuse immediately to the abuse coordinator could place residents and staff in harm's way. The ADM stated they were at the facility to protect the residents. The ADM stated her system to monitor that the abuse policy was being followed implemented, and staff was reporting allegations of abuse was that they trained staff through inservices. The ADM stated policies and signs were posted with the ADM's name and number on the wall. She said she had been trained on the abuse policy, and all staff had been trained. She said she expected to be notified of ANE immediately when and if it happened. She said all staff were responsible for reporting and following the abuse policy. She said she did not know why CNA H and I did not report the allegations immediately. The ADM stated it was reported to her that on 04/25/24, around 7:30 PM. The ADM said that Resident #2 went into Resident #1's room. The ADM stated Resident #1 and Resident #2's rooms are next to each other. She stated staff heard yelling but was unsure where the yelling was coming from. She stated when staff entered the room, they observed Resident #1 on the floor, and Resident #2 was in Resident #1's bed. The ADM stated staff redirected Resident #2 to his room, assessed Resident #1 and did not identify any injuries on either resident. The ADM stated she was notified and physically came to the facility to attempt to get additional support from a local behavior support center for Resident #2's behavior. She said Resident #2 was transported to a behavior support center the same night. The ADM stated that Resident #2 had never done this to Resident #1 before. She stated Resident #1 had a history of aggressive behavior with staff. The ADM said as a result of this incident, on 04/25/24, they conducted training with staff over resident rights, ANE, and that they had consulted with the local behavior support center to conduct training on dealing with aggressive behaviors, but no official date had been set.<BR/>During an interview on 05/08/24 at 12:37 PM, CNA G stated he did not remember the exact date but he had come in at the beginning of his shift. CNA G stated he was getting a report from the night-time CNAs, and it was passed on that Resident #2 had pulled Resident #1 out of bed. CNA G said he was told by CNA H &I that when Resident #2 refused to leave Resident #1's bed, LVN A yelled loudly for Resident #2 to get the fuck out of the bed. CNA G said he was told it was so loud that everyone in the facility could hear it. CNA G said that CNA H & I appeared concerned with how LVN A approached the situation. CNA G stated he immediately reported it to LVN D, and the ADM. CNA G stated as a result of his report of LVN A's verbal abuse immediately that the ADM started getting witness statements but was unaware of what was done with LVN A. CNA G stated he had not seen LVN A back at the facility since the incident. He stated he reported the incident immediately because he had been trained to report all allegations of ANE immediately to the abuse coordinator. <BR/>During an interview on 05/08/24 at 01:34 PM, Resident #2 said he did not recall staff yelling at him, felt safe, had difficulty seeing things, and had no physical incidents with staff or other residents. Resident #2 said he knew where his room was but could not recall a specific room number. He said he did not have any additional concerns. <BR/>During an interview on 05/08/24 at 1:50 PM, Family Member J stated on 04/25/24, she was notified that Resident #2 had thrown Resident #1 on the floor. Family Member J said she was notified that Resident #1 was assessed, received x-rays, and had no injuries. Family Member J said she spoke with Resident #1 and was told he was not hurting too badly.<BR/>During an interview on 05/08/24 at 2:02 PM, Resident #1 stated via telephone that Resident #2 had pulled him off the bed, and he did not want it to happen again.<BR/>During an interview on 05/08/24 at 2:03 PM, Family Member K stated via telephone that she was physically with Resident #1 but that he had a hard time talking because of his stroke. Family Member K said there was an incident where LVN A walked into the room (unsure of the date), and Resident #1 was sideways, hanging onto the bed with one arm. She said she believed there was another incident where Resident #1 tried to protect his feeding tube site. She said she was concerned that this was happening when Resident #1 was sleeping, and that Resident #1 could not defend himself. Family Member K said the staff knew about the incidents and needed to do something. Family Member K said that she had not physically told anyone but was told by Family Member J that she had. <BR/>During an interview on 05/08/24 at 2:18 PM, CNA F stated she was unsure of the exact dates, but about a month before the interview, She and CNA E had caught Resident #2 in Resident #1 room. CNA F said Resident #2 was confused and had difficulty seeing. CNA F said she did not believe Resident #2 was being mean or awful to Resident #1, but he thought he was in his (Resident #2) room. CNA F stated Resident #1 was yelling. CNA F said when they got to Resident #1's room (she and CNA E), they observed the door closed and the lights off. CNA F said when they turned on the lights, they observed Resident #2 trying to pull Resident #1 off the bed. CNA F stated water was on the floor, and Resident #1 Head was on the bed rail. She observed the side table turned over, and Resident #1 was protecting his feeding tube site and crying. CNA F attempted to redirect Resident #2, but he refused to leave. CNA F stated this incident was reported to LVN B. CNA F stated LVN B said she reported the incident to the appropriate parties. CNA F stated a week after that incident (unsure of the exact date), Resident #2 was back in Resident #1's room. CNA F stated that Resident #1 had pushed his call light, and Resident #2 was standing in Resident #1's room when they got to him. CNA F stated that when they attempted to redirect him out of Resident #1's room, Resident #2 stated he wanted his jacket, and they grabbed his hand. Finally, Resident #2 went with them. CNA F stated that there had been a lot of changes in the facility as far as room changes and believed that the separation by gender may have contributed to Resident #2 being confused about where he was going and, in addition, his difficulty being blind. CNA F stated Resident #2 had been moved three or four times. CNA F stated the difficulty they had been having with Resident #2 had been reported to LVN A and LVN B (unsure of the exact time and date). She stated she was under the impression that, as the CNA, she was to report to her charge nurse and that they would proceed further if needed. She said her charge nurses had told her that the incidents with Resident #2 had been reported to higher people. CNA F stated they had wondered when something would be done. CNA F stated she was frustrated with all the incidents that had occurred with Resident #2. She stated that although Resident #2 was not evil and was sweet, his behaviors had worsened, and he had become more confused. CNA F stated that outside of the incidents with Resident #1, Resident #2 had become aggressive with her, and CNA G. CNA F stated that if something had been done, some of the incidents with Resident #2 could have been prevented.<BR/>During an interview on 05/08/24 at 2:58 PM, CNA E stated she could not remember exact dates and times. CNA E stated the first incident between Resident #1 and #2 might have occurred four months ago. CNA E stated that she and CNA F were doing rounds and heard Resident #1 scream aloud. CNA E stated Resident #2 was in Resident #1 room. CNA E stated she observed Resident #1 halfway off the bed. CNA E stated that Resident #1 had his family member in the room. CNA E stated Resident #1 was halfway off of the bed, and she observed the lower half of Resident #1's body off the bed. CNA E said Resident #1 was holding onto the bed rail with his right arm. CNA E stated the incident where Resident #1 was hanging off the bed was the first incident she had ever seen. She said she reported the incident to the charge nurse but could not remember who it was as they have many charge nurses. CNA E stated there was another incident (unsure of the date and time) where Resident #1 screamed. CNA E stated that Resident #2 scratched Resident #1 during this incident. CNA E stated it happened possibly two months ago. CNA E stated Resident #2 had scratches on his chest and right side. CNA E stated this was reported to LVN B. CNA E stated that she had to scream for assistance during this incident. She stated CNA F came to assist her. CNA E stated that this incident scared her and that things were worsening with Resident #2's behaviors. CNA E stated that Resident #2 was telling her that Resident #1's room was his room and yelling at her. CNA E said she kept telling him it was not his room. CNA E said that after they told LVN B, she (LVN B) would notify the appropriate parties. She said Resident #1 appeared scared and had water in his eyes. She said Resident #1 said it was scary. CNA E said Resident #1 used minimal words such as scary, hurt, and oh man to describe what had happened. CNA E said there was another incident where Resident #2 had become agitated and aggressive with staff; this was when she messaged the DON. CNA E said she did not like what was happening, and it made her sad about what had happened to Resident #1. <BR/>During an interview on 05/08/24 at 3:29 PM, LVN A stated that she no longer worked at the facility. LVN A stated on 04/25/24 that she did not witness Resident #2 pulling Resident #1 out of the bed. LVN A stated that she had heard Resident #1 scream and thought it was another resident. LVN A said that when she walked down the hallway, one of the CNAs came running towards her. LVN A stated she could not remember the CNAs name. LVN A when she went into Resident #1's room and observed Resident #2 in Resident #1's bed and Resident #1 was on the floor. LVN A said this was not the first interaction between Resident #1 and Resident #2. LVN A stated this was the second time this had happened. LVN A said that during the incident on 04/25/24, Resident #2 yelled at the staff. LVN A stated she raised her voice for Resident #2 to get out of Resident #1's bed. LVN A said that they were finally able to get Resident #2 out of Resident #1 room. LVN A said she notified the DON of the incident. LVN A stated the DON said that she told the ADM and that the ADM was on the way to the facility to send Resident #2 out for behavior support. LVN A said she had experienced Resident #2 becoming agitated with staff on 04/18/24. She stated that the FNP, PCP, DON, and ADM knew about the incident. She said she had been told by other staff that Resident #2 had attempted to pull Resident #1 out of bed before. She said she was unaware of any interventions that had been put in place. <BR/>During an interview on 05/08/24 at 10:25 PM, CNA I stated on 04/25/24, it was around 7 PM or 9 PM when the residents that smoke go out. CNA I said she observed Resident #1 on the floor. CNA I said she went to get LVN A, and that was when she (LVN A) told Resident #2 to get the fuck out. CNA I said she redirected Resident #2 to his room. CNA I stated she and CNA H placed Resident #1 back in bed. CNA I said their shift was over at 6:00 AM the next morning, and LVN A worked the remainder of her shift. CNA I stated that she did not report the verbal incident because the LVN A knew about it as she was there and had said the words to Resident #2. CNA I stated she reported the incident to the oncoming shift the next morning. CNA I said the ADM and DON reeducated her. CNA I said that she had never heard LVN A curse at the residents but had observed her be loud. CNA I said she and her coworker (CNA H) did discuss that the interaction between Resident #2 and LVN A was aggressive and abrasive. CNA I said she was more focused and glad that Resident #1 was not hurt. CNA I said after that incident and Resident #2 received a shot of Ativan he came back out and was trying to throw a shoe at Resident #1. CNA I said that most of the time when she worked with Resident #2, he would always try to go into Resident #1's room. CNA I said this occurred at least three times a week. Before the incident on 04/25/24, CNA I said that Resident #2 never made physical contact with Resident #1 on her shift. CNA I said there was nothing ever done that she could recall to alleviate the situation, but the staff had placed gloves on the outer door at one point. She stated she could not provide a picture of the gloves on the door to the HHSC worker. CNA I said that she had been trained to report allegations of ANE immediately. <BR/>During an interview on 05/08/24 at 10:51 PM, LVN D stated that the incident on 04/25/24 was the second time that Resident #2 had attempted to pull Resident #1 out of bed. She stated she was not present but had received the information in the report as she typically worked the day shift. LVN D said that they had to redirect Resident #2 consistently. LVN D stated that she did not feel that Resident #2 was explicitly targeting Resident #1 but that he was confused as to where his room was. <BR/>An attempt to contact LVN B was made on 05/08/24 at 10:57 PM. LVN B said she would contact her DON and ADM and return the call. Additional attempts to speak with LVN B were made on 05/09/24 at 10:29 AM. LVN B did not answer. <BR/>During an interview on 05/09/24 at 10:52 AM, the Activity Director stated that she participated in Resident #1's care plan. The Activity Director stated that Family Member J expressed that Resident #2 had wandered into Resident #1's room once or twice. <BR/>During an interview on 05/09/24 at 11:27 AM, Resident #1 stated that Resident #1 had been in his room [ROOM NUMBER]-5 times. Resident #1 said out of those 4-5 times, Resident #2 had become physical with him. Resident #1 stated no one had come to him and interviewed him about the incident outside of the HHSC investigator. Resident #2 said that he was afraid when he had to hang onto the bed. Resident #1 said he had told multiple CNAs and nurses that he did not want Resident #2 in his room. Resident #2 said he could not remember the names of the staff he told. Resident #2 said he felt like his problem was never solved. Resident #1 said that three times when Resident #2 came into his room, it got physical; he was pulled off the bed, scratched, and pulled halfway off the bed. Resident #1 said he could not remember the date and time when the incidents happened but that staff knew about it because they had to help him.<BR/>During an interview on 05/09/24 at 1:07 PM, the ADM clarified that during the initial interview, she stated the incident between Resident #2 and Resident #1 had never happened was because three weeks prior, staff had reported that Resident #2 had gone into the room and scratched Resident #1 and LVN B had redirected Resident #2 out. The ADM stated she was unsure where the scratch was. The ADM stated this type of information was typically reported to the DON. The ADM stated she did not report the incident to the state agency because the nurse had intervened and redirected Resident #2 out of the room. The ADM said she was unaware that Resident #2 had encountered Resident #1 multiple times. The ADM said she was unaware that Resident #2 had attempted to pull Resident #1 out of the bed before the incident on 04/25/24. The ADM said they were monitoring Resident #2's behavior through psychiatric services and medication adjustments. The ADM stated that the staff had expressed concerns about them getting hurt, but she was unaware of the ongoing issues with Resident #1. She said she was only aware of one incident where Resident #2 had become aggressive with staff. She said she was unaware of any other incidents. The ADM said she knew that most of Resident #2's incidents or behaviors occurred at night. The ADM said she did not implement any other interventions outside of the medication adjustments and monitoring from psychiatric services and notifying the family, PCP, and FNP. The ADM said she had never interviewed Resident #1 to see if this had happened. The ADM had never delegated to interview Resident #1. The ADM said the night of the incident (04/25/24), she was more concerned with his well-being and what happened. The ADM said part of the investigation process was interviewing key witnesses and residents and finding out what happened. The ADM said the potential negative outcome of not reporting allegations of abuse to the state governing agency was that resident harm or the resident's safety could be compromised. The ADM said she was unaware of the additional incidents outside of the incident on 04/25/24 between Resident #1 and Resident #2. The ADM said her system for monitoring ANE was that signs were posted that instructed staff to contact her regarding ANE concerns. The ADM said they educate staff to report allegations of abuse immediately, and the ANE policy was attached to those inservices. The ADM said she expected the staff to report immediately if they witnessed or suspected abuse. The ADM said she and the staff had also been trained to report allegations of ANE immediately. The ADM said everyone was responsible for following the abuse policy and reporting ANE immediately.<BR/> During an interview on 05/09/24 at 2:17 PM, the DON stated that the only other incident she knew of between Resident #1 and Resident #2 was where Resident #2 scratched Resident #1. The DON said she was unsure of the date and time when this incident occurred. The DON said that Resident #2 was redirected out of the room. The DON said she was unaware of any other incidents. The DON said that she could not think of any other interventions put in place outside of psychiatric medication adjustments and close monitoring. The DON stated she never interviewed Resident #1. The DON said once an incident was reported to the ADM, she would relinquish the investigation process to the ADM because she had so much on her plate. The DON said the potential negative outcome of not reporting allegations of abuse was that abuse could continue to happen. The DON said she was aware of two incidents between Resident #1 and Resident #2 and was unaware that this was an ongoing situation. The DON said their system for monitoring ANE reporting and following the ANE policy was to educate staff through inservices. The DON said she had never observed Resident #2 enter Resident #1's room. The DON said she expected staff to report all incidents of abuse to the abuse coordinator.<BR/> Record review of salesforce (tulip) revealed from January 2024 until May 2024 date no other reports have been made to state in regard to Resident #1 and Resident #2 other then the incident that has us in the facility. <BR/>Record review of the facility's policy, Abuse, Neglect, Exploitation General Policy, Filing, undated revealed the following:<BR/>PROCEDURE :<BR/>Investigation<BR/> All facility employees, family members and volunteers and educated that alleged or suspected [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 residents (Resident #1) reviewed for abuse. <BR/>The facility failed to report a reasonable suspicion of Abuse for Resident #1 after allegations were made by staff members to Administrator and Resident #1 suffered a spiral fracture to his upper left arm. <BR/>This failure could place all residents at risk of further potential injuries or Abuse. <BR/>Findings included: <BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, <BR/>Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) listed as 3, meaning severe cognitive impairment.<BR/>Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. <BR/>Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words.<BR/> Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. <BR/>Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. <BR/>Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. <BR/>Under C0700 labeled long-term memory is left blank and not completed. <BR/>Under C0800 labeled Memory/Recall Ability is left blank and not completed. <BR/>Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. <BR/>Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. <BR/>Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. <BR/>Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. <BR/>Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under <BR/>B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. <BR/>Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. <BR/>Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. <BR/>Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance.<BR/>Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). <BR/>Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. <BR/>Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. <BR/>Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. <BR/>Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. <BR/>Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. <BR/>Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). <BR/>Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. <BR/>Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. <BR/>Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. <BR/>During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. <BR/>During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. <BR/>During an Interview on 04/13/2023 at 1:16 pm with CNA D, stated that he has worked in the facility for approximately six months. CNA D stated that he had just barely had to meet with the police to give a statement. CNA D stated that he did not know before this that there was a problem. CNA D stated that the facility had not called him to let him know that there was an issue. CNA D stated that when the police called to question him and now being interviewed by State let him know that there was a problem. CNA D stated that he had three interactions with Resident #1 that night that he worked. CNA D stated that the first two interactions with Resident #1 was just to redirect him back to his room. CNA D stated that the last interaction that he had with Resident #1 is when Resident #1 was found by the Monitor Tech in another resident room in an empty bed. CNA D stated that the Monitor Tech L stated that she needed help to transfer Resident #1. CNA D stated that he offered to help. CNA D stated that he tapped Resident #1 on the shoulder a few times to wake him up. CNA D stated that immediately Resident #1 was aggravated when he was awakened. CNA D stated that Resident #1 was telling him to leave him alone. CNA D stated that he walked out of the room for approximately 10 minutes to allow Resident #1 to calm down. CNA D stated that he returned into the room and tapped on the shoulder of Resident #1 again. CNA D stated that Resident #1 was having a hard time standing up so CNA D stated that he grabbed Resident #1 in both of the arm pit areas to pick him up with his (CNA D) thumbs on the outside of the armpits. CNA D stated that Resident #1 began to punch him several times in the CNA D stomach. CNA D stated that it did not bother him that Resident #1 was hitting him because he is not a big guy. CNA D stated, I am a big guy, and I can handle it. CNA D stated that he escorted Resident #1 to his room with no problems. CNA D stated that he escorted Resident #1 by getting behind Resident #1 and grabbing his arms and directing him to go towards his room. CNA D stated that when he was redirecting Resident #1 that he kept trying to pull away from him (CNA D), so CNA D stated he had to grab firmly to keep Resident #1 from trying to pull away while CNA D redirected him. CNA D gave a witness statement that Resident #1 does not like him (CNA D) and he does not know why. CNA D stated that the incident happened on 04/11/2023 on his night shift. CNA D stated, Now as of 04/13/2023, I am probably being suspended since State is in the building). CNA D stated that the administrator didn't tell him anything about the incident or question him yet still until State came in the building. CNA D stated that the Administrator told him that when he is done giving a statement to State then she needed to question him. CNA D stated that he did have another complaint with another resident and had been written up for that one before. CNA D stated that the resident that made that complaint didn't like him either and tried to make accusations that CNA D was rough with him (Resident #2). CNA D stated that is all he is going to say unless he has an attorney. Surveyor ended Interview and thanked CNA D for taking the time to interview. CNA D stated to Surveyor, I'm sure I will have 3 days to be pissed off about all this, I'm sure that's what I am going to do. I can't afford to get suspended again.<BR/>Record Review of the Disciplinary Action for CNA D, provided on 04/13/2023, labeled, Counseling Notice, dated on 03/13/2023, revealed: CNA D had been suspended for three days and a 30-day probation period for a previous accusation of being too rough with a different resident which was used as a sample resident for this investigation. <BR/>Suspension: 3 days<BR/>Reason for Counseling Notice: Complaint from Resident #2 family, See Report on back.<BR/>Report on Back: 03/13/2023, HR counseled with CNA D, discussed his approach to patient care. He apologized and stated he didn't realize he was being too rough. He has been suspended for 3 days. After counseling CNA D agreed to a 30-day probation period and would not be allowed any reports from family or residents. CNA D stated he loved his job and would be agreeable to the 30-probation period, and then would review. <BR/>Supervisor Statement: I have discussed the counseling notice with the employee CNA D. Signatures included Administrator, CNA D, and BOM<BR/>Record Review of the Disciplinary Action for CNA D, provided on 04/14/2023, labeled, Counseling Notice, dated on 04/14/2023 at 12:30 pm revealed: CNA 4 had been terminated on 04/14/2023 via phone with no signature from employee provided. <BR/>Termination-Effective Date: 04/14/2023 at 12:30 pm<BR/>Reason for Counseling Notice: Termination due to employee allegations of Abuse and Neglect. <BR/>Signed by: Administrator, BOM, No Employee signature provided. <BR/>During an interview on 04/13/2023 at 4:20 p.m. with CNA C, stated that she worked with CNA D on the shift of 04/11/2023 going into 04/12/2023 from 7p.m. top 7 a.m. night shift. CNA C stated that she thought the incident was on 04/10/2023 going into 04/11/2023 but could check camera to make sure. CNA C stated that at about 2:30 a.m. the monitoring tech asked her and CNA D if they could help to get Resident #1 out of another room because she had found him asleep in an empty bed that was not his. CNA C stated that she was busy with another resident at the time that the monitoring tech had asked so CNA D stated that he would go help. CNA C stated that the monitoring tech was fully capable of doing it herself and she is unsure why the monitoring tech needed help to walk Resident #1 back to his bed, but she still wanted assistance. CNA C stated that when she was done tending to her resident, she overheard LVN A ask CNA D, What did you do to Resident #1?, CNA C stated that she also heard LVN A ask CNA D, Why is Resident #1 yelling in pain right when you walk out of his room? CNA C stated that she then heard CNA D tell LVN A that he had just grabbed Resident #1 under both of his arms and pulled him up out of the bed to transfer him. CNA C stated that she then witnessed CNA D say that he was all of a sudden feeling sick and she saw him go outside. CNA C stated that when CNA D came back inside the facility he asked if anyone cared if he went home because he did not feel good. CNA C stated that she was surprised because up to that point CNA D had not acted as though he was sick, she stated, He was fine all night. CNA C stated to CNA D that she did not care if he went home and that she could handle the workload, and then he left. CNA C stated that LVN A asked her if she would go with her to Resident #1 room to ask him what happened because he was crying out in pain since CNA D had left his room. CNA C stated that she would go with LVN A to Resident #1s room to find out what happened. CNA C stated that she asked Resident #1 in Spanish what happened and why is he in pain and CNA C stated that Resident #1 stated, He hit me, TWICE (DOS). CNA C stated that she told Resident #1, Why do you say that? CNA C stated that Resident #1 stated, He wanted to fight me. CNA C stated that she observed Resident #1 in a lot of pain. CNA C stated that Resident #1 was crying and moaning in pain. CNA C stated that she showed Resident #1 with her hand and opened her hand and stated, Did he hit you with open hand like this? CNA C stated that she then made a fist and showed Resident #1 and then asked Resident #1, Or did he hit you with a fist? CNA C stated that Resident #1 then made a fist and stated, He hit me like this. CNA C stated that she observed LVN A assess Resident #1 for injuries and they both saw a big red mark on his upper left arm. CNA C stated that LVN A was slightly feeling Resident #1's arm and stated there is a big lump and a space. CNA C stated that LVN A then stated that she needed to call the administrator and get Resident #1 sent out to the hospital. CNA C stated she did know that CNA D is not allowed to go into some of the residents' rooms alone because of being rough with some of the residents. CNA C stated that she did not know if Resident #1 was one of those residents or not, but she does know that he is not allowed in some of the other resident's rooms alone. CNA C stated that she had been told that by the nursing staff when she first started working there. CNA C stated that she was told that sometimes she may have to help him with certain residents and when she asked why that is what she was told. CNA C stated that she has noticed that CNA D would avoid taking care of Resident #1 and he has stated before that he did not like Resident #1. <BR/>During an interview on 04/13/2023 at 5:26 p.m. with Administrator revealed she was aware of the incident that occurred with Resident #1 and CNA D on 04/12/2023. Administrator stated BOM called her at approximately 3:30 a.m. on 04/12/2023 and told Administrator that LVN A called BOM to report that Resident #1 was punched in the face and there was blood everywhere. Administrator stated that she called the facility and spoke to LVN A and was told that Resident #1 was in pain to the point of moaning and was being sent out to the hospital. Administrator stated that LVN A told her that CNA D was involved, and she did assess the resident for injuries. Administrator stated, In my thinking that since Resident #1 was already being sent out to the hospital, that everything was taken care of. I was thinking that since CNA D had gone home sick and Resident #1 was sent out to the hospital, that everything was calm and taken care of. Administrator stated that LVN A stated that CNA D was involved with the incident with Resident #1, but she was thinking now that CNA D went home not feeling well and the resident was sent to the hospital everything is okay for now. Administrator stated that her next plan of action was to make sure the family was notified and that everyone was okay. Administrator stated that she was told by the BOM that she had contacted the Medical Director after the incident happened. Administrator stated that when she came into work that morning around 8 am or 8:30 am, she notified the police, and the police made a report. (Surveyor contacted chief police and informed that in the investigation process and report is not ready to view at this point on 04/14/2023). Administrator stated that she had not interviewed CNA D yet until after surveyor had interviewed him on 04/13/2023 sometime after 2:00 p.m. Administrator stated that when she asked CNA D what happened on 04/13/2023 sometime after 2:00 p.m., he stated that he had transferred Resident #1 to the room and that it. Administrator stated that CNA D had already been written up for a different incident for allegations of abuse, with Resident #2 and now he will be written up for Resident #1. Administrator stated that CNA D is not supposed to be in the room with Resident #2 due to the allegations that was made against him by family member and Resident #2. Administrator stated that he is supposed to have a partner to make sure that nothing happens. Administrator stated that she has had to partner CNA D up with a partner with certain residents due to allegations being made but she does not have the staff to just exclude him from working with certain residents because of the allegations. Administrator stated that her way of monitoring CNA D to make sure that he was using a partner to enter certain residents' rooms was that she wouldn't get any more complaints and that is how she would know. Administrator stated that she had not suspended CNA D at this time but that she is going to suspend him. Administrator stated that CNA D went home because he felt sick during his shift on 04/12/2023 and was not scheduled to work on 04/13/2023 but Administrator stated that she was going to suspend him when he came in to work next. Administrator stated that she does have CNA D phone number and could contact him that way but has not done that. Administrator stated she was just going to suspend him when he came in. Administrator stated that she does know what the policy says about reporting abuse and neglect. Administrator stated that she was not sure how to fill out the provider investigation report but did report but not until the next day when she came to work. Surveyor pulled out the facility provided policy for abuse and showed the Administrator the protocols for reporting allegations of abuse when there is an injury. Administrator stated that she is aware that she was supposed to report within the 2-hour timeframe but was tired and it was the middle of the morning so she was just going to report when she came into work and did not think that would be a problem. Administrator stated that the incident occurred around 3:00-3:30 a.m. and the incident was reported on 04/12/2023 after Administrator got to work sometime after 8:00 or 8:30 a.m. Administrator stated that her staff has been trained in abuse and neglect. Administrator stated that right now the facility does not have a DON or an ADON and she stated that usually the DON and ADON is responsible for making sure that training is completed. Administrator stated that the negative potential outcome for not preventing abuse is that other residents may get hurt.<BR/>During an interview on 04/16/2023 at 9:57 a.m. Administrator brought in a disciplinary form to Surveyor and had stated that she had herself written up for failing to report in the 2-hour timeframe and failure to report on the online portal for Abuse and Neglect. Surveyor reviewed disciplinary document and noticed it was dated as of 04/12/2023 but was provided on 04/16/2023. It shows the document is a written warning. Signed by Administrator, BOM, and an unidentified signature. <BR/>During an Interview on 04/13/2023 at 6:11 p.m. with LVN A, stated that she worked the night shift and that the night of the incident on 04/11/2023-04/12/2023 Resident #1 came to the nurse station and stated, I fell asleep on my hand. LVN A stated that Resident#1 had been asleep since 10 or 11 p.m. and had come to the nurse station approximately around 12:30 a.m. LVN A stated that she told Resident #1 that it would be fine just to give it a couple of minutes and his hand would wake back up. LVN A stated that Resident #1 then walked away, and she did not see what direction he had went. LVN A stated that she just figured that Resident #1 went to the day room to watch tv because he would do that sometimes. LVN A stated that when the Monitor Tech L went to make rounds, she noticed that Resident #1 was not in his bed and came to ask her if LVN A had seen Resident #1. LVN A stated that she told the Monitor Tech L that she had not seen him since he said his hand fell asleep. LVN A stated that she noticed that Monitor Tech L was going room to room to find Resident #1 and had found Resident #1 in Resident #10s room in the vacant bed, asleep. LVN A stated that a couple of minutes go by and LVN A stated that she hears Monitor Tech L and CNA D talking. LVN A stated that she had heard the Monitor Tech L tell CNA D that Resident #1 was in the vacant bed in Resident #10s room by the door. LVN A stated that she heard CNA D state, I will take care of it. LVN A stated that when she saw CNA D next, he had Resident #1 from behind,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to have evidence that all violations, in response to abuse, neglect, exploitation or mistreatment, were thoroughly investigated for 6 of 9 residents (Residents #1, #2, #3, #4, #5 and #6) reviewed for abuse and neglect.<BR/>1. The facility failed to investigate a fall incident that occurred on 05/30/24 with Resident #1 while in the care of CNA E. <BR/>2. The facility failed to investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3. <BR/>3. The facility failed to investigate a sexual incident that occurred on 05/11/24 between Resident #2 and Resident #4. <BR/>4. The facility failed to investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #3. <BR/>5. The facility failed to investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #6. <BR/>These failures could place residents at risk of incidents not being thoroughly investigated.<BR/>The findings included:<BR/>1. Findings for the facility's failure to investigate a fall incident that occurred on 05/30/24 with Resident #1 while in the care of CNA E. <BR/>Record review of Resident #1's face sheet, dated 06/05/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread, and uneasiness), and cognitive communication deficit (difficulty understanding and communicating). <BR/>Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #1 had slurred speech, could make himself understood, and usually understood others. Section GG Functional Abilities and Goals indicated the Resident #1 was dependent and this could mean that the resident did all the effort or that he required the assistance of 2 or more helpers to complete the activity of tub or shower transfer. <BR/>Record review of Resident #1 Care Plan, dated 05/29/24, revealed the following: Resident #1 had an ADL self-care performance deficit r/t to limited range of motion due to CVA. Resident #1's self-performance fluctuate r/t confusion, but he usually requires assistance with ADLs. Resident #1 required 1-2 staff for showering/bath and shower/tub transfer Resident #1 required two+ person physical assists. Resident #1 used a mechanical lift for transfers with a minimum of two staff present unless transferring with therapy/ restorative. Resident #1 was at risk for falls r/t balance problem. Ensuring Resident #1 frequently used items were within reach. Resident #1 had osteoporosis and was at risk for fractures.<BR/>Record review of Resident #1's progress notes revealed the following:<BR/>05/30/24 at 1:10 AM LVN F documented: Xray results show positive intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Physician A notified and received orders to send Resident #1 to ER to evaluate. Notified Family Member A POA. EMS here to transport resident to local hospital. Report called in to ER. ADM and DON notified as well.<BR/>05/30/24 at 1:43 AM the DON documented: 5:38 PM was notified by charge nurse that resident was c/o left hip pain. Instructed charge nurse to notify Physician A. Nurse received orders to obtain x-rays to left hip. Notified administrator of resident c/o left hip pain. Then instructed night nurse to notify as soon as x-ray results received. Received notification at 10:25 pm from night charge nurse that x-ray showed a left acute intertrochanteric hip fracture (upper thigh hip fracture). Immediately notified administrator of findings.<BR/>06/03/24 at 9:29 PM the LVN F documented: Resident readmitted to facility following hospitalization following fall on 5/30 resulting in intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Dynamic hip screw surgery to left hip. Resident weight bearing as tolerated.<BR/>During an interview on 06/05/24 at 12:07 PM, Family Member D stated on 05/30/24, she visited with Resident #1. She stated that he had received a shower that morning from CNA E. She said during the day, around the time they played Bingo, Resident #1 started complaining that his butt hurt. She said she thought maybe he was constipated. She said that when the CNAs (CNA J and CNA K) went to put him in bed, he started complaining of pain. She said Resident #1 pointed to his left side and said, Hurt hurt. She said she waited until the CNAs left to notify RN I to ask Resident #1 what happened because he was complaining more than earlier. Resident #1 told me that he fell in the shower that morning with CNA E. She said Resident #1 said he fell and hit his head. She said CNA E was in the room when Resident #1 fell but he did not see Resident #1 fall because his back was to Resident #1. CNA E was shutting the bathroom door when Resident #1 fell. Family Member D said she asked if Resident #1 had reported to anyone that he had fallen and if the nurse knew. She said Resident #1 said no. She said Resident #1 explained that it was an accident, that he did not want to get CNA E in trouble, and that he liked him. She said she spoke with CNA E after Resident #1's fall (unknown date and time), and he said he was sorry and acknowledged the fall. She said CNA E told her that he told the ADM and therapy. She stated she was not notified of the fall and was at the facility when CNA showered Resident #1. She said she would have liked to have been told so that she could have had Resident #1 checked out immediately. She said no one had come to her and asked her any questions about what Resident #1 had disclosed to her.<BR/>During an interview on 06/09/24 at 12:22 PM, Resident #1 stated that he fell in the shower while showering. Resident #1 said CNA E was in the restroom, but his back was to him. Resident #1 said he fell to the floor and hit his head. Resident #1 said CNA E picked him up and put him in the wheelchair. Resident #1 said no other staff helped CNA E to pick him up. Resident #1 said that a nurse did not check him. Resident #1 said no one from the administration came and talked to him about the incident. Resident #1 said he was in pain when he left the shower room but did not report it because he did not want to get CNA E in trouble. He said at the time of the interview no one had asked him any questions about what happened in the shower room when he fell.<BR/>During an interview on 06/05/24 at 1:49 PM, CNA E stated the incident with Resident #1 occurred on Thursday (05/30/24). CNA E stated he had just completed Resident #1's shower. He stated Resident #1 appeared to be standing fine. He said Resident #1's leg buckled, and as Resident #1 was holding on to the grab bar, he swiveled and hit the wall. He said Resident #1 never completely hit the ground. CNA E stated he called for assistance with Resident #1. CNA E stated he called CNA J and CNA K. CNA E stated he and CNA J and CNA K finished getting Resident #1 dressed and placed Resident #1 in his wheelchair. CNA E stated he asked Resident #1 how he was doing and was told by Resident #1 that he was ok. CNA E stated he had reported what happened to the ADM and the PTA directly after the incident. CNA E stated that he reported to the ADM that the fall was not a complete fall to the ground. CNA E could not recall if he told the ADM that Resident #1 had hit the wall. CNA E did not disclose if the ADM had asked any additional questions about the incident. He stated Resident #1 did not complain of pain or show any signs of discomfort. When he demonstrated to Family Member D what happened, CNA E stated that his head hit the wall. CNA E stated he did not have the nurse look at Resident #1 because he felt he did the correct thing when he reported the incident to the ADM. CNA E stated the ADM told him that the incident was not reportable, so he did not tell anyone else. He said although Resident #1's care plan says to use the mechanical lift, he was a physical transfer. He said the fall might have happened around 11:30 AM on 05/30/24.<BR/>During an interview on 06/05/24 at 2:08 PM, RN I stated that he was unsure when the fall incident happened with Resident #1 but was in the middle of the week. RN I said he did not know anything about it until the end of his shift. He said CNA K came to him and alerted him that Resident #1 was in pain the same day Resident #1 fell. He said he was told by Resident #1 that he had a fall in the shower earlier that day, and he had hit his head and his hip. RN I said Resident #1 said he did not want to get CNA E in trouble. RN I said while Resident #1 was telling him he was crying. RN I stated he notified the DON, and the DON was surprised that CNA E had not told the nursing staff anything about the incident. RN I said he was frustrated because although the incident was communicated to the PTA and the ADM, it was not communicated to him as the charge nurse, and a delay in treatment occurred. He stated that once he became aware of this, he assessed and notified Physician A. RN. I stated that x-rays were ordered, but he did not receive the results on his shift. RN I said he spoke with CNA E and inquired why he was not notified. RN I said CNA E said he could not find RN I and apologized for not reporting the incident to RN I. RN I explained that his license could be on the line and treatment for Resident #1 could be delayed. RN I said that CNA E stated he was doing therapy in the shower to promote movement, and Resident #1 gave out. RN I said that CNA E told him that Resident #1 never hit the ground, but this differed from what Resident #1 told him. He stated he was told by Resident #1 that he fell to the ground. RN I said it was vital that he was notified when fall incidents occurred so that the residents were assessed at the time of injury. RN I said during his assessment of Resident #1, he saw issues with his range of motion and the apparent pain that Resident #1 was expressing. RN I said failure to report the incident to him could compromise resident safety, and with Resident #1 hitting his head, it could have been a more significant issue. RN I said during his assessment he did not see any problems with Resident #1's mental status. RN I stated he did not talk to the PTA or the ADM about the incident as they were already gone for the day and not in the facility. He stated outside of him having concerns about the information not being reported to him no one asked him any additional questions about the incident between Resident #1 and CNA E. <BR/>During an interview on 06/05/24 at 3:10 PM, CNA J stated she was not assisting Resident #1 the day he fell. She said she and her partner (CNA K) heard the call light go off in the shower room. She said that when they saw what was happening, CNA E requested that we bring Resident #1's wheelchair. CNA J stated she did observe Resident #1, and CNA E. CNA J stated that CNA E was holding Resident #1. CNA J said she and her partner provided the wheelchair and walked away. She said she or her partner did not provide any assistance then. CNA J stated that around 4:30-4:45 PM that same day, the call light in Resident #1's room went off, and they were told by Resident #1 and Family Member D to place Resident #1 in bed. CNA J said they (her and CNA K) transferred Resident #1, and he complained that his leg was hurting. After the transfer, CNA J said they reported the leg pain to RN I. CNA J did not disclose that any additional questions were asked of her by the ADM. <BR/>During an interview on 06/05/24 at 3:41 PM, CNA K stated that when Resident #1 fell, she and her partner, CNA J, were not working directly with Resident #1. CNA K said she was working the floor with other residents. She said she and her partner heard the lights go off in the shower room. CNA K said CNA E asked for Resident #1's wheelchair. CNA K stated they provided him with the wheelchair and walked back out of the shower room. She said no additional assistance was provided. She said when she and her partner were in the restroom, CNA E did not look like he needed help. She said that the encounter was before lunch. She said that at around 4:40 PM, Resident #1's call light went off, and she and CNA J went to see what he needed. She said Resident #1 wanted to be transferred to bed, and during the transfer with her and CNA J, Resident #1 expressed that he was in pain. She stated they completed the transfer and got him comfortable. She said she and her partner immediately notified RN I. CNA K stated that RN I went to Resident #1's room, which was all she knew happened. CNA K did not disclose if she was asked any additional questions from the ADM about the incident with CNA E and Resident #1.<BR/>During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not consider Resident #1's incident a fall because CNA E told her that Resident #1 did not fall to the ground. The ADM said CNA E told her that during a transfer, CNA E held Resident #1 up, straightened Resident #1 up, and was able to place him in his wheelchair. The ADM stated she did not talk to Resident #1 about the incident. She stated that she did not because when she was told about the incident, Resident #1 was present in the dining room. The ADM said she was unaware if the presence of CNA E could have influenced Resident #1 not to speak up. She said she did not investigate the incident further after CNA E reported it. She said the only person she spoke with about the incident with Resident #1 was CNA E. She also said she did not consider it a fall because the DOR told her that if a fall occurs during restorative or therapy, it was not considered a fall .<BR/>During an interview on 06/05/24 at 4:24 PM, the DON stated she received a call 05/30/24 from RN I around 5:28 PM or 5:30 PM. RN I said Resident #1 was complaining of pain and stated he had fallen. The DON said she called CNA E, and CNA E told her Resident #1 did not fall. She said CNA E said he reported it to the ADM and the PTA directly after the incident. The DON said she was told by CNA E that Resident #1's legs buckled, and that CNA E held Resident #1 up. The DON said that she was told CNA J and K helped CNA E with Resident #1. The DON said she interviewed CNA J and CNA K and confirmed that they observed CNA E holding Resident #1 up and that they got the wheelchair. The DON said she did not confirm if they helped with the transfer. The DON said she did not ask any additional or follow up questions after the CNAs confirmed that they observed CNA E holding Resident #1 up. The DON said she did not speak with Resident #1 because he had already gone to the hospital. The DON stated she had not spoken with Resident #1 since he returned from the hospital. The SON did not provide a reason why she had not spoken with Resident #1 about the incident between him and CNA E. The DON stated that she understood that since CNA E had been trained, he could transfer Resident #1 alone. <BR/>During an interview on 06/06/24 at 11:00 AM, the PTA stated that on 05/30/24, CNA E approached him. The PTA said CNA E was doing restorative on Resident #1, and he slipped. CNA E stated that he had already reported the incident to the ADM. The PTA stated that CNA E had not given him any additional information. The PTA said that when he was told about the incident, he was not told it was in the shower. The PTA stated that he had not seen Resident #1's care plan and could not verify what it entailed, but two people to transfer was for safety especially when using the mechanical lift. He stated that if the care plan stated that there needs to be two people, then there should be two people, and staff should not deviate from that. The PTA stated that therapists could transfer with one person, and sometimes, it depends on a female or male was doing the transfer. The PTA said he spoke with Resident #1, and all Resident #1 kept saying was fall, fall. The PTA did not disclose if the ADM had spoken with him about the incident between Resident #1 and CNA E.<BR/>During an interview on 06/06/24 at 12:25 PM, the DON stated she was unaware that Resident #1 had fallen in the shower. The DON said she was made aware when the nurse called about Resident #1's pain. The DON stated that the restorative Aide had been trained to report the incident to therapy and the nurse (that included the DON). The DON said that regarding the incident with Resident #1, the potential negative outcome was that similar incidents could also occur with other residents. The DON said the potential negative outcome of not investigating Resident #1's fall was the facility staff would not be following their policy, and there could be a negative outcome for the resident if something internally would have been wrong with the resident. The DON said she was responsible for incident/accident prevention, but the ADM was responsible for investigating incidents. The DON said the purpose of reporting incidents and investigating incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. The DON said the ADM was responsible for investigating the incidents. <BR/>During an interview on 06/06/24 at 1:16 PM, The ADM stated that not investigating incidents could cause continued harm to the residents. The ADM said she was made aware of the incident regarding Resident #1 after CNA E told her about it. The ADM said she was unaware that Resident #1 was in pain and admitted that she did not interview Resident #1. She said the system to monitor investigations was to monitor that falls and to ensure falls were investigated, and ANE policies were followed by training staff on the facility policy. The ADM said she did not investigate the incident because she did not consider the incident a fall since it happened with therapy. <BR/>2. Findings for the facility's failure to investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3 included: <BR/>Record review of Resident #2's face sheet, dated 06/05/24, revealed a [AGE] year-old-male that was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #2 had clear speech, makes himself understood, and understands others. His vision is impaired, and he does not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a blank BIMS score. Section E Behavior revealed that he had had delusions, physical behaviors such as hitting, kicking, pushing, scratching, grabbing, and abusing others. Resident # 2 had exhibited verbal behaviors such as threatening others, screaming, and cursing at others. Resident #2 had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Resident #1 exhibited wandering behavior 1-3 days.<BR/>Record review of Resident #2 care plan, dated 05/01/24 revealed the following: <BR/>Resident #2 wanders in other residents' rooms and gets into their beds at times and had the following interventions: Resident #2 required assistance out of rooms that were not his and staff could use snacks if needed. <BR/>Resident #2 was an elopement risk/wanderer and had the following interventions: Distract Resident #2 from wandering by offering pleasant diversions. Resident #2 prefer having snacks. Followed by [name of psych care]. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor the resident's location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. <BR/>Resident #2 had episodes of verbal and physical aggression r/t dementia with the following interventions: Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of Resident #2<BR/> posing danger to self and others.<BR/>Resident #2 had impaired visual function r/t cataracts and glaucoma. Resident #2 was blind in his right eye with the following interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them.<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>Record review of on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified.<BR/>Record review of on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others.<BR/>Record review of on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities.<BR/>Record review of on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms.<BR/>Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time.<BR/>Record review of on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced.<BR/>Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time.<BR/>Record review of Resident #2's monitoring sheets revealed the following: <BR/>Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.)<BR/>No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM.<BR/>Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.)<BR/>Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM)<BR/>Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness).<BR/>Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. <BR/>Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had potential for psychosocial well-being related to trauma.<BR/>Record review of Resident #3's progress notes revealed the following:<BR/>05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family.<BR/>During an interview on 06/05/24 at 1:49 PM, CNA E stated that one night, when he worked the night shift (unsure of the date and exact time), Resident #2 exposed himself to Resident #3. He said he did not see it but was told by CNA H that Resident #2 had his penis in Resident #3's hand and was jerking off. He said as a result of that incident, Resident #2 was placed on 1:1 and was checked every 15 minutes by the night staff. He said Resident #3 was not in her right mind and would have been unable to consent. He said Resident #3 may have a BIMs of 0. He said prior to the incident involving Resident #3, Resident #2 was not on any close monitoring. He said that when Resident #3 was in the dining room and wanted to return to his room, they would assist him, but after he was in his room, they did not do additional monitoring.<BR/>During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself. He said he reported the incident to the DON. <BR/>During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not report the incident that involved inappropriate sexual contact that occurred with Resident #2 and #3 because all parties had dementia. She said she focused on if the act was willful. She said Resident #3 was asleep and did not know what was happening. She said she was told but could not remember who told her that Resident #2 was standing over Resident #3 with his penis out and Resident #3's hand was on Resident #2's penis. The ADM stated she was not told that Resident #2 was masturbating. The ADM stated that Resident #2 was not put on 1:1 during the first incident involving Resident #3 because he was not aggressive, and this was the first time he displayed this behavior.<BR/>During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incident between Residents #2 and #3 were reported to her, she reported it to the ADM as she was the abuse coordinator. The DON stated the ADM confirmed with the Regional Director that it did not have to be reported because the residents had dementia. The DON said the Regional Director provided documentation to support the decision. The DON stated she did not speak up or take any additional action to investigate the incidents after being told it did not need to be reported.<BR/>During an interview on 06/06/24 at 12:25 PM, the DON stated she did not want to say the wrong things and that she could not think of the potential negative outcome when it came to not investigating sexual incidents between residents, specifically the incidents that occurred between Residents #2 and #3. She said she was aware that the sexual incident had not been reported to the HHSC. The DON said the ADM told her that she did not report it based on the instruction given to her by the Regional Director. The DON said she did not observe the sexual incident between Resident #2 and #3. The DON said she was responsible for incident/accident prevention, but the ADM was responsible for investigating. The DON said the purpose of investigating incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. The DON said the ADM was responsible for investigating the incidents and she did not have a specific reason why the incident was not investigated by the ADM. <BR/>During an interview on 06/06/24 at 1:16 PM, the ADM stated she was aware that she had not reported the sexual incident between Resident #2 and #3. She said the reason she did not report the incident was because after speaking with her Regional Director, who was more experienced, they felt that it was a behavior, not intentional, and abuse did not occur. The ADM said with this being a brand-new behavior for Resident #2, she could see that she did not see anything abnormal, with the conclusion of not reporting the incident of inappropriate sexual behavior. The ADM said her gut feeling was to report the incidents. The ADM said her Regional Director told [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to address, resolve and have a prompt resolution of all grievances in accordance with facility policy for 1 of 8 (Resident #1), 1 Family Member (Family Member J) and staff (CNA E). <BR/>The facility failed to document, resolve, and follow up on grievances related to Resident #2's behavior on behalf of Resident #1. <BR/>The facility failed to document, resolve, and follow up on grievances related to Resident #2's behavior on behalf of Family Member J. <BR/> The facility failed to document, resolve, and follow up on grievances related to Resident #2's behavior on behalf of CNA E.<BR/>This failure had the potential to cause residents, staff and family feelings of helplessness, diminished quality of life and at risk for grievances not being addressed or resolved promptly.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread and uneasiness), cognitive communication deficit (difficulty understanding and communicating). <BR/>Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #1 had slurred speech, could make himself understood and usually understood others. <BR/>Record review of Resident #1's Care Plan, dated 02/29/24, revealed that he was a max assist, depends on staff for meeting his needs, requires tube feeding, has depression (impaired ability to remember), was on antianxiety medications, and that he was pulled from the bed on 04/25/24.<BR/>Record review of Resident #1's progress notes revealed the following:<BR/>04/25/24 at 05:08 PM LVN A documented:<BR/>Resident #1 was found on the floor was pulled out of bed by another resident (unidentified) assist Resident #1 back to bed did assessment no injures noted<BR/>03/30/24 at 12:49 AM LVN B documented:<BR/>Other resident (unidentified) tried to pull Resident #1 out of his bed. other resident (unidentified) scratched Resident #1 across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Other resident (unidentified) was taken to his own room. <BR/>Record review of Resident #2's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was readmitted to the facility on [DATE] with diagnoses to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. <BR/>Record review of Resident #2 care plan, dated 04/30/24 revealed the following: <BR/>Focus (Date initiated:04/26/24 Date revised:04/26/24)<BR/>4-25-24-I pulled another resident out of bed.<BR/>Goal<BR/>I will have no further episodes of aggression through review date.<BR/>Interventions<BR/>Placed 1:1 Sent to a behavior support center. <BR/>Focus (Date initiated:01/22/24 Date revised: 01/22/24)<BR/>I am an elopement risk/wanderer. Wander risk<BR/>Goal<BR/>I will not leave facility unattended through the review date.<BR/>Interventions <BR/>Distract me from wandering by offering pleasant diversions. I prefer having snacks.<BR/>followed by[name of psych care]. notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications.<BR/>Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log.<BR/>Focus (Date initiated: 01/22/24 Date revised:01/22/24)<BR/>I have episodes of verbal and physical aggression r/t dementia.<BR/>Goal<BR/>I will not harm self or others through the review date.<BR/>Interventions <BR/>Give me as many choices as possible about care and activities.<BR/>Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. <BR/>Monitor/document/report PRN any s/sx of me posing danger to self and others.<BR/>When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Focus (Date initiated:01/22/24 Date revised:01/22/24)<BR/>I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye.<BR/>Goal<BR/>I will show no decline in visual function through the review date.<BR/>Interventions <BR/>Arrange consultation with eye care practitioner as required.<BR/>Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Place frequently used items on my left side so I may see them<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>04/25/24 at 04:55 PM LVN A documented:<BR/>Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room.<BR/>04/24/24 at 08:25 PM the DON documented:<BR/>7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and layed down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. <BR/>04/23/24 at 11:34 AM the DON documented:<BR/>Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. <BR/>04/23/24 at 1:06 AM LVN A documented:<BR/>Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2<BR/>04/15/24 at 4:16 AM LVN B documented:<BR/>Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room.<BR/>04/04/24 at 05:11 PM LVN B documented:<BR/>Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking<BR/>cane from rt hands and redirect to room. Admin notified.<BR/>03/30/24 at 12:26 AM LVN B documented:<BR/>Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room.<BR/>03/30/24 at 05:27 PM LVN D documented:<BR/>Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go<BR/>into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room.<BR/>Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision.<BR/>Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1.<BR/>Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every 30 minutes on 05/08/24-05/10/24.<BR/>During an interview on 05/08/24 at 1:50 PM, Family Member J stated on 04/25/24, she was notified that Resident #2 had thrown Resident #1 on the floor. Family Member J said she was notified that Resident #1 was assessed, received x-rays, and had no injuries. Family Member J said she spoke with Resident #1 and was told he was not hurting too badly. Family Member J said before the incident on 04/25/24 that she had participated in Resident #1's care plan meeting and specifically had asked what would be done about Resident #2 going into Resident #1 room. Family Member J said it had been suggested that possibly hanging something on Resident #2's door could help Resident #2 find his room. Family Member J said she did not believe that Resident #2 was intentionally targeting Resident #1 but that he was confused. Family Member J said during the care plan meeting, the MDS coordinator, the ADM, the DON, the DM, and the Activities Director were present. She said she brought up the interaction between Resident #1 and Resident #2 because she had been present when Resident #2 would wander into Resident #1 room. Family Member J said she was lucky that Resident #2 had never been violent with her. Family Member J said she had always successfully redirected him out of Resident #1's room. She said the incident on 04/25/24 was not the first time Resident #2 had entered Resident #1's room. Family Member J said the incident on 04/25/24 was the only time she had been notified. Family Member J said she had been told by the staff (LVN A and other CNAs that she could not remember) that there was an incident (did not know the date) where Resident #2 had come into Resident #1's room and tried to pull him off the bed but was unsuccessful. She said she believes the Social Worker may have mentioned to her about Resident #2 attempting to pull Resident #1 off the bed. Family Member J said that there was an instance (unsure of the date) where she had entered Resident #1's room, and Resident #2's walking cane was behind the dresser in Resident #1's room, indicating he had been there. Family Member J said it was her first time bringing it up to the ADM and DON at the care plan meeting, but she had talked to staff and the nurses' numerous times before the care plan meeting. Family Member J said staff had expressed that they were reporting issues, but nothing was being done. Family Member J said that no incidents with Resident #1 and Resident #2 would occur during the day because she or Family Member K would be there during the day. Family Member J said she was there during the day on Monday, Wednesday, Thursday, and Friday. She said Family Member K was at the facility on Wednesday. Family Member J said that before the incident on 04/25/24, nothing had been done to help Resident #2 know where his room was. <BR/>During an interview on 05/08/24 at 2:58 PM, CNA E stated she could not remember exact dates and times. CNA E stated the first incident between Resident #1 and #2 might have occurred four months ago. CNA E stated that she and CNA F were doing rounds and heard Resident #1 scream aloud. CNA E stated Resident #2 was in Resident #1's room. CNA E stated she observed Resident #1 halfway off the bed. CNA E stated that Resident #2 had his family member in the room. CNA E stated Resident #1 was halfway off of the bed, and she observed the lower half of Resident #1's body off the bed. CNA E said Resident #1 was holding onto the bed rail with his right arm. CNA E stated the incident where Resident #1 was hanging off the bed was the first incident she had ever seen. She said she reported the incident to the charge nurse but could not remember who it was as they have many charge nurses. CNA E stated there was another incident (unsure of the date and time) where Resident #1 screamed. CNA E stated that Resident #2 scratched Resident #1 during this incident. CNA E stated it happened possibly two months ago. CNA E stated Resident #1 had scratches on his chest and right side. CNA E stated this was reported to LVN B. CNA E stated that she had to scream for assistance during this incident. She stated CNA F came to assist her. CNA E stated that this incident scared her and that things were worsening with Resident #2's behaviors. CNA E stated that Resident #2 was telling her that Resident #1's room was his room and yelling at her. CNA E said she kept telling him it was not his room. CNA E said that after they told LVN B, she (LVN B) would notify the appropriate parties. She said Resident #1 appeared scared and had water in his eyes. She said Resident #1 said it was scary. CNA E said Resident #1 used minimal words such as scary, hurt, and oh man to describe what had happened. CNA E said there was another incident where Resident #2 had become agitated and aggressive with staff; this was when she messaged the DON. CNA E said in her text message she notified the DON of her concerns of Resident #2 behavior. CNA E said she did not like what was happening, and it made her sad about what had happened to Resident #1. <BR/>A record review of the text messages sent to the HHSC investigator on 05/08/24 at 3:28 PM from CNA E revealed on 04/23/24 at 3:28 PM that CNA E expressed concern about Resident #2's behavior, not being trained to take care of residents with Resident #2's behaviors, other residents being afraid and the potential for the incident to be worse. The DON responded that Resident #2's medication was adjusted. CNA E expressed concern about what to do when Resident #2 does not take his medication . CNA E expressed in the text message that Resident #2 had several incidents before the aggressive incident with staff. CNA E referenced the incident with Resident #2 protecting his feeding tube and that CNA E had reported the incident to her charge nurse . The DON responded to the concerns by stating that Resident #2's medication was adjusted and that she was unaware what had happened when Resident #2 became aggressive with staff.<BR/>During an interview on 05/09/24 at 10:52 AM, the Activity Director stated that she participated in Resident #1's care plan. The Activity Director stated that Family Member J expressed that Resident #2 had wandered into Resident #1's room once or twice. The Activity Director stated they had gloves on the door so Resident #2 knew where his room was. The Activity Director said she does not know what happened to the gloves because they were no longer there. The Activity Director said she was unaware of any other interventions to prevent Resident #2 from entering Resident #1's room. The Activity Director stated she did not feel that Family Member J was upset but did express concern.<BR/>During an interview on 05/09/24 at 11:00 AM, the DM stated that she participated in Resident #1's care plan. The DM said Family Member J expressed concern about Resident #2 entering Resident #1's room. The DM suggested placing bells or something on Resident #2's door so that he would know which room was his. The DM said Family Member J was concerned that the next time could be worse for Resident #1. The DM stated that before the incident on 04/25/24, Resident #2 had gone into Resident #1's room, but she did not know the date or time. The DM said she was unaware if Resident #2 had been physical with Resident #1. The DM said Family Member J was not upset but concerned.<BR/>During an interview on 05/09/24 at 11:27 AM, Resident #1 stated that Resident #2 had been in his room [ROOM NUMBER]-5 times. Resident #1 stated no one had come to him and interviewed him about the incident outside of the HHSC investigator. Resident #1 said that he was afraid when he had to hang onto the bed. Resident #1 said he had told multiple CNAs and nurses that he did not want Resident #2 in his room. Resident #1 said he could not remember the names of the staff he told. Resident #1 said he felt like his problem was never solved. Resident #1 said that three times when Resident #2 came into his room, it got physical; he was pulled off the bed, scratched, and pulled halfway off the bed. Resident #1 said he could not remember the date and time when the incidents happened, but that staff knew about it because they had to help him. He said he was afraid when the events happened between him and Resident #2.<BR/>During an interview on 05/09/24 at 1:07 PM, the ADM said she was unaware that Resident #2 had encountered Resident #1 multiple times. The ADM said she was unaware that Resident #2 had attempted to pull Resident #1 out of the bed before the incident on 04/25/24. The ADM said she was unsure of Resident #1's care plan meeting date. The ADM said she, the DON, Family Member J, the MDS Coordinator, the ADM, and the Social Worker may have been there. During the care plan meeting, the ADM said Family Member J did not express concerns about Resident #2 coming into Resident #1's room. The ADM said they did discuss potentially placing something on Resident #2's door but never made it official. The ADM said the discussion about Resident #2 did not occur during Resident #1's care plan meeting. The ADM said they were monitoring Resident #2's behavior through psychiatric services and medication adjustments. The ADM stated that the staff had expressed concerns about them getting hurt, but she was unaware of the ongoing issues with Resident #1. She said she was only aware of one incident where Resident #2 had become aggressive with staff. She said she was unaware of any other incidents. The ADM said she knew that most of Resident #2's incidents or behaviors occurred at night. The ADM said she did not implement any other interventions outside of the medication adjustments and monitoring from psychiatric services and notifying the family, PCP, and FNP. The ADM said she was sure the care plan had interventions to address Resident #2's behaviors. The ADM said grievances were for family and residents. The ADM said if staff had a concern, they should be redirected to HR to identify a solution. The ADM said she did not have a system to track staff concerns. The ADM said she was responsible for grievances. The ADM said all staff had been trained to handle grievances as part of ANE and resident rights training. The ADM said she had never interviewed Resident #1 to see if this had happened. The ADM had never delegated to interview Resident #1. The ADM said the night of the incident (04/25/24), she was more concerned with his well-being and what happened. The ADM said part of the investigation process was interviewing key witnesses and residents and finding out what happened. The ADM's potential negative outcome for not following the grievance policy and ensuring that all grievances were resolved was that the staff and the resident's safety could be compromised. The ADM said she used grievance forms to monitor grievances. The ADM said that the grievance form would have pertinent information, such as who it was assigned to and when it was to be completed. The ADM said the purpose of the grievance process was for families and residents to voice their concerns. The ADM said she did not fill out the staff form. The ADM said she was unaware of any additional concerns from staff regarding their safety. The ADM said that in addition to the form, they had the policy readily available for staff if they needed it. The ADM said that she had been trained on the grievance policy, and her staff had been trained too. The ADM said she expected all of her staff to come to her with concerns so that she could resolve the issue. The ADM said everyone was responsible for reporting grievances, but the ADM and the DON were responsible for following through. <BR/>During an interview on 05/09/24 at 2:17 PM, the DON stated that the only other incident she knew of between Resident #1 and Resident #2 was where Resident #2 scratched Resident #1. The DON said she was unsure of the date and time when this incident occurred. The DON said that Resident #2 was redirected out of the room. The DON said she was unaware of any other incidents. The DON said she did participate in Resident #1's care plan meeting. The DON said she was unsure of the date and time. The DON said she, the MDS Coordinator, Family Member J, the Social Worker, and the Activity Director were present. The DON said she could not remember what was brought up specifically. The DON said that she could not think of any other interventions put in place outside of psychiatric medication adjustments and close monitoring. The DON said there was an instance where a nurse tied something to the door to help Resident #2 locate his room, but that was not an official intervention. The DON said staff could file grievances if they had concerns. The DON said there was a compliance number that the staff could call if they felt like their issues were not resolved. The DON said staff could call anonymously if they wanted to and report concerns. The DON said the only concern reported to her was staff potentially getting hurt during an incident with Resident #2 being aggressive. The DON stated she never interviewed Resident #1. The DON said once an incident was reported to the ADM, she would relinquish the investigation process to the ADM because she had so much on her plate. The DON said the potential negative outcome of not following the grievance policy was that residents would have unresolved issues. The DON said she was unaware of any concerns that staff or family members may have had. The DON said the facility did not have a system to address staff member concerns even if staff advocated for residents. The DON said she had been trained on the grievance policy and her staff. The DON said she expected all grievances to be reported to the ADM and DON so that they could be resolved. The DON said that everyone was responsible for reporting but that the ADM was overall responsible. The DON said the social worker was responsible for grievances in other facilities she had worked in but that they did not have a full-time social worker at their facility so the ADM handled the grievances overall.<BR/>Record review of the grievance log from January 2024 until current did not reveal anything related to the family expressing concerns about Resident #1 and Resident #2.<BR/>Record review of the facility's policy, Grievances/Complaints, Filing, dated April 2017 revealed the following:<BR/>Policy Statement<BR/>Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman).<BR/>The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.<BR/>Policy Interpretation and Implementation<BR/>Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.<BR/>All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response.<BR/>Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.<BR/>The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law.<BR/>The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.<BR/>The Administrator will review the findings with Grievance Officer to determine what corrective actions, if any, need to be taken.<BR/>The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.<BR/>1. <BR/>The Administrator, or his or her designee, will make such reports orally within _____ working days of the filing of the grievance or complaint with the facility.<BR/>2. <BR/>A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.<BR/>The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.<BR/>Record review of the facility's policy, Resident Rights, dated December 2016 revealed the following:<BR/>Policy Statement<BR/>Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation<BR/>I. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the<BR/>resident's right to:<BR/>a. a dignified existence;<BR/>b. be treated with respect, kindness, and dignity;<BR/>c. be free from abuse, neglect, misappropriation of property, and exploitation;<BR/>u. voice grievances to the facility, or other agency that hears grievances, without discrimination or<BR/>reprisal and without fear of discrimination or reprisal;<BR/>v. have the facility respond to his or her grievances;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 residents (Residents #1) reviewed for abuse and neglect. <BR/>The facility Staff (Administrator) failed to report the incident that occurred on 03/30/2024 and 04/04/2024 between Resident #1 and Resident #2 to the governing state agency. <BR/>CNA H &I failed to report allegations of abuse to the abuse coordinator within 2 hours of incident.<BR/>These failures could place the residents in the facility at risk of lacking timely reporting of incidents, risk of abuse, neglect, exploitation, or misappropriation of their property by staff members and contribute to further resident abuse.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread, and uneasiness), cognitive communication deficit (difficulty understanding and communicating). <BR/>Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #1 had slurred speech, could make himself understood and usually understood others. <BR/>Record review of Resident #1 Care Plan, dated 02/29/24, revealed that he is a max assist, depends on staff for meeting his needs, requires tube feeding, has depression (impaired ability to remember), is on antianxiety medications, and that he was pulled from the bed on 04/25/24.<BR/>Record review of Resident #1's progress notes revealed the following:<BR/>04/25/24 at 05:08 PM LVN A documented:<BR/>Resident #1 was found on the floor was pulled out of bed by another resident (unidentified) assist Resident #1 back to bed did assessment no injures noted<BR/>03/30/24 at 12:49 AM LVN B documented:<BR/>Other resident (unidentified) tried to pull Resident #1 out of his bed. other resident (unidentified) scratched Resident #1 across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Other resident (unidentified) was taken to his own room. <BR/>Record review of Resident #2's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was readmitted to the facility on [DATE] with diagnosis to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. <BR/>Record review of Resident #2 care plan, dated 04/30/24 revealed the following: <BR/>Focus (Date initiated:04/26/24 Date revised:04/26/24)<BR/>4-25-24-I pulled another resident out of bed.<BR/>Goal<BR/>I will have no further episodes of aggression through review date.<BR/>Interventions<BR/>Placed 1:1 Sent to a behavior support center. <BR/>Focus (Date initiated:01/22/24 Date revised: 01/22/24)<BR/>I am an elopement risk/wanderer. Wander risk<BR/>Goal<BR/>I will not leave facility unattended through the review date.<BR/>Interventions <BR/>Distract me from wandering by offering pleasant diversions. I prefer having snacks.<BR/>followed by psychiatric services. notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications.<BR/>Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log.<BR/>Focus (Date initiated: 01/22/24 Date revised:01/22/24)<BR/>I have episodes of verbal and physical aggression r/t dementia.<BR/>Goal<BR/>I will not harm self or others through the review date.<BR/>Interventions <BR/>Give me as many choices as possible about care and activities.<BR/>Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. <BR/>Monitor/document/report PRN any s/sx of me posing danger to self and others.<BR/>When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Focus (Date initiated:01/22/24 Date revised:01/22/24)<BR/>I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye.<BR/>Goal<BR/>I will show no decline in visual function through the review date.<BR/>Interventions <BR/>Arrange consultation with eye care practitioner as required.<BR/>Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Place frequently used items on my left side so I may see them<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>04/25/24 at 04:55 PM LVN A documented:<BR/>Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room.<BR/>04/24/24 at 08:25 PM the DON documented:<BR/>7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and laid down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. <BR/>04/23/24 at 11:34 AM the DON documented:<BR/>Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. <BR/>04/23/24 at 1:06 AM LVN A documented:<BR/>Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2<BR/>04/15/24 at 4:16 AM LVN B documented:<BR/>Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room.<BR/>04/04/24 at 05:11 PM LVN B documented:<BR/>Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking<BR/>cane from rt hands and redirect to room. Admin notified.<BR/>03/30/24 at 12:26 AM LVN B documented:<BR/>Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room.<BR/>03/30/24 at 05:27 PM LVN D documented:<BR/>Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go<BR/>into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room.<BR/>Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision.<BR/>Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1.<BR/>Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every 30 minutes on 05/08/24-05/10/24.<BR/>During an interview on 05/08/24 at 11:42 AM, the DON stated Resident #2 had advanced dementia. The DON said she, as the DON, had been trained on what to do regarding reporting ANE. She said their system for monitoring ANE was to educate staff through in-services. The DON said all staff had been trained on reporting ANE. The DON said staff were trained upon hire, annually, and when an incident arose. The DON said staff had been trained to report abuse immediately to the abuse coordinator, and she expected her staff to do so. The DON said she was unaware why CNA H and I did not report the allegations of verbal abuse immediately. She said all staff were responsible for reporting ANE immediately to the abuse coordinator. The DON said the ADM was the abuse coordinator. <BR/>During an interview on 05/08/24 at 11:42 AM, the ADM stated she was unsure of the date and exact time, but CNA G came to her and told her that he needed to tell her something. The ADM said CNA G told her that he was told by CNA H & I that LVN A was ugly to Resident #2. The ADM said that she immediately suspended LVN A upon being notified of the situation. She stated she immediately suspended CNA H & I. The ADM stated she reported the incident to the state. She said they conducted safe surveys. She said Resident #2 could not recall the incident. The ADM stated they reported the incident to the sheriff's department.<BR/> During her investigation, the ADM said CNA H admitted that she witnessed LVN A yelling at Resident #2. CNA I also admitted that LVN A yelled at Resident #2. The ADM stated she immediately educated CNA H & I that she was supposed to report it immediately. The ADM said she was unaware why the staff did not report the incident because she was physically in the facility the night of the incident (04/25/24). She said The CNAs did not give her a reason why they did not report it immediately. She said she was never notified until the next morning. The ADM stated that CNA H was an agency staff member but that they had an understanding that all ANEs should be reported immediately. The ADM stated when she spoke with LVN A that LVN A denied the allegations of verbal abuse but that LVN A did tell Resident #2 to get out of bed, which was not his. She said LVN A did admit that she was loud. After consulting with her corporate office, the ADM decided to terminate LVN A based on interviews and her past involvement in other incidents. The ADM stated that she did not terminate the CNAs because they had never had issues with their performance and had reeducated them on ANE. The ADM stated they also considered that CNA H & I did report the incident to another coworker even though they should have reported it to the abuse coordinator as trained. She said the potential negative outcome of not reporting allegations of abuse immediately to the abuse coordinator could place residents and staff in harm's way. The ADM stated they were at the facility to protect the residents. The ADM stated her system to monitor that the abuse policy was being followed implemented, and staff was reporting allegations of abuse was that they trained staff through inservices. The ADM stated policies and signs were posted with the ADM's name and number on the wall. She said she had been trained on the abuse policy, and all staff had been trained. She said she expected to be notified of ANE immediately when and if it happened. She said all staff were responsible for reporting and following the abuse policy. She said she did not know why CNA H and I did not report the allegations immediately. The ADM stated it was reported to her that on 04/25/24, around 7:30 PM. The ADM said that Resident #2 went into Resident #1's room. The ADM stated Resident #1 and Resident #2's rooms are next to each other. She stated staff heard yelling but was unsure where the yelling was coming from. She stated when staff entered the room, they observed Resident #1 on the floor, and Resident #2 was in Resident #1's bed. The ADM stated staff redirected Resident #2 to his room, assessed Resident #1 and did not identify any injuries on either resident. The ADM stated she was notified and physically came to the facility to attempt to get additional support from a local behavior support center for Resident #2's behavior. She said Resident #2 was transported to a behavior support center the same night. The ADM stated that Resident #2 had never done this to Resident #1 before. She stated Resident #1 had a history of aggressive behavior with staff. The ADM said as a result of this incident, on 04/25/24, they conducted training with staff over resident rights, ANE, and that they had consulted with the local behavior support center to conduct training on dealing with aggressive behaviors, but no official date had been set.<BR/>During an interview on 05/08/24 at 12:37 PM, CNA G stated he did not remember the exact date but he had come in at the beginning of his shift. CNA G stated he was getting a report from the night-time CNAs, and it was passed on that Resident #2 had pulled Resident #1 out of bed. CNA G said he was told by CNA H &I that when Resident #2 refused to leave Resident #1's bed, LVN A yelled loudly for Resident #2 to get the fuck out of the bed. CNA G said he was told it was so loud that everyone in the facility could hear it. CNA G said that CNA H & I appeared concerned with how LVN A approached the situation. CNA G stated he immediately reported it to LVN D, and the ADM. CNA G stated as a result of his report of LVN A's verbal abuse immediately that the ADM started getting witness statements but was unaware of what was done with LVN A. CNA G stated he had not seen LVN A back at the facility since the incident. He stated he reported the incident immediately because he had been trained to report all allegations of ANE immediately to the abuse coordinator. <BR/>During an interview on 05/08/24 at 01:34 PM, Resident #2 said he did not recall staff yelling at him, felt safe, had difficulty seeing things, and had no physical incidents with staff or other residents. Resident #2 said he knew where his room was but could not recall a specific room number. He said he did not have any additional concerns. <BR/>During an interview on 05/08/24 at 1:50 PM, Family Member J stated on 04/25/24, she was notified that Resident #2 had thrown Resident #1 on the floor. Family Member J said she was notified that Resident #1 was assessed, received x-rays, and had no injuries. Family Member J said she spoke with Resident #1 and was told he was not hurting too badly.<BR/>During an interview on 05/08/24 at 2:02 PM, Resident #1 stated via telephone that Resident #2 had pulled him off the bed, and he did not want it to happen again.<BR/>During an interview on 05/08/24 at 2:03 PM, Family Member K stated via telephone that she was physically with Resident #1 but that he had a hard time talking because of his stroke. Family Member K said there was an incident where LVN A walked into the room (unsure of the date), and Resident #1 was sideways, hanging onto the bed with one arm. She said she believed there was another incident where Resident #1 tried to protect his feeding tube site. She said she was concerned that this was happening when Resident #1 was sleeping, and that Resident #1 could not defend himself. Family Member K said the staff knew about the incidents and needed to do something. Family Member K said that she had not physically told anyone but was told by Family Member J that she had. <BR/>During an interview on 05/08/24 at 2:18 PM, CNA F stated she was unsure of the exact dates, but about a month before the interview, She and CNA E had caught Resident #2 in Resident #1 room. CNA F said Resident #2 was confused and had difficulty seeing. CNA F said she did not believe Resident #2 was being mean or awful to Resident #1, but he thought he was in his (Resident #2) room. CNA F stated Resident #1 was yelling. CNA F said when they got to Resident #1's room (she and CNA E), they observed the door closed and the lights off. CNA F said when they turned on the lights, they observed Resident #2 trying to pull Resident #1 off the bed. CNA F stated water was on the floor, and Resident #1 Head was on the bed rail. She observed the side table turned over, and Resident #1 was protecting his feeding tube site and crying. CNA F attempted to redirect Resident #2, but he refused to leave. CNA F stated this incident was reported to LVN B. CNA F stated LVN B said she reported the incident to the appropriate parties. CNA F stated a week after that incident (unsure of the exact date), Resident #2 was back in Resident #1's room. CNA F stated that Resident #1 had pushed his call light, and Resident #2 was standing in Resident #1's room when they got to him. CNA F stated that when they attempted to redirect him out of Resident #1's room, Resident #2 stated he wanted his jacket, and they grabbed his hand. Finally, Resident #2 went with them. CNA F stated that there had been a lot of changes in the facility as far as room changes and believed that the separation by gender may have contributed to Resident #2 being confused about where he was going and, in addition, his difficulty being blind. CNA F stated Resident #2 had been moved three or four times. CNA F stated the difficulty they had been having with Resident #2 had been reported to LVN A and LVN B (unsure of the exact time and date). She stated she was under the impression that, as the CNA, she was to report to her charge nurse and that they would proceed further if needed. She said her charge nurses had told her that the incidents with Resident #2 had been reported to higher people. CNA F stated they had wondered when something would be done. CNA F stated she was frustrated with all the incidents that had occurred with Resident #2. She stated that although Resident #2 was not evil and was sweet, his behaviors had worsened, and he had become more confused. CNA F stated that outside of the incidents with Resident #1, Resident #2 had become aggressive with her, and CNA G. CNA F stated that if something had been done, some of the incidents with Resident #2 could have been prevented.<BR/>During an interview on 05/08/24 at 2:58 PM, CNA E stated she could not remember exact dates and times. CNA E stated the first incident between Resident #1 and #2 might have occurred four months ago. CNA E stated that she and CNA F were doing rounds and heard Resident #1 scream aloud. CNA E stated Resident #2 was in Resident #1 room. CNA E stated she observed Resident #1 halfway off the bed. CNA E stated that Resident #1 had his family member in the room. CNA E stated Resident #1 was halfway off of the bed, and she observed the lower half of Resident #1's body off the bed. CNA E said Resident #1 was holding onto the bed rail with his right arm. CNA E stated the incident where Resident #1 was hanging off the bed was the first incident she had ever seen. She said she reported the incident to the charge nurse but could not remember who it was as they have many charge nurses. CNA E stated there was another incident (unsure of the date and time) where Resident #1 screamed. CNA E stated that Resident #2 scratched Resident #1 during this incident. CNA E stated it happened possibly two months ago. CNA E stated Resident #2 had scratches on his chest and right side. CNA E stated this was reported to LVN B. CNA E stated that she had to scream for assistance during this incident. She stated CNA F came to assist her. CNA E stated that this incident scared her and that things were worsening with Resident #2's behaviors. CNA E stated that Resident #2 was telling her that Resident #1's room was his room and yelling at her. CNA E said she kept telling him it was not his room. CNA E said that after they told LVN B, she (LVN B) would notify the appropriate parties. She said Resident #1 appeared scared and had water in his eyes. She said Resident #1 said it was scary. CNA E said Resident #1 used minimal words such as scary, hurt, and oh man to describe what had happened. CNA E said there was another incident where Resident #2 had become agitated and aggressive with staff; this was when she messaged the DON. CNA E said she did not like what was happening, and it made her sad about what had happened to Resident #1. <BR/>During an interview on 05/08/24 at 3:29 PM, LVN A stated that she no longer worked at the facility. LVN A stated on 04/25/24 that she did not witness Resident #2 pulling Resident #1 out of the bed. LVN A stated that she had heard Resident #1 scream and thought it was another resident. LVN A said that when she walked down the hallway, one of the CNAs came running towards her. LVN A stated she could not remember the CNAs name. LVN A when she went into Resident #1's room and observed Resident #2 in Resident #1's bed and Resident #1 was on the floor. LVN A said this was not the first interaction between Resident #1 and Resident #2. LVN A stated this was the second time this had happened. LVN A said that during the incident on 04/25/24, Resident #2 yelled at the staff. LVN A stated she raised her voice for Resident #2 to get out of Resident #1's bed. LVN A said that they were finally able to get Resident #2 out of Resident #1 room. LVN A said she notified the DON of the incident. LVN A stated the DON said that she told the ADM and that the ADM was on the way to the facility to send Resident #2 out for behavior support. LVN A said she had experienced Resident #2 becoming agitated with staff on 04/18/24. She stated that the FNP, PCP, DON, and ADM knew about the incident. She said she had been told by other staff that Resident #2 had attempted to pull Resident #1 out of bed before. She said she was unaware of any interventions that had been put in place. <BR/>During an interview on 05/08/24 at 10:25 PM, CNA I stated on 04/25/24, it was around 7 PM or 9 PM when the residents that smoke go out. CNA I said she observed Resident #1 on the floor. CNA I said she went to get LVN A, and that was when she (LVN A) told Resident #2 to get the fuck out. CNA I said she redirected Resident #2 to his room. CNA I stated she and CNA H placed Resident #1 back in bed. CNA I said their shift was over at 6:00 AM the next morning, and LVN A worked the remainder of her shift. CNA I stated that she did not report the verbal incident because the LVN A knew about it as she was there and had said the words to Resident #2. CNA I stated she reported the incident to the oncoming shift the next morning. CNA I said the ADM and DON reeducated her. CNA I said that she had never heard LVN A curse at the residents but had observed her be loud. CNA I said she and her coworker (CNA H) did discuss that the interaction between Resident #2 and LVN A was aggressive and abrasive. CNA I said she was more focused and glad that Resident #1 was not hurt. CNA I said after that incident and Resident #2 received a shot of Ativan he came back out and was trying to throw a shoe at Resident #1. CNA I said that most of the time when she worked with Resident #2, he would always try to go into Resident #1's room. CNA I said this occurred at least three times a week. Before the incident on 04/25/24, CNA I said that Resident #2 never made physical contact with Resident #1 on her shift. CNA I said there was nothing ever done that she could recall to alleviate the situation, but the staff had placed gloves on the outer door at one point. She stated she could not provide a picture of the gloves on the door to the HHSC worker. CNA I said that she had been trained to report allegations of ANE immediately. <BR/>During an interview on 05/08/24 at 10:51 PM, LVN D stated that the incident on 04/25/24 was the second time that Resident #2 had attempted to pull Resident #1 out of bed. She stated she was not present but had received the information in the report as she typically worked the day shift. LVN D said that they had to redirect Resident #2 consistently. LVN D stated that she did not feel that Resident #2 was explicitly targeting Resident #1 but that he was confused as to where his room was. <BR/>An attempt to contact LVN B was made on 05/08/24 at 10:57 PM. LVN B said she would contact her DON and ADM and return the call. Additional attempts to speak with LVN B were made on 05/09/24 at 10:29 AM. LVN B did not answer. <BR/>During an interview on 05/09/24 at 10:52 AM, the Activity Director stated that she participated in Resident #1's care plan. The Activity Director stated that Family Member J expressed that Resident #2 had wandered into Resident #1's room once or twice. <BR/>During an interview on 05/09/24 at 11:27 AM, Resident #1 stated that Resident #1 had been in his room [ROOM NUMBER]-5 times. Resident #1 said out of those 4-5 times, Resident #2 had become physical with him. Resident #1 stated no one had come to him and interviewed him about the incident outside of the HHSC investigator. Resident #2 said that he was afraid when he had to hang onto the bed. Resident #1 said he had told multiple CNAs and nurses that he did not want Resident #2 in his room. Resident #2 said he could not remember the names of the staff he told. Resident #2 said he felt like his problem was never solved. Resident #1 said that three times when Resident #2 came into his room, it got physical; he was pulled off the bed, scratched, and pulled halfway off the bed. Resident #1 said he could not remember the date and time when the incidents happened but that staff knew about it because they had to help him.<BR/>During an interview on 05/09/24 at 1:07 PM, the ADM clarified that during the initial interview, she stated the incident between Resident #2 and Resident #1 had never happened was because three weeks prior, staff had reported that Resident #2 had gone into the room and scratched Resident #1 and LVN B had redirected Resident #2 out. The ADM stated she was unsure where the scratch was. The ADM stated this type of information was typically reported to the DON. The ADM stated she did not report the incident to the state agency because the nurse had intervened and redirected Resident #2 out of the room. The ADM said she was unaware that Resident #2 had encountered Resident #1 multiple times. The ADM said she was unaware that Resident #2 had attempted to pull Resident #1 out of the bed before the incident on 04/25/24. The ADM said they were monitoring Resident #2's behavior through psychiatric services and medication adjustments. The ADM stated that the staff had expressed concerns about them getting hurt, but she was unaware of the ongoing issues with Resident #1. She said she was only aware of one incident where Resident #2 had become aggressive with staff. She said she was unaware of any other incidents. The ADM said she knew that most of Resident #2's incidents or behaviors occurred at night. The ADM said she did not implement any other interventions outside of the medication adjustments and monitoring from psychiatric services and notifying the family, PCP, and FNP. The ADM said she had never interviewed Resident #1 to see if this had happened. The ADM had never delegated to interview Resident #1. The ADM said the night of the incident (04/25/24), she was more concerned with his well-being and what happened. The ADM said part of the investigation process was interviewing key witnesses and residents and finding out what happened. The ADM said the potential negative outcome of not reporting allegations of abuse to the state governing agency was that resident harm or the resident's safety could be compromised. The ADM said she was unaware of the additional incidents outside of the incident on 04/25/24 between Resident #1 and Resident #2. The ADM said her system for monitoring ANE was that signs were posted that instructed staff to contact her regarding ANE concerns. The ADM said they educate staff to report allegations of abuse immediately, and the ANE policy was attached to those inservices. The ADM said she expected the staff to report immediately if they witnessed or suspected abuse. The ADM said she and the staff had also been trained to report allegations of ANE immediately. The ADM said everyone was responsible for following the abuse policy and reporting ANE immediately.<BR/> During an interview on 05/09/24 at 2:17 PM, the DON stated that the only other incident she knew of between Resident #1 and Resident #2 was where Resident #2 scratched Resident #1. The DON said she was unsure of the date and time when this incident occurred. The DON said that Resident #2 was redirected out of the room. The DON said she was unaware of any other incidents. The DON said that she could not think of any other interventions put in place outside of psychiatric medication adjustments and close monitoring. The DON stated she never interviewed Resident #1. The DON said once an incident was reported to the ADM, she would relinquish the investigation process to the ADM because she had so much on her plate. The DON said the potential negative outcome of not reporting allegations of abuse was that abuse could continue to happen. The DON said she was aware of two incidents between Resident #1 and Resident #2 and was unaware that this was an ongoing situation. The DON said their system for monitoring ANE reporting and following the ANE policy was to educate staff through inservices. The DON said she had never observed Resident #2 enter Resident #1's room. The DON said she expected staff to report all incidents of abuse to the abuse coordinator.<BR/> Record review of salesforce (tulip) revealed from January 2024 until May 2024 date no other reports have been made to state in regard to Resident #1 and Resident #2 other then the incident that has us in the facility. <BR/>Record review of the facility's policy, Abuse, Neglect, Exploitation General Policy, Filing, undated revealed the following:<BR/>PROCEDURE :<BR/>Investigation<BR/> All facility employees, family members and volunteers and educated that alleged or suspected [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Resident #2) reviewed for care plan revisions.<BR/>The facility failed to ensure Resident #2's care plan (focus, goals and interventions) was updated to reflect his increasingly ongoing incident of physical and verbal aggressive behaviors.<BR/>This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. <BR/>The findings included: <BR/>Record review of Resident #2's face sheet, dated 05/08/24, revealed an [AGE] year-old-male was readmitted to the facility on [DATE] with diagnosis to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. <BR/>Record review of Resident #2 care plan, dated 04/30/24 revealed the following: <BR/>Focus (Date initiated:04/26/24 Date revised:04/26/24)<BR/>4-25-24-I pulled another resident out of bed.<BR/>Goal<BR/>I will have no further episodes of aggression through review date.<BR/>Interventions<BR/>Placed 1:1 Sent to a behavior support center. <BR/>Focus (Date initiated:01/22/24 Date revised: 01/22/24)<BR/>I am an elopement risk/wanderer. Wander risk<BR/>Goal<BR/>I will not leave facility unattended through the review date.<BR/>Interventions <BR/>Distract me from wandering by offering pleasant diversions. I prefer having snacks.<BR/>followed by psychiatric services. notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications.<BR/>Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log.<BR/>Focus (Date initiated: 01/22/24 Date revised:01/22/24)<BR/>I have episodes of verbal and physical aggression r/t dementia.<BR/>Goal<BR/>I will not harm self or others through the review date.<BR/>Interventions <BR/>Give me as many choices as possible about care and activities.<BR/>Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. <BR/>Monitor/document/report PRN any s/sx of me posing danger to self and others.<BR/>When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Focus (Date initiated:01/22/24 Date revised:01/22/24)<BR/>I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye.<BR/>Goal<BR/>I will show no decline in visual function through the review date.<BR/>Interventions <BR/>Arrange consultation with eye care practitioner as required.<BR/>Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Place frequently used items on my left side so I may see them<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>04/25/24 at 04:55 PM LVN A documented:<BR/>Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room.<BR/>04/24/24 at 08:25 PM the DON documented:<BR/>7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and layed down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. <BR/>04/23/24 at 11:34 AM the DON documented:<BR/>Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. <BR/>04/23/24 at 1:06 AM LVN A documented:<BR/>Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2<BR/>04/15/24 at 4:16 AM LVN B documented:<BR/>Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room.<BR/>04/04/24 at 05:11 PM LVN B documented:<BR/>Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking<BR/>cane from rt hands and redirect to room. Admin notified.<BR/>03/30/24 at 12:26 AM LVN B documented:<BR/>Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room.<BR/>03/30/24 at 05:27 PM LVN D documented:<BR/>Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go<BR/>into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room.<BR/>Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision.<BR/>Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1.<BR/>Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every30 minutes on 05/08/24-05/10/24.<BR/>During an interview on 05/09/24 at 11:10 AM, the MDS Coordinator stated that she was aware that Resident #2 had pulled Resident #1 out of the bed only once. The MDS Coordinator said that she was unaware that Resident #2 had increased physical or verbal aggression behaviors. The MDS Coordinator said revising the care plan if the behaviors differ was customary. The MDS Coordinator said that Resident #2 did not understand well and that all staff could do was redirect him with a snack or an activity. The MDS Coordinator stated that she revises the care plan each time there was an MDS update. The MDS Coordinator said the MDS was updated annually, quarterly, and sometimes on an off cycle. The MDS Coordinator said she would also update if there was a significant change. The MDS Coordinator said she looked over the care plans each time there was a care plan meeting. The MDS Coordinator said she would have revised the care plan if it had been reported to her each time Resident #2 pulled any resident out of bed. The MDS Coordinator said the interventions were what the staff do to care for the resident, and staff should be watching him closely. <BR/>During an interview on 05/09/24 at 1:07 PM, the ADM said the potential negative outcome of not revising the care plan with the resident's current behavior was harm could come to the resident. The ADM said she believed that the care plan should continually be revised depending on the situation. The ADM said she was unaware that no revisions had been made to Resident #2's verbal and physical care plan since January 2024. The ADM said that Resident #2 has had an incident of verbal and physical aggression since January 2024. The ADM said the MDS coordinator had a checklist that she followed and would ask specific questions so that she was able to update the care plan accordingly. The ADM said she had a general understanding of care plans and revision but had not been trained to complete care plans. The ADM said she expected care plans to be revised if something happened or the resident changed. The ADM said ultimately, she, the DON, and the MDS coordinator were responsible for care plans. The ADM said if the care plan was not revised, staff used old information to care for residents. The ADM said all the staff use the care plans. <BR/>During an interview on 05/09/24 at 2:17 PM, the DON stated the potential negative outcome of not revising care plans was that the care plan may not be appropriate for the resident. The DON said she was unaware that Resident #2's care plan had not been updated regarding Resident #2 physical and verbal aggression. The DON said their system to monitor care plans was if she knew that an update was needed, she would communicate with the MDS Coordinator via telephone or email. The DON said if the MDS coordinator does not know the information, she would be unable to revise. The DON said she had been trained regarding care plan revisions. The DON said she expected residents' care plans to be revised if they knew the specific needs. The DON said Resident #2 has had incidents of physical and verbal aggression since January 2024. The DON said the MDS Coordinator was responsible. The DON said she sometimes looks at the care plans if she was looking for things but does not necessarily monitor them.<BR/>Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated December 2016 revealed the following:<BR/>Policy Statement<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Policy Interpretation and Implementation<BR/>Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:<BR/>3. <BR/>Request revisions to the plan of care;<BR/>The comprehensive, person-centered care plan will:<BR/>1. <BR/>Include measurable objectives and timeframes;<BR/>2. <BR/>Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;<BR/>3. <BR/>Incorporate identified problem areas;<BR/>4. <BR/>Incorporate risk factors associated with identified problems;<BR/>5. <BR/>Reflect treatment goals, timetables and objectives in measurable outcomes;<BR/>6. <BR/>Identify the professional services that are responsible for each element of care;<BR/>7. <BR/>Reflect currently recognized standards of practice for problem areas and conditions.<BR/>Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.<BR/>Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.<BR/>8. <BR/>When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers.<BR/>9. <BR/>Care planning individual symptoms in isolation may have little, if any, benefit for the resident.<BR/>Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>The Interdisciplinary Team must review and update the care plan:<BR/>10. <BR/>When there has been a significant change in the resident's condition;<BR/>b. <BR/>When the desired outcome is not met;<BR/>c. <BR/>When the resident has been readmitted to the facility from a hospital stay; and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 (Residents #1) residents reviewed for adequate supervision and prevention of accidents. <BR/>The facility staff (Administrator and DON) failed to adequately address Resident #2's ongoing behavior of entering Resident #1's room.<BR/>The facility (Administrator and DON) failed to address resident #2's ongoing physical and verbal behavior with appropriate interventions.<BR/>These failures to put supervision measures in place could result in harm to Resident #2 and the remaining residents in the facility. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread and uneasiness), cognitive communication deficit (difficulty understanding and communicating). <BR/>Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #1 had slurred speech, could make himself understood and usually understood others. <BR/>Record review of Resident #1 Care Plan, dated 02/29/24, revealed that he is a max assist, depends on staff for meeting his needs, requires tube feeding, has depression (impaired ability to remember), is on antianxiety medications, and that he was pulled from the bed on 04/25/24.<BR/>Record review of Resident #1's progress notes revealed the following:<BR/>04/25/24 at 05:08 PM LVN A documented:<BR/>Resident #1 was found on the floor was pulled out of bed by another resident (unidentified) assist Resident #1 back to bed did assessment no injures noted<BR/>03/30/24 at 12:49 AM LVN B documented:<BR/>Other resident (unidentified) tried to pull Resident #1 out of his bed. other resident (unidentified) scratched Resident #1 across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Other resident (unidentified) was taken to his own room. <BR/>Record review of Resident #2's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was readmitted to the facility on [DATE] with diagnosis to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. <BR/>Record review of Resident #2 care plan, dated 04/30/24 revealed the following: <BR/>Focus (Date initiated:04/26/24 Date revised:04/26/24)<BR/>4-25-24-I pulled another resident out of bed.<BR/>Goal<BR/>I will have no further episodes of aggression through review date.<BR/>Interventions <BR/>Placed 1:1 Sent to a behavior support center. <BR/>Focus (Date initiated:01/22/24 Date revised: 01/22/24)<BR/>I am an elopement risk/wanderer. Wander risk<BR/>Goal<BR/>I will not leave facility unattended through the review date.<BR/>Interventions <BR/>Distract me from wandering by offering pleasant diversions. I prefer having snacks.<BR/>followed by psychiatric services. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications.<BR/>Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log.<BR/>Focus (Date initiated: 01/22/24 Date revised:01/22/24)<BR/>I have episodes of verbal and physical aggression r/t dementia.<BR/>Goal<BR/>I will not harm self or others through the review date.<BR/>Interventions <BR/>Give me as many choices as possible about care and activities.<BR/>Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. <BR/>Monitor/document/report PRN any s/sx of me posing danger to self and others.<BR/>When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Focus (Date initiated:01/22/24 Date revised:01/22/24)<BR/>I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye.<BR/>Goal<BR/>I will show no decline in visual function through the review date.<BR/>Interventions <BR/>Arrange consultation with eye care practitioner as required.<BR/>Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Place frequently used items on my left side so I may see them<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>04/25/24 at 04:55 PM LVN A documented:<BR/>Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room.<BR/>04/24/24 at 08:25 PM the DON documented:<BR/>7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and laid down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. <BR/>04/23/24 at 11:34 AM the DON documented:<BR/>Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. <BR/>04/23/24 at 1:06 AM LVN A documented:<BR/>Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2<BR/>04/15/24 at 4:16 AM LVN B documented:<BR/>Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room.<BR/>04/04/24 at 05:11 PM LVN B documented:<BR/>Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking<BR/>cane from rt hands and redirect to room. Admin notified.<BR/>03/30/24 at 12:26 AM LVN B documented:<BR/>Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room.<BR/>03/30/24 at 05:27 PM LVN D documented:<BR/>Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go<BR/>into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room.<BR/>Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision.<BR/>Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1.<BR/>Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every30 minutes on 05/08/24-05/10/24.<BR/>During an interview on 05/08/24 at 11:42 AM, the ADM stated Resident #2 went into Resident #1's room. The ADM stated Resident #1 and Resident #2's rooms were next to each other. She stated staff heard yelling from Resident #1. She stated when staff entered the room, they observed Resident #1 on the floor, and Resident #2 was in Resident #1's bed. The ADM stated staff redirected Resident #2 to his room, assessed Resident #1 and did not identify any injuries on either resident. The ADM stated she was notified and physically came to the facility to attempt to get additional support from a local behavior support center for Resident #2's behavior. She said Resident #2 was transported to the behavior support center the same night. The ADM stated that Resident #2 had never done this to Resident #1. She stated Resident #1 had a history of aggressive behavior with staff. The ADM said as a result of this incident, on 04/25/24, they conducted training with staff over resident rights, ANE, and that they had consulted with the local behavior support center to conduct training on dealing with aggressive behaviors, but no official date had been set.<BR/>During an interview on 05/08/24 at 01:34 PM, Resident #2 said he did not recall staff yelling at him, felt safe, had difficulty seeing things, and had no physical incidents with staff or other residents. Resident #2 said he knew where his room was but could not recall a specific room number. He said he did not have any additional concerns. <BR/>During an interview on 05/08/24 at 1:50 PM, Family Member J stated on 04/25/24, she was notified that Resident #2 had thrown Resident #1 on the floor. Family Member J said she was notified that Resident #1 was assessed, received x-rays, and had no injuries. Family Member J said she spoke with Resident #1 and was told he was not hurting too badly. Family Member J said before the incident on 04/25/24 that she had participated in Resident #1 care plan meeting and specifically had asked what would be done about Resident #2 going into Resident #1 room. Family Member J said it had been suggested that possibly hanging something on Resident #2's door could help Resident #2 find his room. Family Member J said she did not believe that Resident #2 was intentionally targeting Resident #1 but that he was confused. Family Member J said during the care plan meeting, the MDS coordinator, the ADM, the DON, the DM, and the Activities Director were present. She said she brought up the interaction between Resident #1 and Resident #2 because she had been present when Resident #2 would wander into Resident #1 room. Family Member J said she was lucky that Resident #2 had never been violent with her. Family Member J said she had always successfully redirected him out of Resident #1's room. She said the incident on 04/25/24 was not the first time Resident #2 had entered Resident #1's room. Family Member J said the incident on 04/25/24 was the only time she had been notified. Family Member J said she had been told by the staff (LVN A and other CNAs that she could not remember) that there was an incident (did not know the date) where Resident #2 had come into Resident #1's room and tried to pull him off the bed, but was unsuccessful. She said she believe the Social Worker may have mentioned to her about Resident #2 attempting to pull Resident #1 off the bed. Family Member J said that there was an instance (unsure of the date) where she had entered Resident #1's room, and Resident #2 walking cane was behind the dresser in Resident #1's room, indicating he had been there. Family Member J said it was her first time bringing it up to the ADM and DON at the care plan meeting, but she had talked to staff and the nurses numerous times before the care plan meeting. Family Member J said staff had expressed that they were reporting issues, but nothing was being done. Family Member J said that no incidents with Resident #1 and Resident #2 would occur during the day because she or Family Member K would be there during the day. Family Member J said she was there during the day on Monday, Wednesday, Thursday, and Friday. She said Family Member K was at the facility on Wednesday. Family Member J said that before the incident on 04/25/24, nothing had been done to help Resident #2 know where his room was. <BR/>During an interview on 05/08/24 at 2:02 PM, Resident #1 stated via telephone that Resident #2 had pulled him off the bed, and he did not want it to happen again.<BR/>During an interview on 05/08/24 at 2:03 PM, Family Member K stated via telephone that she was physically with Resident #1 but that he had a hard time talking because of his stroke. Family Member K said there was an incident where LVN A walked into the room (unsure of the date), and Resident #1 was sideways, hanging onto the bed with one arm. She said she believed there was another incident where Resident #1 tried to protect his feeding tube site. She said she was concerned that this was happening when Resident #1 was sleeping, and that Resident #1 could not defend himself. Family Member K said the staff knew about the incidents and needed to do something. Family Member K said that she had not physically told anyone but was told by Family Member J that she had. <BR/>During an interview on 05/08/24 at 2:18 PM, CNA F stated she was unsure of the exact dates, but about a month before the interview, She and CNA E had caught Resident #2 in Resident #1 room. CNA F said Resident #2 was confused and had difficulty seeing. CNA F said she did not believe Resident #2 was being mean or awful to Resident #1, but he thought he was in his (Resident #2) room. CNA F stated Resident #1 was yelling. CNA F said when they got to Resident #1's room (she and CNA E), they observed the door closed and the lights off. CNA F said when they turned on the lights, they observed Resident #2 trying to pull Resident #1 off the bed. CNA F stated water was on the floor, and Resident #1's head was on the bed rail. She observed the side table turned over, and Resident #1 was protecting his feeding tube site and crying. CNA F attempted to redirect Resident #2, but he refused to leave. CNA F stated this incident was reported to LVN B. CNA F stated LVN B said she reported the incident to the appropriate parties. CNA F stated a week after that incident (unsure of the exact date), Resident #2 was back in Resident #1's room. CNA F stated that Resident #1 had pushed his call light, and Resident #2 was standing in Resident #1's room when they got to him. CNA F stated that when they attempted to redirect him out of Resident #1's room, Resident #2 stated he wanted his jacket, and they grabbed his hand. Finally, Resident #2 went with them. CNA F stated that there had been a lot of changes in the facility as far as room changes and believed that the separation by gender may have contributed to Resident #2 being confused about where he was going and, in addition, his difficulty being blind. CNA F stated Resident #2 had been moved three or four times. CNA F stated the difficulty they had been having with Resident #2 had been reported to LVN A and LVN B (unsure of the exact time and date). She stated she was under the impression that, as the CNA, she was to report to her charge nurse and that they would proceed further if needed. She said her charge nurses had told her that the incidents with Resident #2 had been reported to higher people. CNA F stated they had wondered when something would be done. CNA F stated she was frustrated with all the incidents that had occurred with Resident #2. She stated that although Resident #2 was not evil and was sweet, his behaviors had worsened, and he had become more confused. CNA F stated that outside of the incidents with Resident #1, Resident #2 had become aggressive with her, and CNA G. CNA F stated that if something had been done, some of the incidents with Resident #2 could have been prevented.<BR/>During an interview on 05/08/24 at 2:58 PM, CNA E stated she could not remember exact dates and times. CNA E stated the first incident between Resident #1 and #2 might have occurred four months ago. CNA E stated that she and CNA F were doing rounds and heard Resident #1 scream aloud. CNA E stated Resident #2 was in Resident #1 room. CNA E stated she observed Resident #1 halfway off the bed. CNA E stated that Resident #2 had his wife in the room. CNA E stated Resident #1 was halfway off of the bed, and she observed the lower half of Resident #1's body off the bed. CNA E said Resident #1 was holding onto the bed rail with his right arm. CNA E stated the incident where Resident #1 was hanging off the bed was the first incident she had ever seen. She said she reported the incident to the charge nurse but could not remember who it was as they have many charge nurses. CNA E stated there was another incident (unsure of the date and time) where Resident #1 screamed. CNA E stated that Resident #2 scratched Resident #1 during this incident. CNA E stated it happened possibly two months ago. CNA E stated Resident #2 had scratches on his chest and right side. CNA E stated this was reported to LVN B. CNA E stated that she had to scream for assistance during this incident. She stated CNA F came to assist her. CNA E stated that this incident scared her and that things were worsening with Resident #2's behaviors. CNA E stated that Resident #2 was telling her that Resident #1's room was his room and yelling at her. CNA E said she kept telling him it was not his room. CNA E said that after they told LVN B, she (LVN B) would notify the appropriate parties. She said Resident #1 appeared scared and had water in his eyes. She said Resident #1 said it was scary. CNA E said Resident #1 used minimal words such as scary, hurt, and oh man to describe what had happened. CNA E said there was another incident where Resident #2 had become agitated and aggressive with staff; this was when she messaged the DON. CNA E said she did not like what was happening, and it made her sad about what had happened to Resident #1. <BR/>A record review of text messages sent to the HHSC investigator on 05/08/24 at 3:28 PM from CNA E revealed on 04/23/24 at 3:28 PM that CNA E expressed concern about Resident #2's behavior, not being trained to take care of residents with Resident #2's behaviors, other residents being afraid and the potential for the incident to be worse. The DON responded that Resident #2's medication was adjusted. CNA E expressed concern about what to do when Resident #2 does not take his medication. CNA E expressed in the text message that Resident #2 had several incidents before the aggressive incident with staff. CNA E referenced the incident with Resident #2 protecting his feeding tube and that CNA E had reported the incident to her charge nurse. The DON responded to the concerns by stating that Resident #2's medication was adjusted and that she was unaware what had happened when Resident #2 became aggressive with staff.<BR/>During an interview on 05/08/24 at 3:29 PM, LVN A stated that she no longer worked at the facility. LVN A stated on 04/25/24 that she did not witness Resident #2 pulling Resident #1 out of the bed. LVN A stated that she had heard Resident #1 scream and thought it was another resident. LVN A said that when she walked down the hallway, one of the CNAs came running towards her. LVN A stated she could not remember the CNAs name. LVN A said she went into Resident #1 room and observed Resident #2 in Resident #1's bed and Resident #1 was on the floor. LVN A said this was not the first interaction between Resident #1 and Resident #2. LVN A stated this was the second time this had happened. LVN A said that during the incident on 04/25/24, Resident #2 yelled at the staff. LVN A stated she raised her voice for Resident #2 to get out of Resident #1's bed. LVN A said that they were finally able to get Resident #2 out of Resident #1 room. LVN A said she notified the DON of the incident. LVN A stated the DON said that she told the ADM and that the ADM was on the way to the facility to send Resident #2 out for behavior support. LVN A said she had experienced Resident #2 becoming agitated with staff on 04/18/24. She stated that the FNP, PCP, DON, and ADM knew about the incident. She said she had been told by other staff that Resident #2 had attempted to pull Resident #1 out of bed before. She said she was unaware of any interventions that had been put in place. <BR/>During an interview on 05/08/24 at 10:25 PM, CNA I stated on 04/25/24, it was around 7 PM or 9 PM when the residents that smoke go out. CNA I said she observed Resident #1 on the floor. CNA I said she went to get LVN A, and that was when she (LVN A) told Resident #2 to get the fuck out. CNA I said she redirected Resident #2 to his room. CNA I stated she and CNA H placed Resident #1 back in bed. CNA I said after that incident and Resident #2 received a shot of Ativan he came back out and was trying to throw a shoe at Resident #1. CNA I said that most of the time when she worked with Resident #2, he would always try to go into Resident #1's room. CNA I said this occurred at least three times a week. Before the incident on 04/25/24, CNA I said that Resident #2 never made physical contact with Resident #1 on her shift. CNA I said there was nothing ever done that she could recall to alleviate the situation, but the staff had placed gloves on the outer door at one point. She stated she could not provide a picture of the gloves on the door to the HHSC worker. CNA I said that she had been trained to report allegations of ANE immediately. <BR/>During an interview on 05/08/24 at 10:51 PM, LVN D stated that the incident on 04/25/24 was the second time that Resident #2 had attempted to pull Resident #1 out of bed. She stated she was not present but had received the information in the report as she typically worked the day shift. LVN D said that they had to redirect Resident #2 consistently. LVN D stated that she did not feel that Resident #2 was explicitly targeting Resident #1 but that he was confused as to where his room was. <BR/>An attempt to contact LVN B was made at 10:57 PM. LVN B said she would contact her DON and ADM and return the call. Additional attempts to speak with LVN B were made on 05/09/24 at 10:29 AM. LVN B did not answer. <BR/>During an interview on 05/09/24 at 10:21 AM, the FNP stated that she had consistently been seeing Resident #2 for psychiatric services. The FNP said she was making frequent medication adjustments. The FNP said she was only aware of one incident where Resident #2 had pulled a resident out of the bed, but no other incidents had been reported. The FNP said it had been reported that he had become aggressive with staff.<BR/>During an interview on 05/09/24 at 10:52 AM, the Activity Director stated that she participated in Resident #1's care plan. The Activity Director stated that Family Member J expressed that Resident #2 had wandered into Resident #1's room once or twice. The Activity Director stated they had gloves on the door so Resident #2 knew where his room was. The Activity Director said she does not know what happened to the gloves because they are no longer there. The Activity Director said she was unaware of any other interventions to prevent Resident #2 from entering Resident #1's room. The Activity Director stated she did not feel that Family Member J was upset but did express concern.<BR/>During an interview on 05/09/24 at 11:00 AM, the DM stated that she participated in Resident #1's care plan. The DM said Family Member J expressed concern about Resident #2 entering Resident #1's room. The DM suggested placing bells or something on Resident #2's door so that he would know which room was his. The DM said Family Member J was concerned that the next time could be worse for Resident #1. The DM stated that before the incident on 04/25/24, Resident #2 had gone into Resident #1's room, but she did not know the date or time. The DM said she was unaware if Resident #2 had been physical with Resident #1. The DM said Family Member J was not upset but concerned.<BR/>During an interview on 05/09/24 at 11:10 AM, the MDS Coordinator stated that she was aware that Resident #2 had pulled Resident #1 out of the bed only once. The MDS Coordinator said that she was unaware that Resident #1 had increased physical or verbal aggression behaviors. The MDS Coordinator said revising the care plan if the behaviors differ was customary. The MDS Coordinator said that Resident #2 did not understand well and that all staff could do was redirect him with a snack or an activity. The MDS Coordinator stated that she revises the care plan each time there was an MDS update. The MDS Coordinator said the MDS was updated annually, quarterly, and sometimes on an off cycle. The MDS Coordinator said she would also update us if there was a significant change. The MDS Coordinator said she looked over the care plans each time there was a care plan meeting. The MDS Coordinator said she would have revised the care plan if it had been reported to her each time Resident #2 pulled any resident out of bed. The MDS Coordinator said the interventions were what the staff do to care for the resident, and staff should be watching him closely. <BR/>During an interview on 05/09/24 at 11:27 AM, Resident #1 stated that Resident #2 had been in his room [ROOM NUMBER]-5 times. Resident #1 stated no one had come to him and interviewed him about the incident outside of the HHSC investigator. Resident #1 said that he was afraid when he had to hang onto the bed. Resident #1 said he had told multiple CNAs and nurses that he did not want Resident #2 in his room. Resident #1 said he could not remember the names of the staff he told. Resident #1 said he felt like his problem was never solved. Resident #1 said that three times when Resident #2 came into his room, it got physical; he was pulled off the bed, scratched, and pulled halfway off the bed. Resident #1 said he could not remember the date and time when the incidents happened but that staff knew about it because they had to help him.<BR/>During an interview on 05/09/24 at 1:07 PM, the ADM clarified that during the initial interview, she stated the incident between Resident #2 and Resident #1 had never happened was because three weeks prior, staff had reported that Resident #2 had gone into the room and scratched Resident #1 and LVN B had redirected Resident #2 out. The ADM stated she was unsure where the scratch was. The ADM stated this type of information was typically reported to the DON. The ADM stated she did not report the incident to the state agency because the nurse had intervened and redirected Resident #2 out of the room. The ADM said she was unaware that Resident #2 had encountered Resident #1 multiple times. The ADM said she was unaware that Resident #2 had attempted to pull Resident #1 out of the bed before the incident on 04/25/24. The ADM said she was unsure of Resident #1's care plan meeting . The ADM said she, the DON, Family Member J, The MDS Coordinator, the ADM, and the Social Worker may have been there. <BR/>During the care plan meeting, the ADM said Family Member J did not express concerns about Resident #2 coming into Resident #1's room. The ADM said they did discuss potentially placing something on Resident #2's door but never made it official. The ADM said the discussion about Resident #2 did not occur during Resident #1's care plan meeting. The ADM said they were monitoring Resident #2's behavior through psychiatric services and medication adjustments. The ADM stated that the staff had expressed concerns about them getting hurt, but she was unaware of the ongoing issues with Resident #1. She said she was only aware of one incident where Resident #2 had become aggressive with staff. She said she was unaware of any other incidents. The ADM said she knew that most of Resident #2's incidents or behaviors occurred at night. The ADM said she did not implement any other interventions outside of the medication adjustments and monitoring from psychiatric services and notifying the family, PCP, and FNP. The ADM said she was sure the care plan had interventions to address Resident #2's behaviors. The ADM said all interventions and revisions should be dated. The ADM said grievances were for family and residents. The ADM said if staff had a concern, they should be redirected to HR to identify a solution. The ADM said she did not have a system to track staff concerns. The ADM said she was responsible for grievances. The ADM said all staff had been trained to handle grievances as part of ANE and resident rights training. The ADM said she had never interviewed Resident #1 to see if this had happened. The ADM had never delegated to interview Resident #1. The ADM said the night of the incident (04/25/24), she was more concerned with his well-being and what happened. The ADM said part of the investigation process was interviewing key witnesses and residents and finding out what happened. The ADM said the potential negative harm if they do not attempt to prevent incidents and accidents was that harm could come to the residents and staff. The ADM said the care plan had interventions that helped prevent incidents and accidents. The ADM said they usually would have met weekly if they identified a potential problem. The ADM said that her team had not met every week regarding Resident #2. The ADM said the purpose of preventing incidents and accidents was the residents' overall safety. The ADM said that she could have prevented further incidents if she had known about the multiple incidents between Resident #1 and Resident #2. The ADM said she was unaware of the various times. The ADM said the facility staff monitored incident/accident prevention through daily standup meetings, talking to staff, and in-service. The ADM said she had not done anything specific for the night-time staff but that they had received the same ANE and resident rights training. The ADM said she had no formal training regarding preventing incidents/accidents, but they trained the staff through in-services. The ADM said she had not observed Resident #2 go into Resident #1's room but expected

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure the residents had the right to participate in his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 5 of 15 residents ( Resident #2, Resident #9, Resident #13, Resident #21 and Resident #22) reviewed for resident rights .<BR/>The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #2 prior to administering Perphenazine (is used to treat intermittent explosive disorder (impulse control disorder)).<BR/>The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #9 prior to administering Seroquel (is used to treat schizoaffective disorder (false perceptions in the form of hallucinations)).<BR/>The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #13 prior to administering Olanzapine (is used to treat psychotic disorder (symptoms that affect the mind/ loss of contact with reality) with delusions).<BR/>The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #21 prior to administering Seroquel (is used to treat paranoid schizophrenia).<BR/>The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #22 prior to administering Seroquel (is used to treat schizoaffective disorder (false perceptions in the form of hallucinations)).<BR/>These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party.<BR/>Findings included:<BR/>Resident #2<BR/>Record review of Resident #2's face sheet, dated 07/16/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (impulse control disorder).<BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. <BR/>Section N Medications<BR/>. Medications Received (received the following medications within the 7 days since admission/ or reentry)<BR/>_Antipsychotic<BR/>_Antianxiety<BR/>Record review of Resident #2's Order Summary Report dated 07/16/23 revealed the following:<BR/>Perphenazine Oral Tablet 2 MG give 6 mg by mouth at bed time related to intermittent explosive disorder ordered 07/04/23 (no end date)<BR/>Record review of Resident #2's care plan, revealed the following<BR/>Focus<BR/> I use antipsychotic medications due to intermittent explosive disorder. med- Revision on: 07/07/2023<BR/>Goal<BR/> I will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Date Initiated: 05/31/2023 <BR/>o I will reduce the use of psychotropic medication through the review date. Date Initiated: 05/31/2023 Revision on: 05/31/2023<BR/>Interventions<BR/> o Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side<BR/>effects and effectiveness Q-SHIFT. Date Initiated: 05/31/2023<BR/>o Consult with pharmacy, MD to consider dosage reduction when clinically<BR/>appropriate at least quarterly. Date Initiated: 05/31/2023<BR/>o Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC<BR/>medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles,<BR/>shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression,<BR/>suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of<BR/>appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual<BR/>to the person. Date Initiated: 05/31/2023<BR/>o Monitor/record occurrence of for target behavior symptoms ( pacing, wandering,<BR/>disrobing, inappropriate response to verbal communication, violence/aggression<BR/>towards staff/others. etc.) and document per facility protocol.<BR/>Revision on: 05/31/2023<BR/>Record review of Resident #2's MAR, dated from 06/01/23-06/30/23 revealed she received perphenazine on the following dates:<BR/>06/17/23-06/30/23<BR/>Record review of Resident #2's MAR, dated from 07/01/23-07/18/23 revealed she received perphenazine on the following dates:<BR/>07/01/23-07/03/23<BR/>Record review of the facility consent book did not reveal a medication consent for the following medication for Resident #2:<BR/>Perphenazine 2mg<BR/>Resident #9<BR/>Record review of Resident #9's face sheet, dated 06/17/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include schizoaffective disorder (false perceptions in the form of hallucinations).<BR/>Record review of Resident #9's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. <BR/>Section N Medications<BR/>N0410. Medications Received (received the following medications within the 7 days since admission/ or reentry)<BR/>A_Antipsychotic<BR/>B_Antianxiety<BR/>C_Antidepressant<BR/> Record review of Resident #9's Order Summary Report dated 07/17/23 revealed the following:<BR/>Seroquel Oral Tablet 100 MG give 1 tablet by mouth two times a day related to aggression related to schizoaffective disorder ordered 05/23/23 and started 05/23/23 (no end date)<BR/>Record review of Resident #9's care plan, revealed the following:<BR/>Focus<BR/>I use psychotropic medications r/t bipolar disorder, intermittent explosive disorder. meds-Seroquel<BR/>Revision on: 04/21/2023<BR/>Goal<BR/> o I will be/remain free of psychotropic drug related complications, including movement disorder, discomfort,<BR/>hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Revision on: 04/21/2023 <BR/>o I will reduce the use of psychotropic medication through the review date. Revision on: 04/21/2023<BR/>Interventions<BR/>o Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Revision on: 04/21/2023<BR/>o Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Revision on: 04/21/2023<BR/>o Monitor/document/report PRN any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Revision on: 04/21/2023 <BR/>o Monitor/record occurrence of target behavior symptoms and document per facility<BR/>protocol. Revision on: 04/21/2023<BR/>o non medication interventions for target behaviors include: conversing with me about<BR/>my girlfriend Revision on: 04/21/2023<BR/>Record review of Resident #9 MAR, dated from 06/01/23-06/30/23 revealed he received Seroquel on the following dates:<BR/>06/15/23-06/30/23 at 7:00 AM<BR/>06/13/23-06/30/23 at 7:00 PM<BR/>Record review of Resident #9 MAR, dated from 07/01/23-07/18/23 revealed he received Seroquel on the following dates:<BR/>07/01/23-07/18/23 at 7:00 AM<BR/>07/01/23-07/17/23 at 7:00 PM<BR/>Record review of the facility consent book did not reveal a medication consent for the following medication for Resident #9:<BR/>Seroquel 200 Mg<BR/>Resident #13<BR/>Record review of Resident #13's face sheet, dated 07/18/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include psychotic disorder (symptoms that affect the mind/ loss of contact with reality).<BR/>Record review of Resident #13's Comprehensive Minimum Data Set, dated [DATE] revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. <BR/>Section N Medications<BR/>N0410. Medications Received (received the following medications within the 7 days since admission/ or reentry)<BR/>A_Antipsychotic<BR/>C_Antidepressant<BR/>Record review of Resident #13's Order Summary Report dated 07/17/23 revealed the following:<BR/>Olanzapine Oral Tablet give 2.5 mg by mouth one time a day related to psychotic disorder with delusions ordered date 02/28/23 and start date 03/01/23 (no end date)<BR/>Record review of Resident #13's care plan, revealed:<BR/>Focus<BR/> use antipsychotic medications r/t psychosis. med-Zyprexa Revision on: 03/14/2023<BR/>Goal<BR/> o The resident will reduce the use of psychotropic medication through the review date. Date Initiated: 03/14/2023 <BR/> I will remain free of psychotropic drug related complications, including movement disorder, discomfort,<BR/>hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Revision on: 03/14/2023 <BR/>Interventions<BR/>Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 03/14/2023<BR/> Consult with pharmacy, MD to consider dosage reduction when clinically<BR/>appropriate at least quarterly. Date Initiated: 03/14/2023<BR/> Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 03/14/2023 <BR/>Monitor/record occurrence of for target behavior symptoms ( wandering, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Revision on: 03/14/2023 <BR/>non medication interventions for target behaviors include: conversing with me and offering snacks<BR/>Revision on: 03/14/2023<BR/>Record review of Resident #13's MAR, dated from 06/01/23-06/30/23 revealed he received Olanzapine on the following dates:<BR/>06/01/23-06/30/23 at 7:00 AM<BR/>Record review of Resident #13's MAR, dated from 07/01/23-07/18/23 revealed he received Olazapine on the following dates:<BR/>07/01/23-07/03/23 at 7:00 AM and 07/06/23-07/18/23 at 7:00 AM<BR/>Record review of the facility consent book did not reveal a medication consent for the following medication for Resident #13:<BR/>Olanzapine 2.5 Mg<BR/>Resident #21<BR/>Record review of Resident #21's face sheet, dated 07/18/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia.<BR/>Record review of Resident #21's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. <BR/>Section N Medications<BR/>N0410. Medications Received (received the following medications within the 7 days since admission/ or reentry)<BR/>A_Antipsychotic<BR/>C_Antidepressant<BR/>Record review of Resident #21's Order Summary Report dated 07/18/23 revealed the following:<BR/>Seroquel Oral tablet 200 mg by mouth two times a day related to paranoid schizophrenia ordered 06/13/23 (no end date)<BR/>Record review of Resident #21's care plan, initiated 05/02/22, revealed the following:<BR/>Focus<BR/> use antipsychotic medications r/t schizophrenia. I need these meds to help control behaviors such as delirium and aggression r/t this condition meds-Depakene,Seroquel<BR/>Record review of Resident #21's MAR, dated from 06/01/23-06/30/23 revealed she received Seroquel on the following dates:<BR/>06/01/23-06/30/23 at 7:00 AM<BR/>06/13/23-06/30/23 at 7:00 PM<BR/>Record review of Resident #21's MAR, dated from 07/01/23-07/18/23 revealed she received Seroquel on the following dates:<BR/>07/01/23-07/18/23 at 7:00 AM<BR/>07/01/23-07/17/23 at 7:00 PM<BR/>Record review of the facility consent book did not reveal a medication consent for the following medication for Resident #21:<BR/>Seroquel 100 Mg<BR/>Resident #22<BR/>Record review of Resident #22's face sheet, dated 07/17/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include schizoaffective disorder (false perceptions in the form of hallucinations). <BR/>Record review of Resident #22's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. <BR/>Section N Medications<BR/>N0410. Medications Received (received the following medications within the 7 days since admission/ or reentry)<BR/>A_Antipsychotic<BR/>B_Antianxiety<BR/>Record review of Resident #22's Order Summary Report dated 07/17/23 revealed the following:<BR/>Seroquel Oral tablet 25 mg give 2 tablets by mouth two times a day related to schizoaffective disorder ordered 07/11/23 and started 07/11/23 (no end date)<BR/>Record review of Resident #22's care plan, revealed the following:<BR/>Focus<BR/>I use antipsychotic medications r/t Psychotic disorder meds-Zyprexa,Seroquel Revision on: 10/28/2022<BR/>Goal<BR/>o I will reduce the use of psychotropic medication through the review date. Revision on: 08/08/2022 <BR/>o I will be/remain free of psychotropic drug related complications, including movement disorder, discomfort,<BR/>hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date Revision on: 06/12/2023 <BR/>Interventions<BR/>2-28-23-GDR done on Seroquel Date Initiated: 03/01/2023<BR/>o Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 08/08/2022 <BR/>o Consult with pharmacy, MD to consider dosage reduction when clinically<BR/>appropriate at least quarterly. Date Initiated: 08/08/2022<BR/>o Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of<BR/>appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 08/08/2022<BR/>o Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Date Initiated: 08/08/2022 Revision on: 08/08/2022 Revision by: Licensed Practical Nurse<BR/>o Non medication interventions for target behaviors include: offering me snacks and sitting and conversing with me Revision on: 08/08/2022<BR/>Record review of Resident #22's MAR, dated from 07/01/23-07/18/23 revealed he received Seroquel on the following dates:<BR/>07/06/23-07/11/23 at 7:00 AM<BR/>07/05/23-07/10/23 at 7:00 PM<BR/>Record review of the facility consent book did not reveal a medication consent for the following medication for Resident #22:<BR/>Seroquel 25 Mg<BR/>On 07/18/23 at 11:55 AM, during an interview with the DON, she said the medication consent should be in the book that was provided during the survey. She said they could be on her desk if the resident was a new admission. (The DON checked her desk). She said she had no additional medication consents on her desk. After checking with the ADM, she said there were no additional medication consents anywhere in the facility. She said medication consents should be obtained within seven days after a resident's admission. She said if it was a new medication, then written consent should be obtained before the medication was given to the resident. She said the nurse was responsible for obtaining medication consents. She said if a charge nurse were the only person in the facility, they would be responsible. She said overall, as the DON, she was the person that oversaw that all nursing processes were carried out. She said the potential negative outcome of not obtaining medication consent would mean giving the resident medication without their or their responsible party's consent. She said she could not directly think of any other harm to the resident. She said she has had training in general regarding medication consents as a nurse but has not received training at the facility. After reviewing the consent book provided to the surveyors, she confirmed no medication consent for Resident # 2, #9, #13, #21, and #22 were completed for the discussed medications. She said she was unaware that those consents had not been completed. She said existing medications required a new consent even if the dose was adjusted. After looking in the electronic medical record she confirmed that Resident #22's medication was ordered on 7/1/23, and she said a consent should have been completed before the medication was administered to the resident. After looking in the electronic medical record, she said Resident #9's medication was ordered on 05/23/23. She said this was ordered before her employment, but the expectation would have been that consent should have been completed before medication administration. After looking in the electronic medical record, she said Resident #13's medication was ordered on 03/01/23 and that the consent should have been completed before the medication was administered. After looking in the electronic medical record, she said Resident #21's medication was ordered on 06/13/23, and a medication consent should have been completed before medication administration. After looking in the electronic medical record, she said Resident #2's medication was ordered on 07/04/23, and a medication consent should have been completed before administration. She said that Resident #2 had a medication adjustment, and a medication consent should have been completed before administration and at the time of adjustment. <BR/>On 07/18/23 at 11:55 AM, an observation was made of the DON physically checking her desk for additional consents, checking the consent binder and referring the electronic medical record. <BR/>On 07/18/23 at 12:53 PM, an interview was conducted with the ADM, and he said that the DON was responsible for medication consent. When asked about the facility process, he said the consent should be completed immediately. When asked what the potential negative outcome was for the resident, he said a resident might be taking a medication they were unaware of and could experience adverse outcomes. He said he was unaware that the residents discussed (Resident #2,#9, #13, #21, and #22) did not have medication consents for the identified medications. He said the residents should have a consent or guardian consent before medication administration. He said it should have been referred to the doctor to verify and sign off that taking the medication was in the resident's best interest. He said an audit was completed when the DON first came to the facility. He was not sure why this was not caught during the audit. When asked about a system to monitor medication consent, he said they do a monthly chart audit and discuss it in their QUAPI meetings. He said he would provide any documentation to support these systems. (Nothing provided before exit)<BR/>Record review of facility policy titled Use of psychotropic Medication dated February 2023 (revised), revealed the following:<BR/> Policy: <BR/>Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). These medications require the consent of the resident and/or resident representative.<BR/>5. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. Consent will be given by resident and/or resident representative prior to giving psychotropic medications.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive services with reasonable accommodation of resident's needs and preferences for 1 of 15 (Resident #24) residents reviewed for call light placement. <BR/>The facility failed to ensure the call light system in Resident #24's room was in a position which was accessible.<BR/>This failure could place residents at risk of being unable to obtain assistance in the event of an emergency.<BR/>Findings included:<BR/>Record review of Resident #24's face sheet dated 07/16/23 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis to include unspecified dementia (memory loss), major depressive disorder, muscle weakness, dysphagia (difficulty swallowing), anxiety, and hypertension (high blood pressure). <BR/>Record review of Resident #24's quarterly MDS dated [DATE] revealed a BIMS score of 01 indicating severe cognitive impairment. The MDS revealed in section E Resident #24 had physical and verbal behaviors 4 to 6 days out of 7 but not daily. It further revealed Resident #24 had behavior of rejection of care and wandering behavior 1 to 3 days. Section G of the MDS revealed Resident #24 required two-person extensive assistance with bed mobility, locomotion on/off unit, dressing and eating. The MDS Section G further revealed he was totally dependent on staff for transfers; and toilet use and unsteady when moving from seated to standing position, walking, turning around, moving on/off toilet and surface to surface transfers. The MDS section H revealed resident was always incontinent of bowel and bladder. <BR/>Record review of Resident #24's care plan dated 06/14/23 revealed a focus on falls with interventions including call light is within reach and remind me to use it for assistance as needed. <BR/>Observation on 07/16/23 at 09:45 AM revealed Resident #24's call light was laying on the light fixture above the resident's bed out of reach of the resident. Resident #24 was lying in low bed (bed placed on floor) with his eyes closed. <BR/>Observation on 07/17/23 at 09:36 AM revealed Resident #24 up in his wheelchair in his room and the call light was laying on the light fixture above the resident's bed out of reach of the resident. Resident #24 was not interviewable. <BR/>Observation on 07/17/23 at 10:50 AM revealed Resident #24 up in his wheelchair in his room and the call light was laying on the light fixture above the resident's bed out of reach of the resident. <BR/>Observation on 07/17/23 at 01:42 PM revealed Resident #24 in his wheelchair in his room and the call light was laying on the light fixture above the resident's bed out of reach of the resident. <BR/>Interview on 07/17/23 at 01:43 PM with the DON, she stated the call light should have been within Resident #24's reach. <BR/>Observation on 07/17/23 at 01:43 PM, observed the DON remove the call light from the light fixture and lay the call light on Resident #24's bed within the resident's reach. <BR/>Interview on 07/18/23 at 01:15 PM with the Administrator, he stated all call lights should be within reach. He stated it was the responsibility of all staff to make sure call lights were within the resident's reach. He stated his expectations were that all residents had a call light within reach. He stated the potential negative outcome for a resident not having a call light within reach could be not being able to receive a response to a need.<BR/>Interview on 07/20/23 at 04:09 PM with the DON, she stated call lights were for the resident to be able to call for assistance. She stated a call light that posed a safety risk or choking hazard may be the reason it was kept out of the resident's reach. She stated all staff were responsible for making sure the resident's call light was within reach. She stated her expectation was that residents have a way to call for help and/or frequent checks on those that may not be able to due to physical or mental challenges. She stated a negative outcome of not having the call light within reach could be a resident not being able to call for help when needed.<BR/>Record review of the facility's policy titled Answering the Call Light revised date September 2022 revealed the following:<BR/>General Guidelines .<BR/>4. Be sure that the call light is plugged in and functioning at all times. <BR/>5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for care plans. <BR/>The facility failed to complete an accurate comprehensive care plan for Resident #1's documented change in behavior of undressing in common areas for the last 30 days reviewed. <BR/>These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial need to attain or maintain their highest practicable physical, mental, and psychosocial outcome. <BR/>Findings included: <BR/>Record review of Resident #1's undated face sheet reflected, Resident #1 was admitted to the facility on [DATE] with the <BR/>Findings include: <BR/>Record review of the admission sheet for Resident#1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included: schizoaffective disorder bipolar type (mental illness that can affect your thoughts, mood, and behavior. You may have symptoms of bipolar disorder and schizophrenia. These symptoms may be mania, depression, and psychosis), cognitive communication deficit(problems with communication that have an underlying cause in a cognitive deficit rather than a primary language) and intermittent explosive disorder(mental health condition marked by frequent impulsive anger outbursts or aggression).<BR/>Record review of Resident #1's Comprehensive MDS, dated [DATE] revealed BIMS score 2 out of 15 indicating she was severely impaired cognitively.<BR/>Record review of Resident #1's Progress notes revealed staff documenting that Resident #1 removed her clothing on several occasions on 2/26/23, 3/1/23, 3/6/23, 3/7/23, 3/8/23, 3/17/23. <BR/>Record Review of Resident #1's care plan, dated 3/16/23, revealed no documentation of Focus, Goal or Intervention that identified or documented Resident #1 disrobing and being nude outside of her facility room. <BR/>During an observation and attempted interview on 3/23/23 at 9:23 p.m. near the nurses station, Resident #1 approached the state investigator and stated, I want it off and Resident #1 began pulling on the waistband of her pants. The investigator stated to CNA C who was standing behind the nurses station checking the security camera that Resident #1 needed assistance. CNA C advised Resident #1 he would assist her in a minute. Resident #1 while standing next to the state investigator immediately removed her pants, brief and shirt with no verbal warning and stood next to the Investigator nude. The State Investigator stated to CNA C can you assist her please, she just took off her clothing. CNA C turned around and asked Resident #1 to follow him to her room so he could assist her.<BR/>During an observation on 3/23/23 at 9:44 p.m., Resident #1 walked from her room on B hall towards the nurses station wearing a hospital gown. Resident #1 passed LVN A and Resident #4 was walking behind Resident #1. Resident #4 stated to LVN A, can you cover her up or something? Her whole backside is hanging out. LVN A stopped Resident #1 and asked her to turn around. Resident #1 was observed with the back of the gown tied at her neck but open in the back and her backside was exposed with no brief or under clothing on. LVN A tied Resident #1's gown fully.<BR/>During an interview on 3/24/23 at 9:57 a.m. with CNA D, stated that Resident #1 is independent and out of nowhere will strip down naked. CNA D stated he has redirected Resident #1 to her room several times so he can put a gown on her. CNA D stated Resident #1 will remove the gown again and staff does not know when or where she will remove her clothing again. CNA D stated that Resident #1 has been doing this for several weeks now and all he knows to do is redirect her and try to cover Resident #1 to her room. CNA D stated Resident #1 removes her clothing in all areas of the facility, in front of other residents and staff. <BR/>During an interview on 3/24/23 at 10:29 a.m. with the AD, stated Resident #1 will remove all clothing in the facility and it does not come with warning, and it occurs in front of other residents. The AD stated staff will redirect Resident #1 and try to cover the resident up. The AD stated that she has heard residents say you need to cover that when Resident #1 removed her clothing in front of them.<BR/>During an interview and observation on 3/24/23 at 12:44 p.m. with LVN B; Stated that Resident #1 gets fully nude in the hallways and common areas and there is often no warning before it occurred. The LVN B stated that staff try to redirect her back to her room and help her get dressed. The LVN B stated that there has been no official training on what they are supposed to do when Resident #1 gets undressed and said that there is nothing care planned that she has seen for this behavior. LVN B stated that it would be good for them to have it planned because it has been about a month that she has been doing this. LVN B stated she hasn't heard any residents complain but that if she lived here, it would make her feel uncomfortable to see a resident walking around nude. <BR/>During an interview on 3/24/23 at 12:58 p.m. with Resident #4; stated that Resident #1 gets fully naked in the halls or common areas at least once a day. Resident #4 stated staff will put a gown on her, but they only tie it up at her neck area. Resident #4 stated that they don't tie the bottom area and it bothers her to see a naked resident. Resident #4 stated that she bets the male residents don't mind seeing a naked woman in the facility, but she does. Resident #4 stated that you don't just see her ass, you see her asshole. I am sick of seeing her asshole every day 'cause she bends over and there it is, her asshole. <BR/>During an interview on 3/24/23 at 1:45 p.m. with the BOM and ADM; BOM stated that staff redirect Resident #1 when she undresses in the hallways and this behavior has been occurring for approximately 3 weeks. The BOM and ADM stated that Resident #1's care plan has not been updated to address this behavior yet. The BOM stated that she understands that it could be upsetting for other residents and the staff to see Resident #1 nude in the facility common areas and that visitors would not want to see a nude resident in the facility halls. <BR/>Record Review of the facility's policy titled, Care Plans-Comprehensive Person Centered, revised on December 2016 reflected the following in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>-The Interdisciplinary Team must review and update the care plan:<BR/>1. <BR/>When there has been a significant change in the resident's condition.<BR/>b. <BR/>When the desired outcome is not met.<BR/>c. <BR/>When the resident has been readmitted to the facility from a hospital stay; and<BR/>d. <BR/>At least quarterly, in conjunction with the required quarterly MDS assessment.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 15 (Resident #24) residents reviewed for activities. <BR/>The facility failed to provide activities for Resident #24. <BR/>These failures could place residents at risk of decline in their physical, mental, and psychosocial well-being. <BR/>The findings included:<BR/>Record review of Resident #24's face sheet dated 07/16/23 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis to include unspecified dementia (memory loss), major depressive disorder, muscle weakness, dysphagia (difficulty swallowing), anxiety, and hypertension (high blood pressure). <BR/>Record review of Resident #24's quarterly MDS dated [DATE] revealed a BIMS score of 01 indicating severe cognitive impairment. The MDS revealed in section E Resident #24 had physical and verbal behaviors 4 to 6 days out of 7 but not daily. It further revealed Resident #24 had behavior of rejection of care and wandering behavior 1 to 3 days out of 7 days. Section F - Preferences for customary routine and activities revealed assessment was not completed. Section G - Functional Status revealed resident required extensive assist with bed mobility, locomotion off unit, and eating. It further revealed resident required total dependence with transfers, locomotion on unit, dressing, toilet use and personal hygiene. <BR/>Record review of the care plan dated 06/14/23 for Resident #24, revealed the following Focus. I am dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits. Interventions included the following, Establish and record my (Resident #24) prior level of activity involvement and interests by talking with me, caregivers, and family on admission and as necessary. I (Resident #24) need assistance/escort to activity functions and I (Resident #24) prefer activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as watching TV, listening to music and 1:1 conversation.<BR/>Record review of the Activity Quarterly Evaluation for Resident #24, dated 05/02/23, revealed this was the most current activity evaluation for the resident. The evaluation documented the following, . Resident #24 is passive group activities he does come out to dining room during activities sits listens and watches. Resident #24 does enjoy food events with asst in rm activities tv and activity director read bible verses and daily devotional. When up assist in joining any group activities. Resident #24 doesn't focus to join in activities group wheel away . Activity director will verbal invite Resident #24 to daily activities, encourage him to join and will read the daily devotional with him in room and dining room. <BR/>Observation on 07/16/23 at 09:45 AM revealed Resident #24 lying in bed staring at ceiling.<BR/>Observation on 07/16/23 at 12:11 PM revealed Resident #24 sitting up in low bed chewing on blanket. <BR/>Observation on 07/16/23 at 01:56 PM revealed Resident #24 sitting up in low bed with a blanket in his mouth. <BR/>Observation on 07/17/23 at 09:36 AM revealed Resident #24 in his wheelchair on his roommate's side of the room with nightstand drawers out of the nightstand and chewing on a blanket. Resident #24 roommate was not in the room. <BR/>Observation on 07/17/23 at 10:03 AM revealed Resident #24 in his wheelchair on his roommate's side of the room with a nightstand drawer in his lap sleeping. <BR/>Observation on 07/17/23 at 10:50 AM revealed Resident #24 in his room in his wheelchair clapping his hands.<BR/>Observation on 07/17/23 at 12:40 PM revealed Resident #24 in his room in his wheelchair on his roommate's side of the room sleeping in his wheelchair.<BR/>Observation on 07/17/23 at 01:42 PM revealed Resident #24 in his room in his wheelchair. <BR/>Observation on 07/17/23 at 01:45 PM revealed the DON took Resident #24 to the dining room for an activity after surveyor intervention. <BR/>Record review of activity participation dated July 2023 revealed no activities documented for Sunday 07/16/23. It further revealed Resident #24's activities for Monday 07/17/23 were sleeping, tv watching, wheeling, daily devotional, bingo and trivia time. <BR/>Interview on 07/18/23 at 11:45 AM the AD stated she was responsible for planning the daily activities. She stated all staff worked as a team to provide activities. She stated the monitor techs helped with 1:1 activity. She stated Resident #24 did attend group activities, but he left because he was very active when out of his room. She stated residents who did not attend groups were provided books, daily devotional read to them, sit and visits, cards, music, adult coloring and magazines. She stated, we really encourage all residents to come to group activities. She said Resident #24's planned activities were group, trivia, exercise, sit and visit, and read him daily devotions. She stated 4-5 activities were provided each day. She stated no activities were provided on 07/16/23 for Resident #24. She stated she did not know why activities were not provided. She stated she did not remember visiting with Resident #24 on 07/16/23. She stated Resident #24 was provided an activity in the AM on 07/17/23 watching TV but wheeled himself out. She stated she did not provide him with reading daily devotional in the AM on 07/17/23. She stated, I just got busy and forgot. She stated Resident #24 did attend bingo but wheeled himself out. She stated the potential negative outcome of no activities could be depression and increased behaviors. <BR/>Interview on 07/18/23 at 01:15 PM the Administrator stated the AD was responsible for activities. He stated he did not know why activities were not done on 07/16/23. He stated activities were important to the social aspect of the resident's care. He stated the potential negative outcome of no activities could be depression. He stated his expectations were scheduled activities for all residents and those who do not attend group activities should have individualized activities. He stated the monitoring techs had been helping with activities since May 2023. <BR/>Record review of facility policy titled Activity Programs dated June 2018 (revised), revealed the following:<BR/>Policy Statement: Activity programs are designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. <BR/>Policy Interpretation and Implementation .<BR/>6. Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. <BR/>7. Our activity programs consist of individual, small groups and large group activities better designed to meet the needs and interests of each resident. Activity programs include activities that promote:<BR/>a. comfort<BR/>b. pleasure<BR/>c. education<BR/>d. creativity<BR/>e. success; and<BR/>f. independence .

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 4 staff (Dietary [NAME] A and the DM) and 1 of 1 kitchen, in that:<BR/>1) The DM failed to store, serve or process foods in a manner to prevent contamination<BR/>2) Dietary [NAME] A and the DM failed to properly wear hair restraints while in the food preparation area. <BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings included:<BR/> On 07/16/23 at 10:52 AM, an observation of a dented can of green peas dated 07/13/23 was in the main pantry room along with the remainder of the canned items.<BR/>On 07/16/23 at 10:55 AM, during an interview with the DM, she said she was responsible for ensuring that all food stored in the pantry was labeled correctly and that there were no dented cans in the pantry. The DM said she must have missed the dented can and this was why it was in the pantry. She said the staff helps her with the truck delivery, and it depends on the day and how busy they are. She said the last truck delivery that they received was on Thursday (07/13/23). She said if she were not the person to receive the items from the truck, then she would check the pantry on Friday when she had time. She said she audits the pantry once a week but does not document this anywhere. She said it could affect the resident negatively because when a can was dented, it would be difficult to tell what was in the can, and things such as botulism could set in and potentially make the residents sick. She said she was unaware that the dented can was in the pantry. <BR/>On 07/16/23 at 10:47 AM, Dietary [NAME] A was observed in the food preparation area while preparing roast beef with her hair not properly restrained. Hair was exposed outside her hair restraint. Hair was observed alongside the front of her face and at the nape of her neck. An observation of the DM was also made with her hair not properly restrained. Her hair was exposed on both sides of her face near her ears. She was also in the food preparation area while the food was being prepared. <BR/>On 07/16/23 at 12:00 PM, an observation was made of Dietary [NAME] A in the food preparation area while taking the temperature of the food with her hair not properly restrained. She plated three plates with her hair exposed. Hair was exposed outside her hair restraint. It was observed at the front of her face and the nape of her neck. The DM was also in the food preparation area, and although not preparing food, she was in the food preparation area where residents' food was being prepped, prepared, and plated. The DM hair was not properly restrained. Her hair was exposed outside of the restraint alongside her ears. <BR/>On 07/16/23 at 03:00 PM, Dietary [NAME] A was observed at the kitchen door as she came from the food preparation area. The hair around her face was not restrained by the hair restraint. <BR/>On 07/16/23 at 03:07 PM, during an interview with Dietary [NAME] A, she said she was unaware that her hair was sticking out of her hair net. She said she had been trained that all of her hair should be in her hair net. When asked about the potential negative outcome, she said hair could get in the food and make the residents sick. <BR/>On 07/16/23 at 03:08 PM, during an interview with the Dietary Manager, she said she was unaware that her hair was not fully restrained under her hair net. She said with the humidity, her hair may have come from under the hair net. She also said she came straight to the facility after church service and was unaware that her hair was not properly restrained. She said she had been trained to properly wear her hair restraints. She said how to dress and proper hair restraints were covered in training (Foodborne Illness & Kitchen Sanitation) the kitchen workers received. She said she did not have anything to show the actual contents of the training. She said that she usually checks hair restraints before staff come into the food preparation area. <BR/>On 07/18/23 at 12:53 PM, an interview was conducted with the ADM, and he said that the DM was responsible for all activity that went on in the kitchen. He said dented cans should be removed before they were placed in food prep areas. He said dented cans should have gone on a shelf in the ADM office. He said he monitored the pantry weekly but had no documentation for the surveyor to review. He said that he would text the AIT or the DM. He said he had audited the pantry within the past 30 days but did not give a specific date. He said he monitored hair restraints regularly and was aware of this being an issue when he first started. He said he noticed this when the staff was on the dirty side of the kitchen. He said he verbally corrected them. He said he had no recent issues with hair restraints. He said he was unaware of the hair restraint issue or the dented can concern until after surveyor intervention. He said he expected hair to be restrained properly where it did not come in contact with food and should be inside the hair net. When asked about the potential negative outcome of hair not properly restrained, he said there could be a delay in food service. He said food may have to be thrown away because of potential contamination. Time would have to be taken to wash hands. He said hair could potentially get into the resident's food. When asked about the potential negative outcome for dented cans, he said botulism. When asked what botulism was, he said it was when metal could release bacteria. He said depending on the resident, they could have irritability in their stomach. He said he could not be specific regarding botulism because he was not a doctor. He said he had been trained on proper food storage and hair restraints. He said his expectation for dented cans was not to be placed in any area that could potentially lead to the food being placed in the food preparation area. <BR/>Record review of the facility's Order Summary dated 07/18/23 revealed the following:<BR/>Delivery date: 07/13/23<BR/>Item: Pea Sweet Mixed<BR/>Record review of Dietary [NAME] A's State Food Safety Certification revealed a completion date of 03/12/22 and noted it was valid for 2 years.<BR/>Record review of Dietary [NAME] A's certificate of completion for Foodborne Illness Prevention dated 3/13/23 indicated she received a 90%.<BR/>Record review of Dietary [NAME] A's certificate of completion for Kitchen Sanitation dated 3/13/23 indicated she received a 100%.<BR/>Record review of the DM's ServSafe Certification revealed a completion date of 07/27/21 and expiration of 07/27/26.<BR/>Record review of the DM's certificate of completion for Foodborne Illness Prevention dated 3/7/23 indicated she received a 90%.<BR/>Record review of the DM's certificate of completion for Kitchen Sanitation dated 3/7/23 indicated she received a 100%.<BR/>Record review of facility policy titled Food Deliveries dated 01/05/23 (revised), revealed the following:<BR/>2. The nutrition and food service manager or designee will inspect all deliveries to ensure that food is not spoiled or adulterated.<BR/>All cans must be in good condition and not dented before being transferred into a food preparation/serving area. Should a dented can be found it is to be removed from the service and stored awaiting return to distributor/supplier for exchange/credit.<BR/>Record review of facility policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices dated October 2017 (revised), revealed the following:<BR/>Policy Statement<BR/>Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.<BR/>1. <BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.<BR/>12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 8 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10), reviewed for abuse. <BR/>The facility failed to ensure a safe environment free from abuse for Resident #1 when can D was suspected to have used unnecessary force causing a spiral fracture to Resident #1 on night shift on 04/12/2023. <BR/>The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 resided in a safe environment after making allegations of abuse toward CNA D and CNA D was continued to allow to work with all resident's even after prior allegations of abuse. <BR/>This failure was determined to be an Immediate Jeopardy situation that was identified on 04/14/2023 at 5:51 p.m. While the IJ was removed on 04/17/2023 , the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death. <BR/>Findings include: <BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, <BR/>Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was a 3/15, meaning severe cognitive impairment.<BR/>Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. <BR/>Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words.<BR/> Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. <BR/>Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. <BR/>Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. <BR/>Under C0700 labeled long-term memory is left blank and not completed. <BR/>Under C0800 labeled Memory/Recall Ability is left blank and not completed. <BR/>Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. <BR/>Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. <BR/>Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. <BR/>Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. <BR/>Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under <BR/>B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. <BR/>Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. <BR/>Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. <BR/>Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance.<BR/>Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). <BR/>Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. <BR/>Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. <BR/>Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. <BR/>Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. <BR/>Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. <BR/>Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). <BR/>Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. <BR/>Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. <BR/>Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. <BR/>During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. <BR/>During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. <BR/>*Resident #2:<BR/>Record Review of Resident #2 face sheet documented he is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis which includes: stroke, seizures, difficulty swallowing, facial weakness, major depressive disorder, anxiety disorder, type 2 diabetes, muscle wasting, cognitive communication deficit, lack of coordination, hyperlipidemia (a condition which there are high levels of fat particles (lipids) in the blood). <BR/>Record review of Resident #2's admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 00 meaning zero points are assigned if the resident didn't repeat words correctly<BR/>Under B0600 for Speech Clarity indicated that Resident #2 scored 1 meaning Unclear Speech-slurred or mumbled words. <BR/>Under B0700 for Makes Self Understood indicated that Resident #2 scored 2 for ability to express ideas and wants. meaning sometimes understood ability is limited to making concrete requests. <BR/>Under B0800 for Ability to Understand Others-understanding verbal content scoring a 2 meaning responds adequately to simple and direct communication only. <BR/>Under G0110 for Activities of Daily Living Assistance indicates: A). Bed Mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) Resident #2 scored a 3 meaning extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist. B). Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), Resident #2 scored a 4 indicating total dependence (full staff performance every time during entire 7-day period). G). Dressing how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas, Resident scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist). Resident #2 scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with one person assist. Toilet Use: how resident uses the toilet room, commode, bedpan, or urinal<BR/>Record review of Resident #2s Care Plan dated on 07/01/2022 indicated the following:<BR/>Resident #2 has an ADL self-care performance deficit with interventions of: ADL self-performance fluctuates with confusion but usually requires assistance as follows: Bed mobility-self-performance (Total Dependence), Bed mobility: support provided with 2-person physical assist, Transfer: self-performance (total dependence), Transfer-support provided with 2 person physical assist, walk in room- self-performance (activity did not occur), walk in room- support provided ADL activity did not occur, Walk in corridor- self-performance (Activity did not occur), walk in corridor-support provided ADL activity itself did not occur, Locomotion on unit-self performance (total dependence), Locomotion on unit- support provided one person physical assist, Locomotion off unit- self-performance (total dependence), locomotion off unit- support provided with one person physical assist, Dressing: self-performance (Extensive assistance), Dressing: support provided with two person physical assist, Eating: self-performance (Supervision), Eating: support provided with one person physical assist, Toilet use: self-performance (Total dependence), Toilet use: support provided with two person physical assist, <BR/>Personal hygiene: self-performance (Total dependence), Personal hygiene: support provided with two-person physical assist, Nurse aides to document Resident #2s most dependence self-performance per shift. Monitor for signs and symptoms of ADL decline and notify family, MD, identifying causes and solutions. Monitor/document/report to MD as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. <BR/>Record Review of Resident #2's Progress notes dated 04/15/2023 at 10:57 am, signed by Social Worker revealed: Social worker spoke with Family Member #12 to let her know about the new reporting guidelines for abuse and neglect. She (Family Member #12) asked that it be mailed. She (Family Member #12) may also pick it up today when she is here. The form is also placed in Resident #2's room. <BR/>During an Observation on 04/13/2023 at 12:08 pm with Sampled Resident #2 revealed: Observed Resident #2 laying in his bed visiting with family member. Observed Resident #2 free from distress. <BR/>During an Interview with Resident #2 on 04/13/2023 at 12:07 pm. Resident #2 was able to slowly reveal the complaint that he had against CNA D with the help of family member. Resident #2 stated that during care he went to grab side bars and CNA D pushed him hard and motioned to Surveyor where his head was hit on the side bars. Resident #2 stated, He hits me, hard. (CNA D). Resident #2 put his fingers on top of his head and stated, Devil. Surveyor stated who is the Devil, Resident #2 called CNA D by name. Observed Resident #2 began to show signs of anxiety just talking about it and began to tear up in his eyes. Family member #11 had to console Resident #2 to get him to calm down. <BR/>During an interview on 04/13/2023 at 12:17 p.m., with Family member 12 via telephone for Resident #2, Family Member #11 used her own personal cell phone to reach out to Family member #12 and was happy to share some concerns. Family Member #12 stated that she does have some concerns with CNA D and that she did not have a lot of time because she had to get back to work but would like the opportunity to write down all the concerns and get back with Surveyor in a couple of days. Family Member #12 stated that she was told by Resident #2's old roommate (Resident #9) that he witnessed CNA D tell Resident #2 to stop using the call light so much or the next time he puts him in the Hoyer lift he (CNA D) will leave him there. Family Member #12 stated that the Administrator and BOM both knew that these things were going on and did nothing about it. Family Member #12 stated that she had stressed out so much from worrying about Resident #2 being in the facility when CNA D is working. Family Member #12 stated that she would like to make a written statement to provide to Surveyor about all the things that CNA D did to Resident #2. <BR/>Record Review of a written Statement provided on 04/15/2023 at 8:00 am, from Family member #12, revealed:<BR/>To Whom it May Concern:<BR/>I (Family Member #12) just want to say thank you, my name is (Family Member #12), stated it is unfortunate that they are in the situation that they are in with the facility. Family Member #12 stated that she is willing to share Resident #2 journey at the facility in hopes that something or someone will finally do something to help these residents. Family Member #12 stated that everything had gone fine until the facility had hired CNA D (nights). Family Member #12 stated that she finally became concerned when CNA D had acted in a manner in front of another family member like he didn't like Resident #2 (talking rude to him). Family Member #12 stated that CNA D had a demeanor that he did not have a very caring personality and acted like he didn't want to be there most times. Family Member #12 stated that she had witnessed one of the times that CNA D had been rough with Resident #2 when she walked in when he was providing care and she told CNA D, Hey be easy with him. Family Member #12 stated that it seemed to upset CNA D when she told him because he got an upset look on his face. Family Member #12 stated that as time passed by it got to a point when Resident #2 didn't want family to leave him there alone when CNA D was working. Family Member #12 stated that she finally reported her concerns to the DON and Administrator at the time on October 2022 and she was told that the facility was investigating the situation but nothing ever changed. Family Member #12 stated that she asked weeks later and was still told that it was being investigated and still nothing changed. Family Member #12 stated that she got so frustrated because the facility is supposed to protect the resident's and did nothing to protect. Family Member #12 stated that about the second week of November 2022 she was approached by the DON and stated that the DON told her that there was an incident that the CNA D had Resident #2 up in the Hoyer and CNA D told Resident #2 that if he didn't stop, bitching, and pushing the call light that he (CNA D) would leave him up there. Family Member #12 stated that she was told by DON at the time that CNA D had left Resident #2 in midair in his brief that was soiled and wet for a good period of time. Family member #12 stated that she was told that the situation is being investigated, and again nothing happened. Family Member #12 stated that she went to the DON after days of hearing nothing and asked what was going to be done and DON stated that other residents had to be questioned. Family Member #12 stated that she asked at this time for CNA D not to be allowed to go into the room or care for Resident #2. Family Member #12 stated that she was told by the administrator that the facility could not do that and that is when she knew that there was going to be a problem with this place. Family Member #12 stated that it got to a point that family members would try to go as much as possible in hopes that the situation would stop. Family Member #12 stated that most times she was there that Resident #2 would show anxiety anytime CNA D would work. Family Member #12 stated that another incident happened in December 2022 with CNA D and Resident #2. Family Member #12 stated she was there at the facility with Resident #2, and she pushed the call light because Resident #2 was soaking wet and had, poop in his brief. Family Member #12 stated that Resident #2 started getting really anxious and scared. Family Member #12 stated that CNA D came in the room and told Family Member #12 that she had to leave the room for the privacy of Resident #2. Family Member #12 told CNA D that she would not leave the room. Family Member #12 stated that CNA D then told her that he would not change Resident #2 then. Family Member #12 stated that she told CNA D that she was going to report him to the administrator. Family Member #12 stated when she threatened to report CNA D, he then changed Resident #2, but CNA D was very rough and when he pushed Resident #2 to the side CNA D pushed him so hard that Resident #2 hit his head on the side pull bars. Family Member #12 stated that Resident #2 would cry sometimes and say that he was scared to go to sleep because of CNA D. Family member #12 stated that she did report this to the administrator and again, nothing, just investigating. Family Member #12 stated that she finally got to the point with the administrator that she said, What is it going to take, CNA D seriously hurting someone or killing them? Family Member #12 stated that she was scared daily, and this stressed her out because she was constantly worried about Resident #2. Family member #12 stated that things got worse with CNA D and Resident #2 began telling her that CNA D would twist his arm really hard and yell at him. Family Member #12 stated that she had went to the facility on March 10th, 2023, and already had Resident #2 up and in the wheelchair. Family Member #12 stated that Resident #2 was crying and very scared with his fists clenched. Family Member #12 stated, What's wrong, what happened, to Resident #2. Family Member #12 stated that Resident #2 had told her that CNA D was pulling and hitting him in his bad arm and leg. Family Member #12 stated that she had never been so scared before for Resident #2 because it was getting worse. Family Member #12 stated that she would have to go out of town that day due to her daughter having cancer. Family Member #12 stated that she told the current Administrator and was told by the Administrator that she would have to report this to Human Services, and she would question CNA D to see what happened. Family member #12 stated that when she came back from out of town that the Administrator told her that CNA D was on a 30-probation and was suspended. Family Member #12 stated that she told the Administrator not put CNA D to care for Resident #2 and she was told that this could not happen due to lack of staff that the facility had. <BR/>Resident #3:<BR/>Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: stroke, anorexia, muscle wasting and atrophy (decrease in size of a body part), dementia, lack of coordination, atherosclerotic heart disease (buildup of fats, cholesterol, and other substances on the artery walls), unsteadiness on feet, schizoaffective disorder, depression, anxiety, seizures, insomnia, high blood pressure, abnormalities of gait and mobility. <BR/>Record review of Resident #3 admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 12 meaning cognitively moderately impaired.<BR/>Under B0200-Hearing: Resident #3 was listed as 0 meaning: Adequate- no difficulty in normal conversation, social interaction, listening to tv. <BR/>Under B0600-Speech Clarity: Resident #3 was listed as 0 meaning: distinct intelligible words.<BR/>Under B0700-Makes Self Understood: Resident #3 was listed as 1 meaning: Usually Understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800-Understands Verbal Content however able: Resident #3 is listed as a 1 meaning: Usually understands-misses some part/intent of message but comprehends most conversation. <BR/>Under C1310-Delirium- Resident #3 was listed as a 0 meaning there is no delirium. <BR/>Under G0110-Functional Status: Bed mobility-Resident #3 was listed as extensive assistance with 2 person assist, Transfer-Resident #3 is listed as total dependence with 2 person assist, walk in room- Resident #3 was listed as activity did not occur, Walk in corridor- Resident #3 was listed as activity occurred only once or twice with 1 person assist, Locomotion on Unit- Resident #3 was listed as extensive assistance with one person assist, Locomotion off Unit- Resident #3 w[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 residents (Resident #1) reviewed for abuse. <BR/>The facility failed to report a reasonable suspicion of Abuse for Resident #1 after allegations were made by staff members to Administrator and Resident #1 suffered a spiral fracture to his upper left arm. <BR/>This failure could place all residents at risk of further potential injuries or Abuse. <BR/>Findings included: <BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, <BR/>Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) listed as 3, meaning severe cognitive impairment.<BR/>Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. <BR/>Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words.<BR/> Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. <BR/>Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. <BR/>Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. <BR/>Under C0700 labeled long-term memory is left blank and not completed. <BR/>Under C0800 labeled Memory/Recall Ability is left blank and not completed. <BR/>Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. <BR/>Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. <BR/>Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. <BR/>Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. <BR/>Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under <BR/>B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. <BR/>Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. <BR/>Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. <BR/>Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance.<BR/>Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). <BR/>Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. <BR/>Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. <BR/>Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. <BR/>Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. <BR/>Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. <BR/>Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). <BR/>Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. <BR/>Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. <BR/>Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. <BR/>During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. <BR/>During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. <BR/>During an Interview on 04/13/2023 at 1:16 pm with CNA D, stated that he has worked in the facility for approximately six months. CNA D stated that he had just barely had to meet with the police to give a statement. CNA D stated that he did not know before this that there was a problem. CNA D stated that the facility had not called him to let him know that there was an issue. CNA D stated that when the police called to question him and now being interviewed by State let him know that there was a problem. CNA D stated that he had three interactions with Resident #1 that night that he worked. CNA D stated that the first two interactions with Resident #1 was just to redirect him back to his room. CNA D stated that the last interaction that he had with Resident #1 is when Resident #1 was found by the Monitor Tech in another resident room in an empty bed. CNA D stated that the Monitor Tech L stated that she needed help to transfer Resident #1. CNA D stated that he offered to help. CNA D stated that he tapped Resident #1 on the shoulder a few times to wake him up. CNA D stated that immediately Resident #1 was aggravated when he was awakened. CNA D stated that Resident #1 was telling him to leave him alone. CNA D stated that he walked out of the room for approximately 10 minutes to allow Resident #1 to calm down. CNA D stated that he returned into the room and tapped on the shoulder of Resident #1 again. CNA D stated that Resident #1 was having a hard time standing up so CNA D stated that he grabbed Resident #1 in both of the arm pit areas to pick him up with his (CNA D) thumbs on the outside of the armpits. CNA D stated that Resident #1 began to punch him several times in the CNA D stomach. CNA D stated that it did not bother him that Resident #1 was hitting him because he is not a big guy. CNA D stated, I am a big guy, and I can handle it. CNA D stated that he escorted Resident #1 to his room with no problems. CNA D stated that he escorted Resident #1 by getting behind Resident #1 and grabbing his arms and directing him to go towards his room. CNA D stated that when he was redirecting Resident #1 that he kept trying to pull away from him (CNA D), so CNA D stated he had to grab firmly to keep Resident #1 from trying to pull away while CNA D redirected him. CNA D gave a witness statement that Resident #1 does not like him (CNA D) and he does not know why. CNA D stated that the incident happened on 04/11/2023 on his night shift. CNA D stated, Now as of 04/13/2023, I am probably being suspended since State is in the building). CNA D stated that the administrator didn't tell him anything about the incident or question him yet still until State came in the building. CNA D stated that the Administrator told him that when he is done giving a statement to State then she needed to question him. CNA D stated that he did have another complaint with another resident and had been written up for that one before. CNA D stated that the resident that made that complaint didn't like him either and tried to make accusations that CNA D was rough with him (Resident #2). CNA D stated that is all he is going to say unless he has an attorney. Surveyor ended Interview and thanked CNA D for taking the time to interview. CNA D stated to Surveyor, I'm sure I will have 3 days to be pissed off about all this, I'm sure that's what I am going to do. I can't afford to get suspended again.<BR/>Record Review of the Disciplinary Action for CNA D, provided on 04/13/2023, labeled, Counseling Notice, dated on 03/13/2023, revealed: CNA D had been suspended for three days and a 30-day probation period for a previous accusation of being too rough with a different resident which was used as a sample resident for this investigation. <BR/>Suspension: 3 days<BR/>Reason for Counseling Notice: Complaint from Resident #2 family, See Report on back.<BR/>Report on Back: 03/13/2023, HR counseled with CNA D, discussed his approach to patient care. He apologized and stated he didn't realize he was being too rough. He has been suspended for 3 days. After counseling CNA D agreed to a 30-day probation period and would not be allowed any reports from family or residents. CNA D stated he loved his job and would be agreeable to the 30-probation period, and then would review. <BR/>Supervisor Statement: I have discussed the counseling notice with the employee CNA D. Signatures included Administrator, CNA D, and BOM<BR/>Record Review of the Disciplinary Action for CNA D, provided on 04/14/2023, labeled, Counseling Notice, dated on 04/14/2023 at 12:30 pm revealed: CNA 4 had been terminated on 04/14/2023 via phone with no signature from employee provided. <BR/>Termination-Effective Date: 04/14/2023 at 12:30 pm<BR/>Reason for Counseling Notice: Termination due to employee allegations of Abuse and Neglect. <BR/>Signed by: Administrator, BOM, No Employee signature provided. <BR/>During an interview on 04/13/2023 at 4:20 p.m. with CNA C, stated that she worked with CNA D on the shift of 04/11/2023 going into 04/12/2023 from 7p.m. top 7 a.m. night shift. CNA C stated that she thought the incident was on 04/10/2023 going into 04/11/2023 but could check camera to make sure. CNA C stated that at about 2:30 a.m. the monitoring tech asked her and CNA D if they could help to get Resident #1 out of another room because she had found him asleep in an empty bed that was not his. CNA C stated that she was busy with another resident at the time that the monitoring tech had asked so CNA D stated that he would go help. CNA C stated that the monitoring tech was fully capable of doing it herself and she is unsure why the monitoring tech needed help to walk Resident #1 back to his bed, but she still wanted assistance. CNA C stated that when she was done tending to her resident, she overheard LVN A ask CNA D, What did you do to Resident #1?, CNA C stated that she also heard LVN A ask CNA D, Why is Resident #1 yelling in pain right when you walk out of his room? CNA C stated that she then heard CNA D tell LVN A that he had just grabbed Resident #1 under both of his arms and pulled him up out of the bed to transfer him. CNA C stated that she then witnessed CNA D say that he was all of a sudden feeling sick and she saw him go outside. CNA C stated that when CNA D came back inside the facility he asked if anyone cared if he went home because he did not feel good. CNA C stated that she was surprised because up to that point CNA D had not acted as though he was sick, she stated, He was fine all night. CNA C stated to CNA D that she did not care if he went home and that she could handle the workload, and then he left. CNA C stated that LVN A asked her if she would go with her to Resident #1 room to ask him what happened because he was crying out in pain since CNA D had left his room. CNA C stated that she would go with LVN A to Resident #1s room to find out what happened. CNA C stated that she asked Resident #1 in Spanish what happened and why is he in pain and CNA C stated that Resident #1 stated, He hit me, TWICE (DOS). CNA C stated that she told Resident #1, Why do you say that? CNA C stated that Resident #1 stated, He wanted to fight me. CNA C stated that she observed Resident #1 in a lot of pain. CNA C stated that Resident #1 was crying and moaning in pain. CNA C stated that she showed Resident #1 with her hand and opened her hand and stated, Did he hit you with open hand like this? CNA C stated that she then made a fist and showed Resident #1 and then asked Resident #1, Or did he hit you with a fist? CNA C stated that Resident #1 then made a fist and stated, He hit me like this. CNA C stated that she observed LVN A assess Resident #1 for injuries and they both saw a big red mark on his upper left arm. CNA C stated that LVN A was slightly feeling Resident #1's arm and stated there is a big lump and a space. CNA C stated that LVN A then stated that she needed to call the administrator and get Resident #1 sent out to the hospital. CNA C stated she did know that CNA D is not allowed to go into some of the residents' rooms alone because of being rough with some of the residents. CNA C stated that she did not know if Resident #1 was one of those residents or not, but she does know that he is not allowed in some of the other resident's rooms alone. CNA C stated that she had been told that by the nursing staff when she first started working there. CNA C stated that she was told that sometimes she may have to help him with certain residents and when she asked why that is what she was told. CNA C stated that she has noticed that CNA D would avoid taking care of Resident #1 and he has stated before that he did not like Resident #1. <BR/>During an interview on 04/13/2023 at 5:26 p.m. with Administrator revealed she was aware of the incident that occurred with Resident #1 and CNA D on 04/12/2023. Administrator stated BOM called her at approximately 3:30 a.m. on 04/12/2023 and told Administrator that LVN A called BOM to report that Resident #1 was punched in the face and there was blood everywhere. Administrator stated that she called the facility and spoke to LVN A and was told that Resident #1 was in pain to the point of moaning and was being sent out to the hospital. Administrator stated that LVN A told her that CNA D was involved, and she did assess the resident for injuries. Administrator stated, In my thinking that since Resident #1 was already being sent out to the hospital, that everything was taken care of. I was thinking that since CNA D had gone home sick and Resident #1 was sent out to the hospital, that everything was calm and taken care of. Administrator stated that LVN A stated that CNA D was involved with the incident with Resident #1, but she was thinking now that CNA D went home not feeling well and the resident was sent to the hospital everything is okay for now. Administrator stated that her next plan of action was to make sure the family was notified and that everyone was okay. Administrator stated that she was told by the BOM that she had contacted the Medical Director after the incident happened. Administrator stated that when she came into work that morning around 8 am or 8:30 am, she notified the police, and the police made a report. (Surveyor contacted chief police and informed that in the investigation process and report is not ready to view at this point on 04/14/2023). Administrator stated that she had not interviewed CNA D yet until after surveyor had interviewed him on 04/13/2023 sometime after 2:00 p.m. Administrator stated that when she asked CNA D what happened on 04/13/2023 sometime after 2:00 p.m., he stated that he had transferred Resident #1 to the room and that it. Administrator stated that CNA D had already been written up for a different incident for allegations of abuse, with Resident #2 and now he will be written up for Resident #1. Administrator stated that CNA D is not supposed to be in the room with Resident #2 due to the allegations that was made against him by family member and Resident #2. Administrator stated that he is supposed to have a partner to make sure that nothing happens. Administrator stated that she has had to partner CNA D up with a partner with certain residents due to allegations being made but she does not have the staff to just exclude him from working with certain residents because of the allegations. Administrator stated that her way of monitoring CNA D to make sure that he was using a partner to enter certain residents' rooms was that she wouldn't get any more complaints and that is how she would know. Administrator stated that she had not suspended CNA D at this time but that she is going to suspend him. Administrator stated that CNA D went home because he felt sick during his shift on 04/12/2023 and was not scheduled to work on 04/13/2023 but Administrator stated that she was going to suspend him when he came in to work next. Administrator stated that she does have CNA D phone number and could contact him that way but has not done that. Administrator stated she was just going to suspend him when he came in. Administrator stated that she does know what the policy says about reporting abuse and neglect. Administrator stated that she was not sure how to fill out the provider investigation report but did report but not until the next day when she came to work. Surveyor pulled out the facility provided policy for abuse and showed the Administrator the protocols for reporting allegations of abuse when there is an injury. Administrator stated that she is aware that she was supposed to report within the 2-hour timeframe but was tired and it was the middle of the morning so she was just going to report when she came into work and did not think that would be a problem. Administrator stated that the incident occurred around 3:00-3:30 a.m. and the incident was reported on 04/12/2023 after Administrator got to work sometime after 8:00 or 8:30 a.m. Administrator stated that her staff has been trained in abuse and neglect. Administrator stated that right now the facility does not have a DON or an ADON and she stated that usually the DON and ADON is responsible for making sure that training is completed. Administrator stated that the negative potential outcome for not preventing abuse is that other residents may get hurt.<BR/>During an interview on 04/16/2023 at 9:57 a.m. Administrator brought in a disciplinary form to Surveyor and had stated that she had herself written up for failing to report in the 2-hour timeframe and failure to report on the online portal for Abuse and Neglect. Surveyor reviewed disciplinary document and noticed it was dated as of 04/12/2023 but was provided on 04/16/2023. It shows the document is a written warning. Signed by Administrator, BOM, and an unidentified signature. <BR/>During an Interview on 04/13/2023 at 6:11 p.m. with LVN A, stated that she worked the night shift and that the night of the incident on 04/11/2023-04/12/2023 Resident #1 came to the nurse station and stated, I fell asleep on my hand. LVN A stated that Resident#1 had been asleep since 10 or 11 p.m. and had come to the nurse station approximately around 12:30 a.m. LVN A stated that she told Resident #1 that it would be fine just to give it a couple of minutes and his hand would wake back up. LVN A stated that Resident #1 then walked away, and she did not see what direction he had went. LVN A stated that she just figured that Resident #1 went to the day room to watch tv because he would do that sometimes. LVN A stated that when the Monitor Tech L went to make rounds, she noticed that Resident #1 was not in his bed and came to ask her if LVN A had seen Resident #1. LVN A stated that she told the Monitor Tech L that she had not seen him since he said his hand fell asleep. LVN A stated that she noticed that Monitor Tech L was going room to room to find Resident #1 and had found Resident #1 in Resident #10s room in the vacant bed, asleep. LVN A stated that a couple of minutes go by and LVN A stated that she hears Monitor Tech L and CNA D talking. LVN A stated that she had heard the Monitor Tech L tell CNA D that Resident #1 was in the vacant bed in Resident #10s room by the door. LVN A stated that she heard CNA D state, I will take care of it. LVN A stated that when she saw CNA D next, he had Resident #1 from behind,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for care plans. <BR/>The facility failed to complete an accurate comprehensive care plan for Resident #1's documented change in behavior of undressing in common areas for the last 30 days reviewed. <BR/>These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial need to attain or maintain their highest practicable physical, mental, and psychosocial outcome. <BR/>Findings included: <BR/>Record review of Resident #1's undated face sheet reflected, Resident #1 was admitted to the facility on [DATE] with the <BR/>Findings include: <BR/>Record review of the admission sheet for Resident#1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included: schizoaffective disorder bipolar type (mental illness that can affect your thoughts, mood, and behavior. You may have symptoms of bipolar disorder and schizophrenia. These symptoms may be mania, depression, and psychosis), cognitive communication deficit(problems with communication that have an underlying cause in a cognitive deficit rather than a primary language) and intermittent explosive disorder(mental health condition marked by frequent impulsive anger outbursts or aggression).<BR/>Record review of Resident #1's Comprehensive MDS, dated [DATE] revealed BIMS score 2 out of 15 indicating she was severely impaired cognitively.<BR/>Record review of Resident #1's Progress notes revealed staff documenting that Resident #1 removed her clothing on several occasions on 2/26/23, 3/1/23, 3/6/23, 3/7/23, 3/8/23, 3/17/23. <BR/>Record Review of Resident #1's care plan, dated 3/16/23, revealed no documentation of Focus, Goal or Intervention that identified or documented Resident #1 disrobing and being nude outside of her facility room. <BR/>During an observation and attempted interview on 3/23/23 at 9:23 p.m. near the nurses station, Resident #1 approached the state investigator and stated, I want it off and Resident #1 began pulling on the waistband of her pants. The investigator stated to CNA C who was standing behind the nurses station checking the security camera that Resident #1 needed assistance. CNA C advised Resident #1 he would assist her in a minute. Resident #1 while standing next to the state investigator immediately removed her pants, brief and shirt with no verbal warning and stood next to the Investigator nude. The State Investigator stated to CNA C can you assist her please, she just took off her clothing. CNA C turned around and asked Resident #1 to follow him to her room so he could assist her.<BR/>During an observation on 3/23/23 at 9:44 p.m., Resident #1 walked from her room on B hall towards the nurses station wearing a hospital gown. Resident #1 passed LVN A and Resident #4 was walking behind Resident #1. Resident #4 stated to LVN A, can you cover her up or something? Her whole backside is hanging out. LVN A stopped Resident #1 and asked her to turn around. Resident #1 was observed with the back of the gown tied at her neck but open in the back and her backside was exposed with no brief or under clothing on. LVN A tied Resident #1's gown fully.<BR/>During an interview on 3/24/23 at 9:57 a.m. with CNA D, stated that Resident #1 is independent and out of nowhere will strip down naked. CNA D stated he has redirected Resident #1 to her room several times so he can put a gown on her. CNA D stated Resident #1 will remove the gown again and staff does not know when or where she will remove her clothing again. CNA D stated that Resident #1 has been doing this for several weeks now and all he knows to do is redirect her and try to cover Resident #1 to her room. CNA D stated Resident #1 removes her clothing in all areas of the facility, in front of other residents and staff. <BR/>During an interview on 3/24/23 at 10:29 a.m. with the AD, stated Resident #1 will remove all clothing in the facility and it does not come with warning, and it occurs in front of other residents. The AD stated staff will redirect Resident #1 and try to cover the resident up. The AD stated that she has heard residents say you need to cover that when Resident #1 removed her clothing in front of them.<BR/>During an interview and observation on 3/24/23 at 12:44 p.m. with LVN B; Stated that Resident #1 gets fully nude in the hallways and common areas and there is often no warning before it occurred. The LVN B stated that staff try to redirect her back to her room and help her get dressed. The LVN B stated that there has been no official training on what they are supposed to do when Resident #1 gets undressed and said that there is nothing care planned that she has seen for this behavior. LVN B stated that it would be good for them to have it planned because it has been about a month that she has been doing this. LVN B stated she hasn't heard any residents complain but that if she lived here, it would make her feel uncomfortable to see a resident walking around nude. <BR/>During an interview on 3/24/23 at 12:58 p.m. with Resident #4; stated that Resident #1 gets fully naked in the halls or common areas at least once a day. Resident #4 stated staff will put a gown on her, but they only tie it up at her neck area. Resident #4 stated that they don't tie the bottom area and it bothers her to see a naked resident. Resident #4 stated that she bets the male residents don't mind seeing a naked woman in the facility, but she does. Resident #4 stated that you don't just see her ass, you see her asshole. I am sick of seeing her asshole every day 'cause she bends over and there it is, her asshole. <BR/>During an interview on 3/24/23 at 1:45 p.m. with the BOM and ADM; BOM stated that staff redirect Resident #1 when she undresses in the hallways and this behavior has been occurring for approximately 3 weeks. The BOM and ADM stated that Resident #1's care plan has not been updated to address this behavior yet. The BOM stated that she understands that it could be upsetting for other residents and the staff to see Resident #1 nude in the facility common areas and that visitors would not want to see a nude resident in the facility halls. <BR/>Record Review of the facility's policy titled, Care Plans-Comprehensive Person Centered, revised on December 2016 reflected the following in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>-The Interdisciplinary Team must review and update the care plan:<BR/>1. <BR/>When there has been a significant change in the resident's condition.<BR/>b. <BR/>When the desired outcome is not met.<BR/>c. <BR/>When the resident has been readmitted to the facility from a hospital stay; and<BR/>d. <BR/>At least quarterly, in conjunction with the required quarterly MDS assessment.<BR/>

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 carts (1 medication cart and 1 treatment cart) of 2 carts reviewed for storage:<BR/>The facility failed to ensure both the medication cart and treatment cart were locked when unattended. <BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. <BR/>Findings included:<BR/>During an observation on 3/23/23 at 9:05 p.m.; observed an unlocked medication cart, with the lock not pushed in and no staff standing at the cart while LVN A was standing behind the nurses station at the treatment cart with her back towards the medication cart and the medication drawers not in view of LVN A. <BR/>During an interview and observation on 3/23/23 at 9:08 p.m., LVN A stated while standing at the treatment cart that she was assigned to the unlocked medication cart. LVN A stepped away from the unlocked treatment cart and walked out from behind the nurses station and locked the medication cart. LVN A was observed leaving the treatment cart unlocked and walked down the hall to the break room to get her cell phone. As LVN A walked away, Resident #1 approached the nurses station, and stood in the entrance of the nurses station next to the unlocked treatment cart.<BR/>During an interview and observation on 3/23/23 at 9:12 p.m., LVN A returned to the nurses station and was informed by the Investigator that LVN A left the treatment cart unlocked. LVN A stated I should have locked it when I left the area. A resident could get into it. Observation revealed posted on the wall above the treatment cart: carts must remain locked at all times. Resident #1 was still standing at nurses station. LVN A stated that the treatment cart contains ointments, creams, wound care supplies, syringes and breathing treatment supplies. <BR/>During an interview on 3/23/23 at 10:04 p.m., the Administrator stated that staff are trained to keep the medication cart and treatment cart at locked all times. The Administrator stated that staff know better, and it is posted on the wall as a reminder to lock them. Administrator stated that both the medication and treatment cart should be locked at all times when the nurse is not standing at the cart. The Administrator stated that if the nurse was at the treatment cart that the medication cart was supposed to be locked.<BR/>During an interview on 3/24/23 at 9:20 a.m. with the RN; stated medication carts should be locked at all times, even if LVN A was behind the nurses station desk at the treatment cart, she should have locked the medication cart. RN stated that the treatment cart should have been locked by LVN A when she walked away from the treatment cart. The RN stated that residents will get into those carts because they know those carts have their medications. RN stated she is unsure what is stored in the treatment cart, but it should be locked at all times when not being used. <BR/>During an interview on 3/24/23 at 10:06 a.m. with the Medication Aide (MA); stated that she has been trained to keep medication and treatment carts locked at all times. The MA stated that the treatment cart contains topicals, creams, inhalers, breathing treatment supplies and medications, wound care supplies and insulin needles. The MA stated carts are supposed to be locked at all times because a resident could take any medication that is not theirs and have a reaction to it. The MA stated that in the treatment carts residents could grab needles, topical ointments and put them in their mouth and cause injury. <BR/>During an interview and observation on 3/24/23 at 12:44 p m with LVN B; stated that they are trained to keep the medication cart and treatment cart locked at all times and pointed to the notice on the wall instructing staff to keep them locked. LVN B opened up the drawers of the treatment cart and revealed several prescription medications in the treatment cart. LVN B picked up vials of liquid stating that they are insulin and there are 7 bottles of insulin, 1 insulin pen, and lancets. LVN B revealed oral glucose gel, prescription creams, suppositories, and inhalers in the treatment cart drawers. LVN B opened the bottom drawer and several prescription medication cards were observed in the drawer. LVN B stated that medications are for residents who need medications crushed and administered through the g-tubes. LVN B stated that the medication aides cannot crush the medications and administer through the g-tubes, so those medications are kept in the treatment cart with g-tube supplies for the nurses to administer. LVN B also revealed nail clippers, saline, wound care items, and bleach wipes in the cart. LVN B stated that it is important to keep the cart locked at all times unless the nurse is standing in front of the carts because a resident could come and open a medication cart or treatment cart and take medications, scissors, nail clippers, ointments, medications, or anything else in the medication or treatment cart and ingest the medications or harm themselves with the wound care items. <BR/>Review of the facility's policy titled Security of Medication Cart last revised April 2007 reflected the following: . Policy statement <BR/>The medication cart shall be secured during medication passes<BR/>Policy interpretation and Implementation<BR/>1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.<BR/>2. The medication cart should be parked in the doorway of the resident's room during the medication pass<BR/>3. The cart should be against the wall with drawers and doors facing the wall. <BR/>4. Medication carts must be securely locked at all times when out of the nurse's view. <BR/>5. When medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for care plans. <BR/>The facility failed to complete an accurate comprehensive care plan for Resident #1's documented change in behavior of undressing in common areas for the last 30 days reviewed. <BR/>These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial need to attain or maintain their highest practicable physical, mental, and psychosocial outcome. <BR/>Findings included: <BR/>Record review of Resident #1's undated face sheet reflected, Resident #1 was admitted to the facility on [DATE] with the <BR/>Findings include: <BR/>Record review of the admission sheet for Resident#1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included: schizoaffective disorder bipolar type (mental illness that can affect your thoughts, mood, and behavior. You may have symptoms of bipolar disorder and schizophrenia. These symptoms may be mania, depression, and psychosis), cognitive communication deficit(problems with communication that have an underlying cause in a cognitive deficit rather than a primary language) and intermittent explosive disorder(mental health condition marked by frequent impulsive anger outbursts or aggression).<BR/>Record review of Resident #1's Comprehensive MDS, dated [DATE] revealed BIMS score 2 out of 15 indicating she was severely impaired cognitively.<BR/>Record review of Resident #1's Progress notes revealed staff documenting that Resident #1 removed her clothing on several occasions on 2/26/23, 3/1/23, 3/6/23, 3/7/23, 3/8/23, 3/17/23. <BR/>Record Review of Resident #1's care plan, dated 3/16/23, revealed no documentation of Focus, Goal or Intervention that identified or documented Resident #1 disrobing and being nude outside of her facility room. <BR/>During an observation and attempted interview on 3/23/23 at 9:23 p.m. near the nurses station, Resident #1 approached the state investigator and stated, I want it off and Resident #1 began pulling on the waistband of her pants. The investigator stated to CNA C who was standing behind the nurses station checking the security camera that Resident #1 needed assistance. CNA C advised Resident #1 he would assist her in a minute. Resident #1 while standing next to the state investigator immediately removed her pants, brief and shirt with no verbal warning and stood next to the Investigator nude. The State Investigator stated to CNA C can you assist her please, she just took off her clothing. CNA C turned around and asked Resident #1 to follow him to her room so he could assist her.<BR/>During an observation on 3/23/23 at 9:44 p.m., Resident #1 walked from her room on B hall towards the nurses station wearing a hospital gown. Resident #1 passed LVN A and Resident #4 was walking behind Resident #1. Resident #4 stated to LVN A, can you cover her up or something? Her whole backside is hanging out. LVN A stopped Resident #1 and asked her to turn around. Resident #1 was observed with the back of the gown tied at her neck but open in the back and her backside was exposed with no brief or under clothing on. LVN A tied Resident #1's gown fully.<BR/>During an interview on 3/24/23 at 9:57 a.m. with CNA D, stated that Resident #1 is independent and out of nowhere will strip down naked. CNA D stated he has redirected Resident #1 to her room several times so he can put a gown on her. CNA D stated Resident #1 will remove the gown again and staff does not know when or where she will remove her clothing again. CNA D stated that Resident #1 has been doing this for several weeks now and all he knows to do is redirect her and try to cover Resident #1 to her room. CNA D stated Resident #1 removes her clothing in all areas of the facility, in front of other residents and staff. <BR/>During an interview on 3/24/23 at 10:29 a.m. with the AD, stated Resident #1 will remove all clothing in the facility and it does not come with warning, and it occurs in front of other residents. The AD stated staff will redirect Resident #1 and try to cover the resident up. The AD stated that she has heard residents say you need to cover that when Resident #1 removed her clothing in front of them.<BR/>During an interview and observation on 3/24/23 at 12:44 p.m. with LVN B; Stated that Resident #1 gets fully nude in the hallways and common areas and there is often no warning before it occurred. The LVN B stated that staff try to redirect her back to her room and help her get dressed. The LVN B stated that there has been no official training on what they are supposed to do when Resident #1 gets undressed and said that there is nothing care planned that she has seen for this behavior. LVN B stated that it would be good for them to have it planned because it has been about a month that she has been doing this. LVN B stated she hasn't heard any residents complain but that if she lived here, it would make her feel uncomfortable to see a resident walking around nude. <BR/>During an interview on 3/24/23 at 12:58 p.m. with Resident #4; stated that Resident #1 gets fully naked in the halls or common areas at least once a day. Resident #4 stated staff will put a gown on her, but they only tie it up at her neck area. Resident #4 stated that they don't tie the bottom area and it bothers her to see a naked resident. Resident #4 stated that she bets the male residents don't mind seeing a naked woman in the facility, but she does. Resident #4 stated that you don't just see her ass, you see her asshole. I am sick of seeing her asshole every day 'cause she bends over and there it is, her asshole. <BR/>During an interview on 3/24/23 at 1:45 p.m. with the BOM and ADM; BOM stated that staff redirect Resident #1 when she undresses in the hallways and this behavior has been occurring for approximately 3 weeks. The BOM and ADM stated that Resident #1's care plan has not been updated to address this behavior yet. The BOM stated that she understands that it could be upsetting for other residents and the staff to see Resident #1 nude in the facility common areas and that visitors would not want to see a nude resident in the facility halls. <BR/>Record Review of the facility's policy titled, Care Plans-Comprehensive Person Centered, revised on December 2016 reflected the following in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>-The Interdisciplinary Team must review and update the care plan:<BR/>1. <BR/>When there has been a significant change in the resident's condition.<BR/>b. <BR/>When the desired outcome is not met.<BR/>c. <BR/>When the resident has been readmitted to the facility from a hospital stay; and<BR/>d. <BR/>At least quarterly, in conjunction with the required quarterly MDS assessment.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 (Residents #1) residents reviewed for adequate supervision and prevention of accidents. <BR/>The facility staff (Administrator and DON) failed to adequately address Resident #2's ongoing behavior of entering Resident #1's room.<BR/>The facility (Administrator and DON) failed to address resident #2's ongoing physical and verbal behavior with appropriate interventions.<BR/>These failures to put supervision measures in place could result in harm to Resident #2 and the remaining residents in the facility. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread and uneasiness), cognitive communication deficit (difficulty understanding and communicating). <BR/>Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #1 had slurred speech, could make himself understood and usually understood others. <BR/>Record review of Resident #1 Care Plan, dated 02/29/24, revealed that he is a max assist, depends on staff for meeting his needs, requires tube feeding, has depression (impaired ability to remember), is on antianxiety medications, and that he was pulled from the bed on 04/25/24.<BR/>Record review of Resident #1's progress notes revealed the following:<BR/>04/25/24 at 05:08 PM LVN A documented:<BR/>Resident #1 was found on the floor was pulled out of bed by another resident (unidentified) assist Resident #1 back to bed did assessment no injures noted<BR/>03/30/24 at 12:49 AM LVN B documented:<BR/>Other resident (unidentified) tried to pull Resident #1 out of his bed. other resident (unidentified) scratched Resident #1 across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Other resident (unidentified) was taken to his own room. <BR/>Record review of Resident #2's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was readmitted to the facility on [DATE] with diagnosis to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye.<BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. <BR/>Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. <BR/>Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. <BR/>Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. <BR/>Record review of Resident #2 care plan, dated 04/30/24 revealed the following: <BR/>Focus (Date initiated:04/26/24 Date revised:04/26/24)<BR/>4-25-24-I pulled another resident out of bed.<BR/>Goal<BR/>I will have no further episodes of aggression through review date.<BR/>Interventions <BR/>Placed 1:1 Sent to a behavior support center. <BR/>Focus (Date initiated:01/22/24 Date revised: 01/22/24)<BR/>I am an elopement risk/wanderer. Wander risk<BR/>Goal<BR/>I will not leave facility unattended through the review date.<BR/>Interventions <BR/>Distract me from wandering by offering pleasant diversions. I prefer having snacks.<BR/>followed by psychiatric services. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications.<BR/>Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log.<BR/>Focus (Date initiated: 01/22/24 Date revised:01/22/24)<BR/>I have episodes of verbal and physical aggression r/t dementia.<BR/>Goal<BR/>I will not harm self or others through the review date.<BR/>Interventions <BR/>Give me as many choices as possible about care and activities.<BR/>Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. <BR/>Monitor/document/report PRN any s/sx of me posing danger to self and others.<BR/>When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Focus (Date initiated:01/22/24 Date revised:01/22/24)<BR/>I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye.<BR/>Goal<BR/>I will show no decline in visual function through the review date.<BR/>Interventions <BR/>Arrange consultation with eye care practitioner as required.<BR/>Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.<BR/>Place frequently used items on my left side so I may see them<BR/>Record review of Resident #2's progress notes revealed the following:<BR/>04/25/24 at 04:55 PM LVN A documented:<BR/>Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room.<BR/>04/24/24 at 08:25 PM the DON documented:<BR/>7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and laid down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. <BR/>04/23/24 at 11:34 AM the DON documented:<BR/>Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. <BR/>04/23/24 at 1:06 AM LVN A documented:<BR/>Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2<BR/>04/15/24 at 4:16 AM LVN B documented:<BR/>Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room.<BR/>04/04/24 at 05:11 PM LVN B documented:<BR/>Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking<BR/>cane from rt hands and redirect to room. Admin notified.<BR/>03/30/24 at 12:26 AM LVN B documented:<BR/>Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room.<BR/>03/30/24 at 05:27 PM LVN D documented:<BR/>Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go<BR/>into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room.<BR/>Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision.<BR/>Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1.<BR/>Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every30 minutes on 05/08/24-05/10/24.<BR/>During an interview on 05/08/24 at 11:42 AM, the ADM stated Resident #2 went into Resident #1's room. The ADM stated Resident #1 and Resident #2's rooms were next to each other. She stated staff heard yelling from Resident #1. She stated when staff entered the room, they observed Resident #1 on the floor, and Resident #2 was in Resident #1's bed. The ADM stated staff redirected Resident #2 to his room, assessed Resident #1 and did not identify any injuries on either resident. The ADM stated she was notified and physically came to the facility to attempt to get additional support from a local behavior support center for Resident #2's behavior. She said Resident #2 was transported to the behavior support center the same night. The ADM stated that Resident #2 had never done this to Resident #1. She stated Resident #1 had a history of aggressive behavior with staff. The ADM said as a result of this incident, on 04/25/24, they conducted training with staff over resident rights, ANE, and that they had consulted with the local behavior support center to conduct training on dealing with aggressive behaviors, but no official date had been set.<BR/>During an interview on 05/08/24 at 01:34 PM, Resident #2 said he did not recall staff yelling at him, felt safe, had difficulty seeing things, and had no physical incidents with staff or other residents. Resident #2 said he knew where his room was but could not recall a specific room number. He said he did not have any additional concerns. <BR/>During an interview on 05/08/24 at 1:50 PM, Family Member J stated on 04/25/24, she was notified that Resident #2 had thrown Resident #1 on the floor. Family Member J said she was notified that Resident #1 was assessed, received x-rays, and had no injuries. Family Member J said she spoke with Resident #1 and was told he was not hurting too badly. Family Member J said before the incident on 04/25/24 that she had participated in Resident #1 care plan meeting and specifically had asked what would be done about Resident #2 going into Resident #1 room. Family Member J said it had been suggested that possibly hanging something on Resident #2's door could help Resident #2 find his room. Family Member J said she did not believe that Resident #2 was intentionally targeting Resident #1 but that he was confused. Family Member J said during the care plan meeting, the MDS coordinator, the ADM, the DON, the DM, and the Activities Director were present. She said she brought up the interaction between Resident #1 and Resident #2 because she had been present when Resident #2 would wander into Resident #1 room. Family Member J said she was lucky that Resident #2 had never been violent with her. Family Member J said she had always successfully redirected him out of Resident #1's room. She said the incident on 04/25/24 was not the first time Resident #2 had entered Resident #1's room. Family Member J said the incident on 04/25/24 was the only time she had been notified. Family Member J said she had been told by the staff (LVN A and other CNAs that she could not remember) that there was an incident (did not know the date) where Resident #2 had come into Resident #1's room and tried to pull him off the bed, but was unsuccessful. She said she believe the Social Worker may have mentioned to her about Resident #2 attempting to pull Resident #1 off the bed. Family Member J said that there was an instance (unsure of the date) where she had entered Resident #1's room, and Resident #2 walking cane was behind the dresser in Resident #1's room, indicating he had been there. Family Member J said it was her first time bringing it up to the ADM and DON at the care plan meeting, but she had talked to staff and the nurses numerous times before the care plan meeting. Family Member J said staff had expressed that they were reporting issues, but nothing was being done. Family Member J said that no incidents with Resident #1 and Resident #2 would occur during the day because she or Family Member K would be there during the day. Family Member J said she was there during the day on Monday, Wednesday, Thursday, and Friday. She said Family Member K was at the facility on Wednesday. Family Member J said that before the incident on 04/25/24, nothing had been done to help Resident #2 know where his room was. <BR/>During an interview on 05/08/24 at 2:02 PM, Resident #1 stated via telephone that Resident #2 had pulled him off the bed, and he did not want it to happen again.<BR/>During an interview on 05/08/24 at 2:03 PM, Family Member K stated via telephone that she was physically with Resident #1 but that he had a hard time talking because of his stroke. Family Member K said there was an incident where LVN A walked into the room (unsure of the date), and Resident #1 was sideways, hanging onto the bed with one arm. She said she believed there was another incident where Resident #1 tried to protect his feeding tube site. She said she was concerned that this was happening when Resident #1 was sleeping, and that Resident #1 could not defend himself. Family Member K said the staff knew about the incidents and needed to do something. Family Member K said that she had not physically told anyone but was told by Family Member J that she had. <BR/>During an interview on 05/08/24 at 2:18 PM, CNA F stated she was unsure of the exact dates, but about a month before the interview, She and CNA E had caught Resident #2 in Resident #1 room. CNA F said Resident #2 was confused and had difficulty seeing. CNA F said she did not believe Resident #2 was being mean or awful to Resident #1, but he thought he was in his (Resident #2) room. CNA F stated Resident #1 was yelling. CNA F said when they got to Resident #1's room (she and CNA E), they observed the door closed and the lights off. CNA F said when they turned on the lights, they observed Resident #2 trying to pull Resident #1 off the bed. CNA F stated water was on the floor, and Resident #1's head was on the bed rail. She observed the side table turned over, and Resident #1 was protecting his feeding tube site and crying. CNA F attempted to redirect Resident #2, but he refused to leave. CNA F stated this incident was reported to LVN B. CNA F stated LVN B said she reported the incident to the appropriate parties. CNA F stated a week after that incident (unsure of the exact date), Resident #2 was back in Resident #1's room. CNA F stated that Resident #1 had pushed his call light, and Resident #2 was standing in Resident #1's room when they got to him. CNA F stated that when they attempted to redirect him out of Resident #1's room, Resident #2 stated he wanted his jacket, and they grabbed his hand. Finally, Resident #2 went with them. CNA F stated that there had been a lot of changes in the facility as far as room changes and believed that the separation by gender may have contributed to Resident #2 being confused about where he was going and, in addition, his difficulty being blind. CNA F stated Resident #2 had been moved three or four times. CNA F stated the difficulty they had been having with Resident #2 had been reported to LVN A and LVN B (unsure of the exact time and date). She stated she was under the impression that, as the CNA, she was to report to her charge nurse and that they would proceed further if needed. She said her charge nurses had told her that the incidents with Resident #2 had been reported to higher people. CNA F stated they had wondered when something would be done. CNA F stated she was frustrated with all the incidents that had occurred with Resident #2. She stated that although Resident #2 was not evil and was sweet, his behaviors had worsened, and he had become more confused. CNA F stated that outside of the incidents with Resident #1, Resident #2 had become aggressive with her, and CNA G. CNA F stated that if something had been done, some of the incidents with Resident #2 could have been prevented.<BR/>During an interview on 05/08/24 at 2:58 PM, CNA E stated she could not remember exact dates and times. CNA E stated the first incident between Resident #1 and #2 might have occurred four months ago. CNA E stated that she and CNA F were doing rounds and heard Resident #1 scream aloud. CNA E stated Resident #2 was in Resident #1 room. CNA E stated she observed Resident #1 halfway off the bed. CNA E stated that Resident #2 had his wife in the room. CNA E stated Resident #1 was halfway off of the bed, and she observed the lower half of Resident #1's body off the bed. CNA E said Resident #1 was holding onto the bed rail with his right arm. CNA E stated the incident where Resident #1 was hanging off the bed was the first incident she had ever seen. She said she reported the incident to the charge nurse but could not remember who it was as they have many charge nurses. CNA E stated there was another incident (unsure of the date and time) where Resident #1 screamed. CNA E stated that Resident #2 scratched Resident #1 during this incident. CNA E stated it happened possibly two months ago. CNA E stated Resident #2 had scratches on his chest and right side. CNA E stated this was reported to LVN B. CNA E stated that she had to scream for assistance during this incident. She stated CNA F came to assist her. CNA E stated that this incident scared her and that things were worsening with Resident #2's behaviors. CNA E stated that Resident #2 was telling her that Resident #1's room was his room and yelling at her. CNA E said she kept telling him it was not his room. CNA E said that after they told LVN B, she (LVN B) would notify the appropriate parties. She said Resident #1 appeared scared and had water in his eyes. She said Resident #1 said it was scary. CNA E said Resident #1 used minimal words such as scary, hurt, and oh man to describe what had happened. CNA E said there was another incident where Resident #2 had become agitated and aggressive with staff; this was when she messaged the DON. CNA E said she did not like what was happening, and it made her sad about what had happened to Resident #1. <BR/>A record review of text messages sent to the HHSC investigator on 05/08/24 at 3:28 PM from CNA E revealed on 04/23/24 at 3:28 PM that CNA E expressed concern about Resident #2's behavior, not being trained to take care of residents with Resident #2's behaviors, other residents being afraid and the potential for the incident to be worse. The DON responded that Resident #2's medication was adjusted. CNA E expressed concern about what to do when Resident #2 does not take his medication. CNA E expressed in the text message that Resident #2 had several incidents before the aggressive incident with staff. CNA E referenced the incident with Resident #2 protecting his feeding tube and that CNA E had reported the incident to her charge nurse. The DON responded to the concerns by stating that Resident #2's medication was adjusted and that she was unaware what had happened when Resident #2 became aggressive with staff.<BR/>During an interview on 05/08/24 at 3:29 PM, LVN A stated that she no longer worked at the facility. LVN A stated on 04/25/24 that she did not witness Resident #2 pulling Resident #1 out of the bed. LVN A stated that she had heard Resident #1 scream and thought it was another resident. LVN A said that when she walked down the hallway, one of the CNAs came running towards her. LVN A stated she could not remember the CNAs name. LVN A said she went into Resident #1 room and observed Resident #2 in Resident #1's bed and Resident #1 was on the floor. LVN A said this was not the first interaction between Resident #1 and Resident #2. LVN A stated this was the second time this had happened. LVN A said that during the incident on 04/25/24, Resident #2 yelled at the staff. LVN A stated she raised her voice for Resident #2 to get out of Resident #1's bed. LVN A said that they were finally able to get Resident #2 out of Resident #1 room. LVN A said she notified the DON of the incident. LVN A stated the DON said that she told the ADM and that the ADM was on the way to the facility to send Resident #2 out for behavior support. LVN A said she had experienced Resident #2 becoming agitated with staff on 04/18/24. She stated that the FNP, PCP, DON, and ADM knew about the incident. She said she had been told by other staff that Resident #2 had attempted to pull Resident #1 out of bed before. She said she was unaware of any interventions that had been put in place. <BR/>During an interview on 05/08/24 at 10:25 PM, CNA I stated on 04/25/24, it was around 7 PM or 9 PM when the residents that smoke go out. CNA I said she observed Resident #1 on the floor. CNA I said she went to get LVN A, and that was when she (LVN A) told Resident #2 to get the fuck out. CNA I said she redirected Resident #2 to his room. CNA I stated she and CNA H placed Resident #1 back in bed. CNA I said after that incident and Resident #2 received a shot of Ativan he came back out and was trying to throw a shoe at Resident #1. CNA I said that most of the time when she worked with Resident #2, he would always try to go into Resident #1's room. CNA I said this occurred at least three times a week. Before the incident on 04/25/24, CNA I said that Resident #2 never made physical contact with Resident #1 on her shift. CNA I said there was nothing ever done that she could recall to alleviate the situation, but the staff had placed gloves on the outer door at one point. She stated she could not provide a picture of the gloves on the door to the HHSC worker. CNA I said that she had been trained to report allegations of ANE immediately. <BR/>During an interview on 05/08/24 at 10:51 PM, LVN D stated that the incident on 04/25/24 was the second time that Resident #2 had attempted to pull Resident #1 out of bed. She stated she was not present but had received the information in the report as she typically worked the day shift. LVN D said that they had to redirect Resident #2 consistently. LVN D stated that she did not feel that Resident #2 was explicitly targeting Resident #1 but that he was confused as to where his room was. <BR/>An attempt to contact LVN B was made at 10:57 PM. LVN B said she would contact her DON and ADM and return the call. Additional attempts to speak with LVN B were made on 05/09/24 at 10:29 AM. LVN B did not answer. <BR/>During an interview on 05/09/24 at 10:21 AM, the FNP stated that she had consistently been seeing Resident #2 for psychiatric services. The FNP said she was making frequent medication adjustments. The FNP said she was only aware of one incident where Resident #2 had pulled a resident out of the bed, but no other incidents had been reported. The FNP said it had been reported that he had become aggressive with staff.<BR/>During an interview on 05/09/24 at 10:52 AM, the Activity Director stated that she participated in Resident #1's care plan. The Activity Director stated that Family Member J expressed that Resident #2 had wandered into Resident #1's room once or twice. The Activity Director stated they had gloves on the door so Resident #2 knew where his room was. The Activity Director said she does not know what happened to the gloves because they are no longer there. The Activity Director said she was unaware of any other interventions to prevent Resident #2 from entering Resident #1's room. The Activity Director stated she did not feel that Family Member J was upset but did express concern.<BR/>During an interview on 05/09/24 at 11:00 AM, the DM stated that she participated in Resident #1's care plan. The DM said Family Member J expressed concern about Resident #2 entering Resident #1's room. The DM suggested placing bells or something on Resident #2's door so that he would know which room was his. The DM said Family Member J was concerned that the next time could be worse for Resident #1. The DM stated that before the incident on 04/25/24, Resident #2 had gone into Resident #1's room, but she did not know the date or time. The DM said she was unaware if Resident #2 had been physical with Resident #1. The DM said Family Member J was not upset but concerned.<BR/>During an interview on 05/09/24 at 11:10 AM, the MDS Coordinator stated that she was aware that Resident #2 had pulled Resident #1 out of the bed only once. The MDS Coordinator said that she was unaware that Resident #1 had increased physical or verbal aggression behaviors. The MDS Coordinator said revising the care plan if the behaviors differ was customary. The MDS Coordinator said that Resident #2 did not understand well and that all staff could do was redirect him with a snack or an activity. The MDS Coordinator stated that she revises the care plan each time there was an MDS update. The MDS Coordinator said the MDS was updated annually, quarterly, and sometimes on an off cycle. The MDS Coordinator said she would also update us if there was a significant change. The MDS Coordinator said she looked over the care plans each time there was a care plan meeting. The MDS Coordinator said she would have revised the care plan if it had been reported to her each time Resident #2 pulled any resident out of bed. The MDS Coordinator said the interventions were what the staff do to care for the resident, and staff should be watching him closely. <BR/>During an interview on 05/09/24 at 11:27 AM, Resident #1 stated that Resident #2 had been in his room [ROOM NUMBER]-5 times. Resident #1 stated no one had come to him and interviewed him about the incident outside of the HHSC investigator. Resident #1 said that he was afraid when he had to hang onto the bed. Resident #1 said he had told multiple CNAs and nurses that he did not want Resident #2 in his room. Resident #1 said he could not remember the names of the staff he told. Resident #1 said he felt like his problem was never solved. Resident #1 said that three times when Resident #2 came into his room, it got physical; he was pulled off the bed, scratched, and pulled halfway off the bed. Resident #1 said he could not remember the date and time when the incidents happened but that staff knew about it because they had to help him.<BR/>During an interview on 05/09/24 at 1:07 PM, the ADM clarified that during the initial interview, she stated the incident between Resident #2 and Resident #1 had never happened was because three weeks prior, staff had reported that Resident #2 had gone into the room and scratched Resident #1 and LVN B had redirected Resident #2 out. The ADM stated she was unsure where the scratch was. The ADM stated this type of information was typically reported to the DON. The ADM stated she did not report the incident to the state agency because the nurse had intervened and redirected Resident #2 out of the room. The ADM said she was unaware that Resident #2 had encountered Resident #1 multiple times. The ADM said she was unaware that Resident #2 had attempted to pull Resident #1 out of the bed before the incident on 04/25/24. The ADM said she was unsure of Resident #1's care plan meeting . The ADM said she, the DON, Family Member J, The MDS Coordinator, the ADM, and the Social Worker may have been there. <BR/>During the care plan meeting, the ADM said Family Member J did not express concerns about Resident #2 coming into Resident #1's room. The ADM said they did discuss potentially placing something on Resident #2's door but never made it official. The ADM said the discussion about Resident #2 did not occur during Resident #1's care plan meeting. The ADM said they were monitoring Resident #2's behavior through psychiatric services and medication adjustments. The ADM stated that the staff had expressed concerns about them getting hurt, but she was unaware of the ongoing issues with Resident #1. She said she was only aware of one incident where Resident #2 had become aggressive with staff. She said she was unaware of any other incidents. The ADM said she knew that most of Resident #2's incidents or behaviors occurred at night. The ADM said she did not implement any other interventions outside of the medication adjustments and monitoring from psychiatric services and notifying the family, PCP, and FNP. The ADM said she was sure the care plan had interventions to address Resident #2's behaviors. The ADM said all interventions and revisions should be dated. The ADM said grievances were for family and residents. The ADM said if staff had a concern, they should be redirected to HR to identify a solution. The ADM said she did not have a system to track staff concerns. The ADM said she was responsible for grievances. The ADM said all staff had been trained to handle grievances as part of ANE and resident rights training. The ADM said she had never interviewed Resident #1 to see if this had happened. The ADM had never delegated to interview Resident #1. The ADM said the night of the incident (04/25/24), she was more concerned with his well-being and what happened. The ADM said part of the investigation process was interviewing key witnesses and residents and finding out what happened. The ADM said the potential negative harm if they do not attempt to prevent incidents and accidents was that harm could come to the residents and staff. The ADM said the care plan had interventions that helped prevent incidents and accidents. The ADM said they usually would have met weekly if they identified a potential problem. The ADM said that her team had not met every week regarding Resident #2. The ADM said the purpose of preventing incidents and accidents was the residents' overall safety. The ADM said that she could have prevented further incidents if she had known about the multiple incidents between Resident #1 and Resident #2. The ADM said she was unaware of the various times. The ADM said the facility staff monitored incident/accident prevention through daily standup meetings, talking to staff, and in-service. The ADM said she had not done anything specific for the night-time staff but that they had received the same ANE and resident rights training. The ADM said she had no formal training regarding preventing incidents/accidents, but they trained the staff through in-services. The ADM said she had not observed Resident #2 go into Resident #1's room but expected

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 15 residents (Residents #138) reviewed for baseline care plans. <BR/>The facility failed to complete Resident #138's baseline care plans within 48 hours. <BR/>This failure could place newly admitted residents at risk of not receiving the necessary care and services needed. <BR/>The findings included:<BR/>Resident #138<BR/>Record Review of Resident #138's face sheet dated 05/22/22 documented a [AGE] year-old male admitted [DATE] with the following diagnoses: anxiety, rheumatoid arthritis, schizoaffective disorder, bipolar type, nicotine dependence and dementia without behavioral disturbance.<BR/>Record Review of Resident #138's comprehensive MDS (Minimum Data Set) dated 05/18/22 documented the following: <BR/> Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 15 which is rated as cognitively intact (Alert and Oriented x time, place, person).<BR/>Record review of Resident #138's baseline care plan could not be viewed as it was not in the electronic medical record for the resident. <BR/>During an interview with the DON on 05/24/22 at 10:29 AM, she stated she was not familiar with the MDS sections as she is not responsible for completing the assessment. She stated she is responsible for the baseline care plans. She stated she failed to complete the baseline care plan for Resident #138. She stated that she had been trained, kinda, related to baseline care plans. She said the baseline care plan, like the care plan, gives the initial introduction to the resident when they first come to the facility. She stated that not having a baseline care plan could negatively affect the resident's care. The resident may not receive the care that they need and the care for the resident is important as it can prevent decline in health for the resident. She said that she could see the break in the system (baseline care plans). She stated that her expectation was for baseline care plans to be done according to policy. She stated the 48-hour baseline care plan was not done for the resident. She knew this because the alert she saw when she opened up the resident's electronic medical record indicated that the baseline care plan was past due. <BR/>During an interview with the Administrator on 05/24/22 at 12:32 PM, she stated the baseline care plan should be conducted as soon as the residents get to the facility or within the first three days. This, like the care plan, gives you an overview of what the resident needs. She stated she could not think of a reason why a baseline care plan would not be completed. She said that staff might miss important care areas if this is not completed, and the resident could miss out on the care that is needed. She stated the DON and care plan coordinator is responsible ensuring the care plans are done.<BR/>Record review the facility's policy, Care Plans-Baseline, revision date December 2016, revealed:<BR/>Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 (48) hours of admission.<BR/>Policy Interpretation and Implementation:<BR/>1. <BR/>To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. <BR/>3. <BR/>The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, including supports for daily living safely for 2 of 3 hallways and 1 of 2 common areas observed for environmental concerns in that: <BR/>-Discarded chicken wing bones observed on end table in the facility t.v. room. <BR/>-Floors were observed with dried brown liquid stains outside room [ROOM NUMBER]. <BR/>-Floor was observed with brown dime and quarter size food outside room [ROOM NUMBER]. <BR/>-Odors were observed upon entrance into the facility and strong odors on Hall B.<BR/>-Trash barrels were observed on Hall B outside room [ROOM NUMBER] with strong odors and used for discarding soiled briefs.<BR/>-Strong odor in Hall B outside room [ROOM NUMBER].<BR/>-room [ROOM NUMBER] observed with strong odors, urine filled urinal container and bottles of Resident #2's urine. <BR/>These failures placed residents at risk of living in an unclean, uncomfortable, un-homelike environment. <BR/>Findings include:<BR/>During an observation on 3/23/23 at 9:03 p.m., strong odors of urine, feces or pungent odors were observed upon entrance into the facility. <BR/>During an observation on 3/23/23 at 9:05 p.m. upon arrival to the nurses station, odors of urine, feces and pungent odors became stronger. <BR/>During an observation on 3/23/23 at 9:22 p.m. while walking down B hall odors of urine and feces were observed stronger as approaching near room [ROOM NUMBER]. Two trash barrels with lids with strong pungent odors were observed against the wall next to the door of room [ROOM NUMBER].<BR/>During an interview and observation with the BOM, the Investigator notified the BOM that there is a strong odor in the hallway near the nurses station and the odor was very strong near the trash barrels outside room [ROOM NUMBER]. The Investigator informed the BOM that there was a strong odor of feces and urine in hall B. The BOM stated that she noticed the smell when she arrived at the facility and approached the nurses station. <BR/>During an observation on 3/23/23 at 9:39 p.m., strong smell of feces was observed in hall B, observed CNA C placing soiled bagged brief in the trash can in hall B outside of room [ROOM NUMBER].<BR/>During an observation on 3/23/23 at 9:40 p.m., several pieces of a brown food type substance were observed on the hallway floor outside of room [ROOM NUMBER]. Observation revealed several brown stains appearing to be spilled dried liquid in the hallway outside of room [ROOM NUMBER].<BR/>During an interview and observation on 3/23/23 at 9:55 p.m. with BOM; Investigator toured facility with BOM and pointed out brown food substance outside room [ROOM NUMBER] and brown dried liquid substance outside room [ROOM NUMBER] in the hallway. The Investigator asked BOM if she smelled the odor in hall B, the BOM stated yes, it is bad as she removed the lid from the trash barrels and stated there were dirty briefs in the trash cans. The BOM stated there Resident #2 in hall B that collects his urine in containers, spills urine on the floor and his mattress and will spill urine through the screen of his window to the outside of the building. The BOM stated that Resident #2 will not allow staff to empty his urine containers or clean his room and staff have to wait until he is in the shower to clean his room. The BOM stated that she will get staff to clean the hall floor and would also locate something to neutralize the odors in the building.<BR/>During an observation on 3/23/23 at 9:59 p.m., an unidentified female resident left chicken wing bones on table in t.v. room and left the area. <BR/>During an interview and observation on 3/23/23 at 10 p.m., the BOM was observed on the phone requesting code to the storage closet because staff needed access to a broom, mop and mop bucket to clean the floors. During phone call, the BOM asked housekeeping staff if there was any sort of odor neutralizer so she could spray the hallways. The BOM was notified of resident leaving chicken wing bones on table in t.v. room. The Administrator entered building and office during interview with BOM. <BR/>During an interview on 3/23/23 at 10:04 p.m. with the Administrator and BOM; the Investigator informed ADM that there is an odor in the building and odor is very strong in hall b near room [ROOM NUMBER]. The BOM advised ADM that the smell is bad, I called housekeeping to see if we have an odor neutralizer spray somewhere. The ADM stated, there was a smell when I came into the building tonight. The ADM stated that she will check on the source of the odor and if there is a way to neutralize the odor. The BOM stated that housekeeping does not empty the barrels in Hall B and the CNAs are supposed to empty them during their shift. The BOM stated that she called the housekeeping supervisor because the night shift cannot get into the locked housekeeping closet to access brooms, mops, or a mop bucket. <BR/>During an interview on 3/24/23 at 9:46 a.m. with Resident #3; stated that it always smells in the mornings because of the poop barrels that are in the hall near his room. The Resident #3 stated I can smell the poop smell from my bed, and I do not like it.<BR/>During an interview on 3/24/23 at 9:57 a.m. with CNA D; stated that there is always a smell near room [ROOM NUMBER] because Resident #2 throws his urine out through the window screen. CNA D stated Resident #2 does not want staff in his room, and they have to wait until he showers to attempt to deep clean it.<BR/>During an interview on 3/24/23 at 10:06 a.m. with the MA; stated that Hall B does smell in the mornings when she comes to work, and she has noticed the smell on several occasions when she arrives to work. MA stated that the smell is in Hall B, which is where room [ROOM NUMBER] is located. The MA stated that Resident #2's room [ROOM NUMBER] smells like urine all the time because he wets the bed and won't get up to use the restroom. The MA stated resident in room [ROOM NUMBER] also will fill the urinal container with urine, cups, bottles, or anything else he can urinate into. Stated that the resident also gets urine on the floor and the window screen when he pours urine out the window screen. The MA stated when she arrives to work in the mornings, the overnight CNAs do not always empty the trash barrels before they leave. <BR/>During an interview on 3/24/23 at 10:16 a.m. with the HK, stated that she doesn't empty the trash barrels because they contain dirty briefs, and the CNAs are supposed to do that. The HK stated that the smell in room [ROOM NUMBER] is overpowering because the resident empties his urinal in cups and bottles. The HK stated that they only can clean his room when he goes into the shower because he does not want staff in his room. The HK stated she has come in at 8 a.m. several times and the barrel in hall B is not empty and is full of dirty briefs that the CNAs have not emptied yet. The HK stated that the barrels are almost always stored in hall B.<BR/>During an interview on 3/24/23 at 10:29 a.m. with the AD, Stated that on several occasions when she arrived to work in the morning, the trash barrels in hall b were not emptied by the night shift. The AD stated there is an odor of urine and feces on those days and it does smell, and it is bad. The AD stated this is the residents' home and they shouldn't have to smell that. <BR/>Record Review of Resident #2's face sheet revealed the resident is a [AGE] year-old male, admission date of 9/10/21 and diagnoses include: Alzheimer's disease (type of dementia that affects memory, thinking and behavior), Undifferentiated Schizophrenia (Symptoms of more than one subtype of schizophrenia are present, but a person does not exhibit enough of one to be classified as that subtype), anxiety disorder(symptoms of intense anxiety or panic that are directly caused by a physical health problem.), Paranoid Schizophrenia(predominantly positive symptoms of schizophrenia, including delusions and hallucinations), Intermittent explosive disorder (impulse-control disorder characterized by sudden episodes of unwarranted anger), Type 2 diabetes(problem in the way the body regulates and uses sugar as a fuel.), and schizoaffective disorder bipolar type(mental illness that can affect your thoughts, mood and behavior). <BR/>Record Review of Resident #2's MDS dated [DATE], revealed BIMS score of 2 out of 15 indicating he was severely impaired cognitively.<BR/>During an interview and observation on 3/24/23 at 12:36 p.m. with Resident #2; Resident #2 permitted Investigator to enter room. Observed Resident #2 laying on mattress with no sheets on bed, half-filled urinal container bottle on bedside table, several opened soda cans and bottles with yellow liquid on dresser and nightstands. Observed strong odor of urine in room. Resident #2 stated he bathes and uses the restroom without assistance and asked Investigator to leave his room. <BR/>During an interview and observation on 3/24/23 at 12:44 p m with LVN B; stated that on Mondays there is a strong odor of urine and feces from the trash barrels in the hallway and from Resident #2's room. Stated that the CNAs on the night shift do not always empty the trash barrels before they leave for the day. Stated that Resident #2's room has a strong urine odor because he urinates on the floor, and empties his urine from his containers through the screen of his window. Stated that he will not let staff clean his room or empty his urine containers. Stated that he will not let housekeeping in the room and they sneak in there and try to clean when he is in the shower. Stated that the barrels are dirty and smell and we need to work on it to control the odor problem.<BR/>Record review of the facility policy and procedure entitled Homelike Environment dated revised May 2017; read in part: residents are provided with a safe, clean, comfortable, and homelike environment .the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include .clean, sanitary, and orderly environment .pleasant, neutral scents.<BR/>Record Review of the facility policy and procedure entitled Quality of Life-Homelike Environment dated revised May 2008; Policy Statement Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. <BR/>-Policy Interpretation and Implementation in part reads: <BR/>The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include: Clean, sanitary, and orderly environment, pleasant, neutral scents<BR/>The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting to include: institutional odors<BR/>Record Review of the facility provided undated Resident Rights policy, revealed in part: Dignity and Respect, You have the right to: live in safe, decent, and clean conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 8 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10), reviewed for abuse. <BR/>The facility failed to ensure a safe environment free from abuse for Resident #1 when can D was suspected to have used unnecessary force causing a spiral fracture to Resident #1 on night shift on 04/12/2023. <BR/>The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 resided in a safe environment after making allegations of abuse toward CNA D and CNA D was continued to allow to work with all resident's even after prior allegations of abuse. <BR/>This failure was determined to be an Immediate Jeopardy situation that was identified on 04/14/2023 at 5:51 p.m. While the IJ was removed on 04/17/2023 , the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death. <BR/>Findings include: <BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, <BR/>Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was a 3/15, meaning severe cognitive impairment.<BR/>Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. <BR/>Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words.<BR/> Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. <BR/>Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. <BR/>Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. <BR/>Under C0700 labeled long-term memory is left blank and not completed. <BR/>Under C0800 labeled Memory/Recall Ability is left blank and not completed. <BR/>Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. <BR/>Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. <BR/>Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. <BR/>Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. <BR/>Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under <BR/>B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. <BR/>Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. <BR/>Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. <BR/>Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance.<BR/>Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). <BR/>Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. <BR/>Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. <BR/>Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. <BR/>Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. <BR/>Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. <BR/>Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). <BR/>Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. <BR/>Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. <BR/>Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. <BR/>Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. <BR/>During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. <BR/>During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. <BR/>*Resident #2:<BR/>Record Review of Resident #2 face sheet documented he is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis which includes: stroke, seizures, difficulty swallowing, facial weakness, major depressive disorder, anxiety disorder, type 2 diabetes, muscle wasting, cognitive communication deficit, lack of coordination, hyperlipidemia (a condition which there are high levels of fat particles (lipids) in the blood). <BR/>Record review of Resident #2's admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 00 meaning zero points are assigned if the resident didn't repeat words correctly<BR/>Under B0600 for Speech Clarity indicated that Resident #2 scored 1 meaning Unclear Speech-slurred or mumbled words. <BR/>Under B0700 for Makes Self Understood indicated that Resident #2 scored 2 for ability to express ideas and wants. meaning sometimes understood ability is limited to making concrete requests. <BR/>Under B0800 for Ability to Understand Others-understanding verbal content scoring a 2 meaning responds adequately to simple and direct communication only. <BR/>Under G0110 for Activities of Daily Living Assistance indicates: A). Bed Mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) Resident #2 scored a 3 meaning extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist. B). Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), Resident #2 scored a 4 indicating total dependence (full staff performance every time during entire 7-day period). G). Dressing how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas, Resident scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist). Resident #2 scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with one person assist. Toilet Use: how resident uses the toilet room, commode, bedpan, or urinal<BR/>Record review of Resident #2s Care Plan dated on 07/01/2022 indicated the following:<BR/>Resident #2 has an ADL self-care performance deficit with interventions of: ADL self-performance fluctuates with confusion but usually requires assistance as follows: Bed mobility-self-performance (Total Dependence), Bed mobility: support provided with 2-person physical assist, Transfer: self-performance (total dependence), Transfer-support provided with 2 person physical assist, walk in room- self-performance (activity did not occur), walk in room- support provided ADL activity did not occur, Walk in corridor- self-performance (Activity did not occur), walk in corridor-support provided ADL activity itself did not occur, Locomotion on unit-self performance (total dependence), Locomotion on unit- support provided one person physical assist, Locomotion off unit- self-performance (total dependence), locomotion off unit- support provided with one person physical assist, Dressing: self-performance (Extensive assistance), Dressing: support provided with two person physical assist, Eating: self-performance (Supervision), Eating: support provided with one person physical assist, Toilet use: self-performance (Total dependence), Toilet use: support provided with two person physical assist, <BR/>Personal hygiene: self-performance (Total dependence), Personal hygiene: support provided with two-person physical assist, Nurse aides to document Resident #2s most dependence self-performance per shift. Monitor for signs and symptoms of ADL decline and notify family, MD, identifying causes and solutions. Monitor/document/report to MD as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. <BR/>Record Review of Resident #2's Progress notes dated 04/15/2023 at 10:57 am, signed by Social Worker revealed: Social worker spoke with Family Member #12 to let her know about the new reporting guidelines for abuse and neglect. She (Family Member #12) asked that it be mailed. She (Family Member #12) may also pick it up today when she is here. The form is also placed in Resident #2's room. <BR/>During an Observation on 04/13/2023 at 12:08 pm with Sampled Resident #2 revealed: Observed Resident #2 laying in his bed visiting with family member. Observed Resident #2 free from distress. <BR/>During an Interview with Resident #2 on 04/13/2023 at 12:07 pm. Resident #2 was able to slowly reveal the complaint that he had against CNA D with the help of family member. Resident #2 stated that during care he went to grab side bars and CNA D pushed him hard and motioned to Surveyor where his head was hit on the side bars. Resident #2 stated, He hits me, hard. (CNA D). Resident #2 put his fingers on top of his head and stated, Devil. Surveyor stated who is the Devil, Resident #2 called CNA D by name. Observed Resident #2 began to show signs of anxiety just talking about it and began to tear up in his eyes. Family member #11 had to console Resident #2 to get him to calm down. <BR/>During an interview on 04/13/2023 at 12:17 p.m., with Family member 12 via telephone for Resident #2, Family Member #11 used her own personal cell phone to reach out to Family member #12 and was happy to share some concerns. Family Member #12 stated that she does have some concerns with CNA D and that she did not have a lot of time because she had to get back to work but would like the opportunity to write down all the concerns and get back with Surveyor in a couple of days. Family Member #12 stated that she was told by Resident #2's old roommate (Resident #9) that he witnessed CNA D tell Resident #2 to stop using the call light so much or the next time he puts him in the Hoyer lift he (CNA D) will leave him there. Family Member #12 stated that the Administrator and BOM both knew that these things were going on and did nothing about it. Family Member #12 stated that she had stressed out so much from worrying about Resident #2 being in the facility when CNA D is working. Family Member #12 stated that she would like to make a written statement to provide to Surveyor about all the things that CNA D did to Resident #2. <BR/>Record Review of a written Statement provided on 04/15/2023 at 8:00 am, from Family member #12, revealed:<BR/>To Whom it May Concern:<BR/>I (Family Member #12) just want to say thank you, my name is (Family Member #12), stated it is unfortunate that they are in the situation that they are in with the facility. Family Member #12 stated that she is willing to share Resident #2 journey at the facility in hopes that something or someone will finally do something to help these residents. Family Member #12 stated that everything had gone fine until the facility had hired CNA D (nights). Family Member #12 stated that she finally became concerned when CNA D had acted in a manner in front of another family member like he didn't like Resident #2 (talking rude to him). Family Member #12 stated that CNA D had a demeanor that he did not have a very caring personality and acted like he didn't want to be there most times. Family Member #12 stated that she had witnessed one of the times that CNA D had been rough with Resident #2 when she walked in when he was providing care and she told CNA D, Hey be easy with him. Family Member #12 stated that it seemed to upset CNA D when she told him because he got an upset look on his face. Family Member #12 stated that as time passed by it got to a point when Resident #2 didn't want family to leave him there alone when CNA D was working. Family Member #12 stated that she finally reported her concerns to the DON and Administrator at the time on October 2022 and she was told that the facility was investigating the situation but nothing ever changed. Family Member #12 stated that she asked weeks later and was still told that it was being investigated and still nothing changed. Family Member #12 stated that she got so frustrated because the facility is supposed to protect the resident's and did nothing to protect. Family Member #12 stated that about the second week of November 2022 she was approached by the DON and stated that the DON told her that there was an incident that the CNA D had Resident #2 up in the Hoyer and CNA D told Resident #2 that if he didn't stop, bitching, and pushing the call light that he (CNA D) would leave him up there. Family Member #12 stated that she was told by DON at the time that CNA D had left Resident #2 in midair in his brief that was soiled and wet for a good period of time. Family member #12 stated that she was told that the situation is being investigated, and again nothing happened. Family Member #12 stated that she went to the DON after days of hearing nothing and asked what was going to be done and DON stated that other residents had to be questioned. Family Member #12 stated that she asked at this time for CNA D not to be allowed to go into the room or care for Resident #2. Family Member #12 stated that she was told by the administrator that the facility could not do that and that is when she knew that there was going to be a problem with this place. Family Member #12 stated that it got to a point that family members would try to go as much as possible in hopes that the situation would stop. Family Member #12 stated that most times she was there that Resident #2 would show anxiety anytime CNA D would work. Family Member #12 stated that another incident happened in December 2022 with CNA D and Resident #2. Family Member #12 stated she was there at the facility with Resident #2, and she pushed the call light because Resident #2 was soaking wet and had, poop in his brief. Family Member #12 stated that Resident #2 started getting really anxious and scared. Family Member #12 stated that CNA D came in the room and told Family Member #12 that she had to leave the room for the privacy of Resident #2. Family Member #12 told CNA D that she would not leave the room. Family Member #12 stated that CNA D then told her that he would not change Resident #2 then. Family Member #12 stated that she told CNA D that she was going to report him to the administrator. Family Member #12 stated when she threatened to report CNA D, he then changed Resident #2, but CNA D was very rough and when he pushed Resident #2 to the side CNA D pushed him so hard that Resident #2 hit his head on the side pull bars. Family Member #12 stated that Resident #2 would cry sometimes and say that he was scared to go to sleep because of CNA D. Family member #12 stated that she did report this to the administrator and again, nothing, just investigating. Family Member #12 stated that she finally got to the point with the administrator that she said, What is it going to take, CNA D seriously hurting someone or killing them? Family Member #12 stated that she was scared daily, and this stressed her out because she was constantly worried about Resident #2. Family member #12 stated that things got worse with CNA D and Resident #2 began telling her that CNA D would twist his arm really hard and yell at him. Family Member #12 stated that she had went to the facility on March 10th, 2023, and already had Resident #2 up and in the wheelchair. Family Member #12 stated that Resident #2 was crying and very scared with his fists clenched. Family Member #12 stated, What's wrong, what happened, to Resident #2. Family Member #12 stated that Resident #2 had told her that CNA D was pulling and hitting him in his bad arm and leg. Family Member #12 stated that she had never been so scared before for Resident #2 because it was getting worse. Family Member #12 stated that she would have to go out of town that day due to her daughter having cancer. Family Member #12 stated that she told the current Administrator and was told by the Administrator that she would have to report this to Human Services, and she would question CNA D to see what happened. Family member #12 stated that when she came back from out of town that the Administrator told her that CNA D was on a 30-probation and was suspended. Family Member #12 stated that she told the Administrator not put CNA D to care for Resident #2 and she was told that this could not happen due to lack of staff that the facility had. <BR/>Resident #3:<BR/>Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: stroke, anorexia, muscle wasting and atrophy (decrease in size of a body part), dementia, lack of coordination, atherosclerotic heart disease (buildup of fats, cholesterol, and other substances on the artery walls), unsteadiness on feet, schizoaffective disorder, depression, anxiety, seizures, insomnia, high blood pressure, abnormalities of gait and mobility. <BR/>Record review of Resident #3 admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 12 meaning cognitively moderately impaired.<BR/>Under B0200-Hearing: Resident #3 was listed as 0 meaning: Adequate- no difficulty in normal conversation, social interaction, listening to tv. <BR/>Under B0600-Speech Clarity: Resident #3 was listed as 0 meaning: distinct intelligible words.<BR/>Under B0700-Makes Self Understood: Resident #3 was listed as 1 meaning: Usually Understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. <BR/>Under B0800-Understands Verbal Content however able: Resident #3 is listed as a 1 meaning: Usually understands-misses some part/intent of message but comprehends most conversation. <BR/>Under C1310-Delirium- Resident #3 was listed as a 0 meaning there is no delirium. <BR/>Under G0110-Functional Status: Bed mobility-Resident #3 was listed as extensive assistance with 2 person assist, Transfer-Resident #3 is listed as total dependence with 2 person assist, walk in room- Resident #3 was listed as activity did not occur, Walk in corridor- Resident #3 was listed as activity occurred only once or twice with 1 person assist, Locomotion on Unit- Resident #3 was listed as extensive assistance with one person assist, Locomotion off Unit- Resident #3 w[TRUNCATED]