Mid City Community Nursing And Rehab

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#2) of 1 resident reviewed for Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP). Findings:Review of the facility's policy titled, Enhanced Barrier Precautions with a revision date of 04/2024 revealed the following, in part:Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high-contact resident care activities.Policy Explanation and Compliance Guidelines:2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i.indwelling medical devices (e.g., feeding tubes)4. High-contact resident care activities include: f. changing briefs or assisting with toiletingReview of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of Traumatic Subarachnoid Hemorrhage and Gastrostomy Status.Review of Resident #2's current Physician Orders revealed the following, in part: Start date: 06/02/2025; Enhanced Barrier Precautions when providing high-contact resident care.Review of Resident #2's current Care Plan revealed the following, in part:Focus: I require staff to use EBP.Intervention: Wear required PPE when preforming contact care. On 08/18/2025 at 4:00 p.m., an observation was made of the EBP sign posted on the wall above Resident #2's bed. The sign revealed the following, in part: Providers and staff must also:Wear gloves and a gown for the following high-contact resident care activities.In addition to standard precautions, everyone must gown and glove for these resident care activities - Changing briefs On 08/18/2025 at 4:00 p.m., an observation was made of incontinent care on Resident #2. S2CNA changed Resident #2's brief without wearing a gown. On 08/18/2025 at 4:05 p.m., an interview was conducted with S2CNA. She confirmed Resident #2 had a Percutaneous Endoscopic Gastrostomy (PEG) tube. She further confirmed she did not wear the appropriate PPE while performing incontinent care and should have. On 08/20/2025 at 11:59 a.m., an interview was conducted with S1DON. She confirmed she would expect staff to wear the appropriate PPE when providing incontinent care to a resident with a PEG tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's laboratory tests were completed as ordered by the physician for 1(#52) of 22 residents investigated in the final sample.
Findings:
Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with a diagnosis which included Diabetes.
Review of Resident #52's Physician's Orders revealed, in part:
Order date 11/25/2024- laboratory blood draw for HGBA1C every three months in March, June, September, December once every 3 months starting on the 25th of each month.
Review of Resident #52's clinical record revealed the last collected HGBA1C was performed on 10/26/2024.
Review of the Medication Administration Record from November 2024 to present revealed no documented evidence Resident #52's HGBA1C labs were collected.
Review of Resident #52's Care Plan Report revealed the following:
Focus- I have a History of Diabetes
Interventions- Obtain lab work as ordered
An interview was conducted on 03/19/2025 at 3:08 p.m. with a local laboratory spokesperson. He stated the last collected lab on record for HGBA1C for Resident #52 was collected on 10/26/2024.
An interview was conducted on 03/19/2025 at 3:10 p.m. with S2DON. She reviewed Resident #52's clinical record and confirmed the last documented HGA1C collection was performed on 10/26/2024. She confirmed no additional HGBA1C labs were collected from admission to present and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#4) of 22 residents reviewed in the final sample.
Findings:
Review of Resident #4's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included morbid obesity.
Review of Resident #4's Significant Change MDS with an ARD of 02/25/2025 revealed a BIMS of 14, which indicated she was cognitively intact.
On 03/17/2025 at 11:05 a.m., an observation was made of Resident #4 in her room. She was lying in bed, with her call light resting on the floor behind the bed.
On 03/17/2025 at 11:10 a.m., an interview was conducted with Resident #4. Resident #4 stated she was independent with eating but was dependent for all other ADL care. Resident #4 stated her call light was frequently out of reach and she had to yell out until someone responded.
On 03/17/2025 at 1:45 p.m., an observation was made of Resident # 4 in her room. She was lying in bed, with her call light resting on the floor behind the bed.
On 03/18/2025 at 10:41 a.m., an observation was made of Resident #4 in her room. She was lying in bed, with her call light resting on the floor behind the bed.
On 03/18/2025 at 12:44 p.m., an observation was made of Resident #4 in her room. She was lying in bed, with her call light resting on the floor behind the bed.
On 03/19/2025 at 9:42 a.m., an interview was conducted with S4LPN. S4LPN confirmed call lights should be within the resident's reach at all times. She verified Resident #4 was able to use her call light. S4LPN further stated Resident #4's call light was frequently not within reach and resident would yell out for the nurse if needed.
On 03/19/2025 at 2:55 p.m., an interview was conducted with S2DON. S2DON was made aware of the above observations and confirmed she expected staff to keep call lights within a resident's reach.

Based on observation, record review, and interview, the facility failed to ensure the results from the most recent complaint survey was readily available for resident review.
This deficient practice had the potential to affect the 104 residents who currently resided in the facility.
Findings:
Review of the facility's Survey History revealed the most recent survey was a Complaint Survey on 02/11/2025.
An observation was made on 03/17/2025 at 9:30 a.m. of the facility's Survey Results folder located near the entrance of the facility.
Review of the Survey Results folder revealed the last survey posted in the binder was dated 04/18/2024. Further review revealed no documented evidence of the survey results from complaint survey dated 02/11/2025.
An interview was conducted on 03/17/2025 at 9:35 a.m. with S1ADM. He reviewed the facility's Survey Results folder. He confirmed the survey results from complaint survey dated 02/11/2025 were not located in the folder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#4 and #50) residents out of a total of 22 sampled residents. The facility failed to ensure:
1.
Resident #4 was coded correctly for functional abilities and goals; and
2.
Resident #50 was coded correctly for medications.
Findings:
Resident #4
Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE].
Review of Resident #4's Significant Change MDS with an ARD of 02/25/2025 revealed a BIMS of 14, which indicated she was cognitively intact. Further review revealed she was coded as being independent for toileting hygiene, showering/bathing, and putting on/taking off footwear in Section GG: Functional Abilities and Goals.
On 03/17/2025 at 11:10 a.m., an interview was conducted with Resident #4. Resident #4 stated she was independent with eating but was dependent for all other ADL care.
On 03/19/2025 at 1:37 p.m., an interview was conducted with S4LPN. S4LPN stated Resident #4 was not able to perform toileting hygiene, shower/bathe, nor put on/take off footwear independently.
On 03/19/2025 at 1:52 p.m., an interview was conducted with S3MDS. S3MDS stated she was responsible for completing Resident #4's MDS assessments. S3MDS reviewed Resident #4's Significant Change MDS with an ARD of 02/25/2025. S3MDS confirmed toileting hygiene, showering/bathing, and putting on/taking off footwear should have been coded as dependent and was not.
On 03/19/2025 at 2:55 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #4's Significant Change MDS with an ARD of 02/25/2025. She confirmed Resident #4 was not coded accurately for toileting hygiene, showering/bathing, and putting on/taking off footwear.
Resident #50
Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction.
Review of Resident #50's Quarterly MDS with an ARD of 02/05/2025 revealed he was coded as receiving antiplatelets and anticoagulants in Section N: Medications.
Review of Resident #50's Physician Orders dated January 2025-March 2025 revealed the following, in part:
Aspirin 81 mg orally one time a day.
Clopidogrel Bisulfate 75 mg orally one time a day.
On 03/19/2025 at 1:50 p.m., an interview was conducted with S3MDS. She stated she was responsible for completing Resident #50's MDS assessments. She reviewed Resident #50's Quarterly MDS assessment dated [DATE] and verified he was coded for anticoagulants. She reviewed Resident #50's physician orders and confirmed he had an order for Clopidogrel and Aspirin, which were antiplatelets, not anticoagulants. She stated Resident #50 should not have been coded for anticoagulants.
On 03/19/2025 at 2:55 p.m., an interview was conducted with S2DON. She reviewed Resident #50's physician orders dated January 2025-March 2025. She verified Aspirin and Clopidogrel were antiplatelet medications and confirmed Resident #50's Quarterly MDS assessment should not have been coded for anticoagulants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility to ensure nursing staff communicated a significant change in status to the residents' nurse practitioner for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for notification of change.
Findings:
Review of the facility's policy dated 02/2025 and titled, Notification of a Change in a Patient's Condition or Status revealed the following, in part:
Procedure: The Nurse will notify the patient's Attending Physician or On-Call Physician when there has been:
An accident or incident involving a patient
Resident #1
A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder.
A review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 13, which indicated Resident #1 was cognitively intact.
Resident #2
A review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder.
A review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/07/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #2 was cognitively intact.
A review of an Incident Report dated 01/18/2025 at 6:30 p.m. revealed following, in part:
S7CNA reported Resident #1 and Resident #2 were arguing in their room and Resident #2 hit Resident #1 with a reacher tool. S4LPN assessed the situation and the residents had no injuries. Resident #2 was moved to another room and was monitored.
A review of S7CNA's written statement revealed the following, in part:
On 01/18/2025, Resident #2 hit Resident #1 with a reacher tool, and Resident #1 punched Resident #2 in the face. S7CNA immediately reported the altercation to S4LPN.
An interview was conducted on 02/10/2025 at 2:15 p.m., with S7CNA. She stated she witnessed the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she separated the residents and notified S4LPN of the altercation immediately on 01/18/2025.
An interview was conducted on 2/10/2025 at 2:20 p.m., with S4LPN. She stated S7CNA notified her immediately of the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she did not notify the on-call nurse practitioner of the incident until 01/20/2025 when Resident #1 began to have swelling in his right hand. She stated she should have notified the on-call nurse practitioner of the incident on 01/18/2025.
An interview was conducted on 02/11/2025 at 2:00 p.m., with S9NP. She stated she was the on-call nurse practitioner for 01/18/2025. She reviewed her call logs for 01/18/2025 and confirmed she did not receive a notification of the altercation between Resident #1 and Resident #2 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents reviewed for physical abuse.
The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025.
Findings:
Review of the facility's policy dated 02/2025 and titled, Abuse, Neglect, and Exploitation revealed in part, the following:
Definitions:
Physical Abuse-includes, but is not limited to hitting, slapping, punching.
Prevention of Abuse-The facility will implement policies and procedures to prevent and prohibit all types of abuse.
Resident #1
Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia.
Review of Resident #1's MDS with an ARD of 11/06/2024 revealed a BIMS of 13, which indicated he was cognitively intact.
Resident #2
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cervical Disc Disorder.
Review of Resident #2's MDS with an ARD of 01/07/2025 revealed a BIMS of 15, which indicated he was cognitively intact.
Resident #3
Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit.
Review of Resident #3's MDS with an ARD of 11/13/2024 revealed a BIMS of 13, which indicated she was cognitively intact.
Resident #4
Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Dementia.
Review of Resident #4's MDS with an ARD of 10/09/2024 revealed a BIMS of 13, which indicated he was cognitively intact.
Review of the facility's Incident Log dated December 2024 through January 2025 revealed the following:
1. A physical aggression incident between Resident #1 and Resident #4 on 12/18/2024.
2. A physical aggression incident between Resident #2 and Resident #3 on 12/24/2024.
3. A physical aggression incident between Resident #1 and Resident #2 on 01/18/2025.
On 02/10/2025, review of the facility's incident report dated 12/18/2024, revealed in part, the following:
Incident Description: Resident #1 went to the nurses' station and stated, I f***ed him up. He stated he was referring to Resident #4. Staff immediately went into the residents' room and found Resident #4 with scratches to his left arm. Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. Resident #1 stated, Everyday he is just sleeping and I'm tired of it.
Immediate Action Taken: Staff assessed both residents and no injuries were noted. The residents were immediately separated and Resident #1 was placed in another room. 1:1 monitoring began on both residents. Monitoring was discontinued when Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024 when the NP, DON, and RP were notified. Resident #4 was treated in-house with antibiotic cream and had no complaints of pain or being fearful of Resident #1.
An interview was conducted on 02/10/2025 at 10:10 a.m., with S5LPN. She stated on 12/18/2024, around midnight, Resident #1 came to the nurses' station and stated, I f***ed him up. She stated Resident #1 stated he was referring to Resident #4. She stated she immediately went into the residents' room and found Resident #4 with scratches to his left arm. She stated Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. She stated Resident #1 stated, Everyday he is just sleeping and I'm tired of it. She stated she assessed both residents. She stated she immediately separated them, and placed Resident #1 in another room. She stated 1:1 monitoring began on both residents on 12/18/2024. She stated Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024 when the NP, DON, and RP were notified. She stated Resident #4 was treated in-house with antibiotic cream and had no complaints of pain or being fearful of Resident #1. She stated after Resident #1 returned to the facility, he had a new diagnosis, a medication was added to his orders, and his care plan was updated. She stated Resident #1 was also placed in a new room. 1:1 monitoring continued for days, and psychiatric staff began to assess him further. She stated all staff felt these changes were effective for Resident #1. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025.
An interview was conducted on 02/10/2025 at 10:30 a.m., with Resident #1. He stated in December 2024, he scratched Resident #4 on his arm several times because he would not stop sleeping all day. He stated Resident #4 then pinched him on his hand.
An interview was conducted on 02/10/2025 at 10:41 a.m., with Resident #4. He stated in December 2024, Resident #1 scratched him on his arm several times. He stated he pinched Resident #1 on his hand.
An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated on 12/18/2024 around midnight, Resident #1 came to the nurses' station and stated, I f***ed him up. He stated Resident #1 stated he was referring to Resident #4. He stated S5LPN immediately went into the residents' room and found Resident #4 with scratches to his left arm. He stated Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. He stated Resident #1 stated, Everyday he is just sleeping and I'm tired of it. He stated S5LPN assessed both residents. He stated S5LPN immediately separated the residents, and placed Resident #1 in another room. He stated 1:1 monitoring began on both residents. He stated Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024 when the NP, DON, and RP were notified. He stated Resident #4 was treated in-house with antibiotic cream and had no complaints of pain or being fearful of Resident #1. He stated after Resident #1 returned to the facility, he had a new diagnosis, a new medication was added to his orders, and his care plan was updated. Resident #1 was also placed in a new room, 1:1 monitoring continued for two days, and psychiatric staff began to assess him further. He stated all staff felt these changes were effective for Resident #1. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025.
On 02/10/2025, review of the facility's incident report dated 12/24/2024, revealed in part, the following:
Incident Description: S3LPN was notified by S6CNA that Resident #2 had slapped Resident #3 in the face.
Immediate Action Taken: Staff assessed both residents and no injuries were noted. The residents were immediately separated. S3LPN notified S8NP and S1ADM of the altercation. 1:1 monitoring began on both residents and was discontinued when Resident #2 was sent to a behavioral hospital on [DATE]. Resident #3 had no complaints of pain or being fearful of Resident #2.
An interview was conducted on 02/10/2025 at 10:37 a.m., with Resident #2. He stated in December 2024, he slapped Resident #3 on the forehead when he wanted to be assisted instead of her.
An interview was conducted on 02/10/2025 at 10:41 a.m., with Resident #3. She stated in December 2024, Resident #2 slapped her on the forehead when she received assistant and not him.
An interview was conducted on 02/10/2025 at 1:45 p.m., with S6CNA. She stated she witnessed the incident which occurred on 12/24/2024 between Resident #2 and Resident #3. She stated on 12/24/2024, Resident #2 slapped Resident #3 on the forehead because Resident #2 wanted the resident who was assisting Resident #3 to assist him instead. She stated she separated both residents and immediately reported the incident to S3LPN. She stated Resident #3 had no complaints of pain or being fearful of Resident #2. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025.
An interview was conducted on 02/10/2025 at 1:55 p.m., with S3LPN. He stated on 12/24/2024, S6CNA notified him of Resident #2 slapping Resident #3 on the forehead. He stated S6CNA immediately separated the residents. He stated he assessed both residents and no injuries were noted. He stated he reported the incident to S8NP and S1ADM who were located nearby. He stated both residents were placed on 1:1 monitoring on 12/24/2024, and monitoring was discontinued when Resident #2 was sent to a behavioral hospital on [DATE]. He stated Resident #3 had no complaints of pain or being fearful of Resident #2. He stated after Resident #2 returned to the facility, he had a new diagnosis, a medication was added to his orders, and his care plan was updated. He stated 1:1 monitoring continued for two days and psychiatric staff began to assess him further. He stated all staff felt these changes were effective for Resident #2. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025.
An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated on 12/24/2024, S3LPN notified him of Resident #2 slapping Resident #3 in the forehead. He stated S6CNA immediately separated the residents. He stated S3LPN assessed both residents and no injuries were noted. He stated both residents were placed on 1:1 monitoring on 12/24/2024, and monitoring was discontinued when Resident #2 was sent to a behavioral hospital on [DATE]. He stated Resident #3 had no complaints of pain or being fearful of Resident #2. He stated after Resident #2 returned to the facility, he had a new diagnosis, a medication was added to his orders, and his care plan was updated. He stated 1:1 monitoring continued for two days and psychiatric staff began to assess him further. He stated all staff felt these changes were effective for Resident #2. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025.
Review of S7CNA's written statement dated 01/18/2025 revealed in part, the following: Resident #2 hit Resident #1 with a reacher tool, and Resident #1 punched Resident #2 in the face. S7CNA immediately reported the altercation to S4LPN.
On 02/10/2025, review of the facility's incident report dated 01/18/2025 revealed in part, the following:
Incident Description: S7CNA reported Resident #1 and Resident #2, were arguing in their room, and Resident #2 hit Resident #1 with a reacher tool.
Immediate Action Taken: Staff assessed both residents and no injuries were noted. The residents were immediately separated. S7CNA notified S4LPN of the altercation. 1:1 monitoring began on both residents. On 01/20/2025, Resident #1 was noted to have swelling of his right hand. Resident #1 had a mobile x-ray completed, which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. Resident #1 was sent to a local hospital on [DATE]. Resident #2 had no complaints of pain or being fearful of Resident #1.
An interview was conducted on 02/10/2025 at 10:30 a.m., with Resident #1. He stated a few weeks ago, he punched Resident #2 on his face a few times. He stated Resident #2 poked him with his reacher tool. He stated he did not have any pain until two days later.
An interview was conducted on 02/10/2025 at 10:37 a.m., with Resident #2. He stated a few weeks ago, he poked Resident #1 with his reacher tool and Resident #1 punched him in the side of his face. He stated S7CNA witnessed this incident.
An interview was conducted on 02/10/2025 at 2:15 p.m., with S7CNA. She stated she witnessed the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she heard raised voices coming from Resident #1 and Resident #2's room. She stated when she entered the room, Resident #2 was standing at Resident #1's bedside poking him with his reacher tool. She stated Resident #1 then punched Resident #2 three times on the side of his face with a closed fist. She stated she separated them, and notified S4LPN of the altercation immediately on 01/18/2025. She stated her witness statement was completed on 01/18/2025 and placed in the shift report box. She stated both residents had no complaints of pain. She stated Resident #2 denied being fearful of Resident #1. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. She stated Resident #1 did not exhibit behaviors that would indicate physical altercations from the time of the 12/18/2024 until 01/18/2024. She stated Resident #2 did not exhibit behaviors that would indicate physical altercations from the time of the 12/24/2024 until 01/18/2024.
An interview was conducted on 2/10/2025 at 2:20 p.m., with S4LPN. She stated S7CNA notified her immediately of the incident on 01/18/2025. She stated S7CNA separated the residents. She stated she assessed both residents and no injuries were noted. She stated both residents were placed on 1:1 monitoring on 01/18/2025. She stated on 01/20/2025, Resident #1 was noted to have swelling of his right hand. She stated Resident #1 had a mobile x-ray completed which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. She stated Resident #1 was sent to a local hospital on [DATE]. She stated Resident #2 had no complaints of pain or being fearful of Resident #1. She stated after Resident #2 returned to the facility, 1:1 monitoring continued for two days and psychiatric staff began to assess him further. She stated both residents now attend a day program, attend 1:1 counseling with administrative staff, and both of the residents' care plans were updated. She stated all staff felt these changes were effective for Resident #2. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. She stated Resident #1 did not exhibit behaviors that would indicate physical altercations from the time of the 12/18/2024 until 01/18/2024. She stated Resident #2 did not exhibit behaviors that would indicate physical altercations from the time of the 12/24/2024 until 01/18/2024.
An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated on 01/20/2025, Resident #1 began to have swelling to his right hand. He stated he was then notified of Resident #1 punching Resident #2 in the face on 01/18/2025 and also received S7CNA's written statement dated 01/18/2025. He stated on 01/18/2025 after the incident, S7CNA immediately separated the residents. He stated S4LPN assessed both residents and no injuries were noted. He stated both residents were placed on 1:1 monitoring on 01/18/2025, until Resident #1 was sent to a local hospital on [DATE] after a mobile x-ray resulted as a 5th Metacarpal Neck Fracture of the Right Hand. He stated Resident #2 had no complaints of pain or being fearful of Resident #1. He stated after Resident #2 returned to the facility, 1:1 monitoring continued for two days and psychiatric staff began to assess him further. He stated both residents now attend a day program, attend 1:1 counseling with administrative staff, and both residents' care plans were updated. He stated all staff felt these changes were effective for Resident #2. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. He stated monitoring started on 01/20/2025 and will be ongoing weekly until 02/20/2025.
Throughout the survey from 02/10/2025 to 02/11/2025, observations, record review, and staff interviews revealed staff received training on the facility's abuse policies and procedures, de-escalating aggressive behaviors, and the effect of staff approach in relation to resident's behaviors. Interviews revealed staff were knowledgeable of the types of abuse and were aware abuse should be reported to administration immediately.
The facility had implemented the following actions to correct the deficient practice:
1. Corrective actions were accomplished on 01/20/2025 for residents found to be affected by the alleged deficient practice include:
a. Resident #2 was moved to another room. Monitoring tool in place for both residents.
b. Both residents were to behavioral hospital.
c. Both residents continue to be seen by psychiatric, attend the day program, and 1:1 counseling with administrative staff.
2. All residents have the potential to be affected by this alleged deficient practice.
3. The measures put into place to prevent this alleged deficient practice from re-occurring on 01/20/2025:
a. In-service all staff regarding policy and procedure for abuse prevention and prohibition.
b. Residents with a BIMS of 9-15 interviewed by staff to ensure that the resident has not felt abused and that each resident feels safe.
4. Facility will monitor its performance to ensure sustained compliance starting on 01/20/2025 weekly for 4 weeks, by the following:
a. Administrator and or designee will have a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition.
b. Administrator and or designee will follow-up in morning meeting for 4 weeks and as needed to ensure a resident has not voiced concerns of potential abuse.
c. Additional in-servicing and/or progressive disciplinary action will occur if further noncompliance is noted.
5. Corrective action will be completed by 01/21/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure allegations of physical abuse were reported to the facility's administrator and the state agency in an appropriate time frame for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for physical abuse. The facility failed to ensure:
1.
Staff immediately reported physical abuse to administration when Resident #1 and Resident #2 got into a physical altercation; and
2.
The administrator reported 3 separate incidents of physical abuse involving Resident #1 and #2; Resident #2 and #3; and Resident # 1 and #4 to the state survey agency.
This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025.
Findings:
Cross Reference F600
Review of the facility's policy dated 02/2025 and titled, Abuse, Neglect, and Exploitation revealed in part, the following:
Definitions:
Physical Abuse-includes, but is not limited to hitting, slapping, punching.
Reporting/Response:
1. Reporting of all alleged violations to the Administrator, state agency .within specified timeframes:
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.
Resident #1
Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia.
Resident #2
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cervical Disc Disorder.
Resident #3
Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit.
Resident #4
Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Dementia.
1.
Review of the facility's incident report dated 01/18/2025, revealed in part, the following:
Incident Description: S7CNA reported Resident #1 and Resident #2, were arguing in their room, and Resident #2 hit Resident #1 with a reacher tool at 6:30 p.m.
An interview was conducted on 02/10/2025 at 10:30 a.m., with Resident #1. He stated a few weeks ago, he punched Resident #2 on his face a few times with his right hand. He stated Resident #2 poked him with his reacher tool so he punched him. He stated he did not have any pain or swelling to the right hand after punching Resident #2 until two days later when he was diagnosed with a right finger fracture.
An interview was conducted on 02/10/2025 at 2:15 p.m., with S7CNA. She stated she witnessed the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she heard raised voices coming from Resident #1 and Resident #2's room. She stated when she entered the room, Resident #2 was standing at Resident #1's bedside poking him with his reacher tool. She stated Resident #1 then punched Resident #2 three times on the side of his face with a closed fist. She stated she notified S4LPN of the altercation immediately on 01/18/2025 around 6:30 p.m. She stated a resident punching another resident was a type of physical abuse and should be reported.
An interview was conducted on 02/10/2025 at 2:20 p.m., with S4LPN. She stated S7CNA notified her immediately of the incident on 01/18/2025 around 6:30 p.m. She stated she did not report the incident to anyone else until 01/20/2025, when Resident #1 was noted to have swelling of his right hand. She stated Resident #1 had a mobile x-ray on 01/20/2025 completed which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. She stated a resident punching another resident was physical abuse and should be reported. She stated she knew to report it, but she failed to do so on 01/18/2025.
An interview was conducted on 02/11/2025 at 2:02 p.m., with S9NP. She stated she was the on-call nurse practitioner for 01/18/2025. She reviewed her call logs for 01/18/2025 and confirmed she did not receive a notification of the altercation between Resident #1 and Resident #2 and should have.
An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated S4LPN should have reported the physical abuse between Resident #1 and Resident #2 to him on 01/18/2025 and did not until 01/20/2025. He stated all physical abuse should be reported to the DON and Administrator immediately and reported to the state agency within 2 hours.
2.
Review of the facility's incident report dated 12/24/2024, revealed in part, the following:
Incident Description: S3LPN was notified by S6CNA at 11:45 a.m. that Resident #2 had slapped Resident #3 in the face.
An interview was conducted on 02/10/2025 at 1:45 p.m., with S6CNA. She stated she witnessed the incident which occurred on 12/24/2024 at 11:45 a.m. between Resident #2 and Resident #3. She stated on 12/24/2024, Resident #2 slapped Resident #3. She stated she separated both residents and immediately reported the incident to S3LPN on 12/24/2024 at 11:45 a.m. She stated a resident slapping another resident was a type of physical abuse and should be reported.
An interview was conducted on 02/10/2025 at 1:55 p.m., with S3LPN. He stated on 12/24/2024, S6CNA notified him around 11:45 a.m. of Resident #2 slapping Resident #3 on the forehead. He stated he immediately reported the incident to S8NP and S1ADM on 12/24/2024. He stated a resident slapping another resident was a type of physical abuse and should be reported.
Review of the facility's incident report dated 12/18/2024, revealed in part, the following:
Incident Description: Resident #1 went to the nurses' station and stated, I f***ed him up. He stated he was referring to Resident #4. Staff immediately went into the residents' room and found Resident #4 with scratches to his left arm. Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. Resident #1 stated, Everyday he is just sleeping and I'm tired of it.
An interview was conducted on 02/10/2025 at 10:10 a.m., with S5LPN. She stated on 12/18/2024, around midnight, Resident #1 and Resident #4 got into an altercation. She stated she immediately separated them, and placed Resident #1 in another room. She stated 1:1 monitoring began on both residents. She stated Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024. She stated she notified the NP, DON, and RP of the incident on 12/19/2024 around 7:00 a.m. She stated a resident scratching another resident was a type of physical abuse and should be reported.
An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated in December 2024 through January 2025, S2CON was responsible for reporting to the state agency and he was the DON. He stated he became the Administrator later in January 2025 after the aforementioned incidents. He stated he was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. He confirmed the incidents were abuse, should have been reported, and were not.
An interview was conducted on 02/11/2025 at 2:00 p.m., with S2CON. She stated in December 2024 through January 2025, she was responsible for reporting to the state agency and was the Administrator during that time. She stated she was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. She stated these incidents were not physical abuse, and therefore she did not report them to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASARR.
Findings:
Review of the facility's policy dated 02/2025 and titled, Resident Assessment-Coordination with PASARR Program revealed in part, the following:
1.
All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State's Medicaid rules for screening.
1ai. Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.
Resident #1
A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder. Further review revealed additional medical diagnosis of Unspecified Psychosis (onset date of 12/19/2024).
Further review revealed Resident #1 was diagnosed with Unspecified Psychosis on 12/19/2024 and no review for a Level II evaluation and determination had been submitted after Resident #1 received this diagnosis.
Resident #2
A review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cervical Disc Disorder with Myelopathy. Further review revealed additional medical diagnosis of Bipolar Disorder (onset date of 01/02/2025).
Further review revealed Resident #2 was diagnosed with Bipolar Disorder on 01/02/2025 and no review for a Level II evaluation and determination had been submitted after Resident #2 received this diagnosis.
An interview was conducted on 02/11/2025 at 11:10 a.m., with S11SW. She stated she was responsible for filing PASARR Level I and II paperwork in resident records. She stated she was unsure who was responsible for completing resident assessment following a new psychiatric diagnosis, and who was responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services.
An interview was conducted on 02/11/2025 at 11:15 a.m., with S1ADM. He stated he was unsure of who was responsible for completing resident assessment following a new psychiatric diagnosis, and who was responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services. He stated S10PNP may have more information regarding roles/responsibilities pertaining to psychiatric services and PASARR. He reviewed both Resident #1 and Resident #2's diagnoses and confirmed that they acquired new psychiatric diagnoses since Level I approval, and a new Level I Pre-admission Screening and Resident Review was not completed and should have been.
An interview was conducted on 02/11/2025 at 11:38 a.m., with S10PNP. She stated she was responsible for assessing and treating residents with psychiatric diagnoses on a routine basis. She stated any evaluations, new diagnoses, treatment notes, and recommendations were reported via email to the Administrative staff. She further stated she was not responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure:
1. Residents with newly diagnosed mental illnesses were reevaluated for PASRR Level II determinations for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASRR; and
2. Allegations of physical abuse were reported to the state agency, immediately but not later than 2 hours after the allegation for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for abuse; and
3. Allegations of physical abuse were reported to the administrator immediately after the allegation for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for abuse.
The deficient practice had the potential to affect a census of 110 residents.
This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025.
Findings:
Cross Reference F609.
Cross Reference F644.
1.
Resident #1
A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder.
Further review revealed Resident #1 was diagnosed with Unspecified Psychosis on 12/19/2024 and no documentation a Level II evaluation and determination had been submitted after Resident #1 received this diagnosis.
Resident #2
A review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE].
Further review revealed Resident #2 was diagnosed with Bipolar Disorder on 01/02/2025 and no documentation a Level II evaluation and determination had been submitted after Resident #2 received this diagnosis.
An interview was conducted on 02/11/2025 at 11:10 a.m. with S11SW. She stated she was responsible for filing PASRR Level I and II paperwork in resident records upon admission to the facility. She stated she was unsure who was responsible for completing resident assessments following a new psychiatric diagnosis after admission, and who was responsible for submitting a new Resident Review to determine candidacy for Level II services.
An interview was conducted on 02/11/2025 at 11:15 a.m. with S1ADM. He stated he was unsure who was responsible for completing resident assessments following a new psychiatric diagnosis, and who was responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services. He reviewed both Resident #1 and Resident #2's diagnoses and confirmed they acquired new psychiatric diagnoses since Level I approval, and a new Level I Pre-admission Screening and Resident Review was not completed and should have been.
An interview was conducted on 02/11/2025 at 2:00 p.m. with S2CON. She stated she was unaware of who was responsible for ensuring residents received evaluations for PASRR determination of services after new psychiatric diagnoses.
2.
Resident #1
Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia.
Review of Resident #1's MDS with an ARD of 11/06/2024 revealed a BIMS of 13, which indicated he was cognitively intact.
Resident #4
Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Dementia.
Review of Resident #4's MDS with an ARD of 10/09/2024 revealed a BIMS of 13, which indicated he was cognitively intact.
Review of the facility's incident report dated 12/18/2024, revealed in part, the following:
Incident Description: Resident #1 went to the nurses' station and stated, I f***ed him up. He stated he was referring to Resident #4. Staff immediately went into the residents' room and found Resident #4 with scratches to his left arm. Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. Resident #1 stated, Everyday he is just sleeping and I'm tired of it.
Resident #3
Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit.
Review of Resident #3's MDS with an ARD of 11/13/2024 revealed a BIMS of 13, which indicated she was cognitively intact.
Review of the facility's Incident Log dated December 2024 through January 2025 revealed the following:
A physical aggression incident between Resident #2 and Resident #3 on 12/24/2024.
Review of the facility's incident report dated 12/24/2024, revealed in part, the following:
Incident Description: S3LPN was notified by S6CNA at 11:45 a.m. that Resident #2 had slapped Resident #3 in the face.
An interview was conducted on 02/10/2025 at 1:45 p.m. with S1ADM. He stated December 2024 through January 2025, S2CON was responsible for reporting to the state agency and he was the DON. He stated he was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. He confirmed the incidents were abuse, should have been reported to state agency, and were not.
An interview was conducted on 02/11/2025 at 2:00 p.m. with S2CON. She stated December 2024 through January 2025, she was responsible for reporting to the state agency and was the Administrator during that time. She stated she was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. She stated these incidents were not physical abuse, and therefore she did not report them to the state agency.
3.
Review of the facility's incident report dated 01/18/2025, revealed in part, the following:
Incident Description: S7CNA reported Resident #1 and Resident #2 were arguing in their room, and Resident #2 hit Resident #1 with a reacher tool at 6:30 p.m.
An interview was conducted on 02/10/2025 at 2:15 p.m. with S7CNA. She stated she witnessed Resident #1 punch Resident #2 on 01/18/2025. She stated she notified S4LPN of the altercation immediately on 01/18/2025 around 6:30 p.m.
An interview was conducted on 02/10/2025 at 2:20 p.m. with S4LPN. She stated S7CNA notified her immediately of the incident on 01/18/2025 around 6:30 p.m. She stated she did not report the incident to anyone else until 01/20/2025, when Resident #1 was noted to have swelling of his right hand. She stated Resident #1 had a mobile x-ray on 01/20/2025 completed which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. She stated a resident punching another resident was physical abuse and should be reported. She stated she knew to report it, but she failed to do so on 01/18/2025.
An interview was conducted on 02/10/2025 at 1:45 p.m. with S1ADM. He stated he was made aware on 01/20/2025 of the incident between Resident #1 and Resident #2 which occurred on 01/18/2025. He confirmed the incident was abuse, should have been reported on 01/18/2025, and was not.
An interview was conducted on 02/11/2025 at 2:00 p.m. with S2CON. She stated she was made aware on 01/20/2025 of the incident between Resident #1 and Resident #2 which occurred on 01/18/2025. She stated this incident was not physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the residents' status by failing to ensure a resident's Minimum Data Set was accurately coded for PASRR Level II (Pre-admission Screening and Resident Review) for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101) sampled residents reviewed for PASRR.
Findings:
Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizoaffective Disorder, Bipolar Type (05/06/2022).
Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed the following in Section A1500 PASRR:
Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition with an entry of 0 (No).
Section A1510A: Serious Mental Illness Level II PASRR conditions was blank.
Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following:
Evaluation Placement Recommendations:
The individual has a serious mental illness and is recommended nursing home admission.
An interview was conducted on 04/18/2024 at 5:16 p.m. with S4MDSC. She verified Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed he was issued a Level II PASRR and has a serious mental illness. She reviewed Resident #12's Yearly MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not.
An interview was conducted with S2DON on 04/18/2024 at 5:33 p.m. She reviewed Resident #12's Yearly MDS assessment dated [DATE]. S2DON confirmed Resident #12 was evaluated by Level II PASRR and was determined to have a serious mental illness. S2DON confirmed Section A1500 should have been coded as 1-Yes, and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to protect the resident's right to be free from verbal and mental abuse by a staff member for 1 (#116) of 22 residents reviewed in the final sample.
This deficient practice resulted in psychosocial harm on 04/18/2024 at 11:24 a.m. when surveyor observed S10CNA provide care to Resident #116, a [AGE] year old moderately cognitively impaired resident with a diagnosis of Guillain Barre Syndrome. Upon S10CNA entering the room, Resident #116 became visibly tense throughout her body, hands clenched into tight fist around the side rail, and her eyes filled with tears. S10CNA rushed through care then became argumentative with a rude, aggressive tone and tense body language after the resident requested to have her teeth brushed. This interaction left Resident #116 tearful and her body language tense. Resident #116 stated S10CNA made her feel worthless. Resident #116 reported S10CNA and other CNA staff spoke to her with harsh tones, exhibited negative attitudes and harsh body language towards her. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #116, it could be determined a reasonable person would have experienced psychosocial harm as a result of the staff's behaviors, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility.
Findings:
Resident #116
Review of Resident #116's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses; which included, in part, Guillain Barre Syndrome, Muscle Wasting and Atrophy, Generalized Muscle Weakness, Lack of Coordination, Cognitive Communication Deficit, Abnormalities of Gait and Mobility, and Neuralgia.
Review of Resident #116's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 10, which indicated the resident was moderately cognitively impaired. Further review revealed the resident required two person physical assist plus hoyer lift for transfers; and one to two person assist for repositioning and activities of daily living (ADLs).
An interview was conducted on 04/18/2024 at 8:30 a.m. with Resident #116. She stated S10CNA was rough when assisting her with care. She said when she asked her not to be so rough, she would be rude to her. Resident #116 was observed to become tearful during the interview as she stated some of the staff, specifically S10CNA made her feel like less of a person because she needed assistance. She stated on days when she could not help staff with her ADL care due to her condition, she would have to ask for more help and S10CNA would frequently respond with a negative attitude and tell her you know you can do that. Resident #116 stated S10CNA made her feel judged when she provided assistance to her because S10CNA thought she shouldn't need so much help at her age. She stated S10CNA made her feel like she was bothering her when she called for assistance or needed to be changed. She explained it was not what S10CNA said but the tone and body language in which she said it. She stated S10CNA's facial expressions and body language made her feel like S10CNA did not want to provide the assistance requested. She stated S10CNA would rush her and the care she needed in order to get out of her room as fast as possible. She said S10CNA would not meet all of her needs and when she would try to stop her for more help, she was met with a negative attitude or ignored all together. She stated she had never spoken with anyone in an administrative role at the facility or her family about the issues because she was fearful things would get worse if she told anyone.
An observation and interview was conducted on 04/18/2024 at 11:25 a.m. when Resident #116 was being transferred from the shower bed to her bed by S10CNA with the assistance of another staff member. When S10CNA entered the room, Resident #116 became visibly tense throughout her body, hands clenched into tight fist around the side rail, and her eyes filled with tears. Upon completion of the transfer and as S10CNA began walking out of the room, Resident #116 was observed asking S10CNA to assist her with brushing her teeth before she left. S10CNA stated in a very gruff, aggressive tone you already did that today and then quickly turned and began walking back towards the door to exit the room. Resident #116 stated No, they didn't get a chance to while I was in the shower so I still need to do it. S10CNA was observed arguing in a short, abrupt tone with Resident #116 about whether or not she needed to brush her teeth right now. S10CNA was observed turning to exit and looked at this surveyor standing in the corner then turned back to Resident #116, loudly exhaled and huffed then gruffly stated fine, let me go get what you need then quickly exited the room. S10CNA returned to the room visibly aggravated with a tense angry facial expression and tense body movements as she prepared to assist Resident #116 with brushing her teeth. S10CNA told the resident, with an aggressive tone of voice, go ahead and get this done real quick. After S10CNA exited the room, Resident #116 stated S10CNA made her feel worthless because of the way she spoke down to her and got an attitude when she asked for assistance. Resident #116 stated there were days when she was having a bad day and wasn't able to remember things so she would ask staff questions. She stated they would respond rudely and tell her she should know that information then refuse to tell her. She stated other times she couldn't move her legs or arms like usual and they would fuss at her telling her not to be lazy.
An interview was conducted on 04/18/2024 at 8:30 a.m. with Resident #116's roommate. She stated she had overheard interactions between Resident #116 and S10CNA. She stated S10CNA would get rude with Resident #116 when she asked for assistance. She stated S10CNA talked to Resident #116 like a dog, and explained she meant the tone and manner in which she talked to her, not specifically what she said to her. She stated the way S10CNA spoke to Resident #116 made it very clear she did not want to be doing what Resident #116 was asking from her.
Review of Resident #116's roommate's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact.
An interview was conducted on 04/18/2024 at 2:30 p.m. with S2DON. She confirmed she would expect all members of staff to speak to and handle a resident with the utmost respect. She stated it was unacceptable for staff to verbally communicate with or demonstrate body language that made a resident tearful and feel bad about themselves. Upon being provided with the observation made on 04/18/2024 at 11:25 a.m., she agreed Resident #116 was not treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life.
An interview was conducted on 04/18/2024 at 3:10 p.m. with S1ADM. She confirmed a resident should never be made to feel bad about themselves due to the way a staff member speaks to them or treats them during their interactions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a comprehensive person-centered plan of care by failing to follow Physician's Orders for 1 (#45) of 4 (#4, #43, ##66, #114) residents reviewed for nutrition. The facility failed to ensure Resident #45 received a House Supplement with Meals three times daily.
Findings:
Review of Resident #45's medical records revealed he was admitted to the facility on [DATE].
Review of the Quarterly MDS with an ARD of 10/27/2023 revealed Resident #45 had a BIMS of 15, which indicated he was cognitively intact.
Review of Resident #45's current physician orders revealed:
House Supplement with Meals; Three times daily.
On 04/18/2024 at 09:29 a.m., an interview was conducted with Resident #45. He stated his physician ordered a house supplement to be given with meals, three times a day. He stated he was not receiving his house supplement.
On 04/17/2024 at 12:36 p.m. an observation was made of Resident #45's lunch tray. His house supplement was not on his meal tray or his bedside.
On 04/18/2024 at 09:29 a.m., an observation was made of Resident #45's breakfast tray. His house supplement was not on his meal tray or his beside.
On 04/18/2024 09:43 a.m., an interview was conducted with S3DM. He stated he observed Resident #45's meal tray, and there was no house supplement on his tray or his bedside. He confirmed a house supplement was ordered and not provided to Resident #45.
On 04/18/2024 at 4:45 p.m. and interview was conducted with S2DON. She confirmed Resident #45 should receive his house supplement three times a day with meals, as ordered and he was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that appealing options of similar nutritive value were offered to residents who choose not to eat food that is initially served or who request a different meal choice for 1 (#45) of 32 sampled residents reviewed in the initial pool.
Findings:
Review of the Clinical Record revealed Resident #45 was admitted to the facility on [DATE].
Review of the Quarterly MDS with an ARD of 10/27/2023 revealed Resident #45 had a BIMS of 13, which indicated he was cognitively intact.
Review of the current Care Plan revealed Resident # 45 was care planned for the following problems:
Problems:
My current diet is regular.
Approaches:
Offer food alternatives when appropriate
On 04/17/2024 at 12:36 p.m., an interview was conducted with Resident #45. He stated his food was cold. He stated he asked kitchen staff for it to be heated or substituted. He stated the kitchen did not honor his request.
On 04/18/2024 at 9:29 a.m., an interview was conducted with Resident #45. He stated his food was cold. He stated he asked kitchen staff for substitutes or to reheat his tray. The kitchen did not honor his request.
On 04/18/2024 at 9:34 a.m., an interview was conducted with S8LPN. She stated she was aware of Resident #45 complaining about his food preferences and choices. She confirmed sometimes the food was cold and needing substitutes frequently. She stated sometimes Resident #45's request was missed by the kitchen staff.
On 04/18/2024 at 4:45 p.m., an interview was conducted with S2DON. She confirmed Resident #45 should have received alternative options, and should have had his meals reheated when requested and did not.
On 04/18/2024 9:43 a.m., an interview was conducted with S3DM. He stated Resident #45 complained about the food being cold and needing a substitute frequently. He stated sometimes Resident #45's request was missed by the kitchen staff. He confirmed Resident #45 should be provided a substitute or his meals heated on request.

Based on observations and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions by failing to maintain a clean kitchen environment. There were 109 facility residents residing in the facility who received food from the facility's kitchen.
Findings:
An initial tour was conducted of the facility's kitchen with S11KC on 04/16/2024 beginning at 8:56 a.m. There was a slug moving on the floor under the mixer on the electrical cord of the mixer. There were three slugs actively moving on the floor behind the plate warmer between the tile and the wall. There was food debris on the floor throughout the kitchen. There was accumulated food debris under the oven, stove, plate warmer, steam table, and dishwasher. There were four french fries on the floor between the steam table and plate warmer. An interview was conducted with S11KC during the observations. S11KC confirmed the observation of the slugs. S11KC stated the french fries were from supper the night before. She stated the kitchen floor should have been cleaned nightly.
A tour was conducted of the facility's kitchen with S3DM on 04/16/2024 at 9:16 a.m. S3DM confirmed there was food debris on the floor throughout the kitchen and under the kitchen appliances. S3DM stated it was evident the floor had not been cleaned nightly, especially under the kitchen appliances. S3DM stated the kitchen floor should have been cleaned nightly.
An interview was conducted with S1Adm on 04/17/2024 at 10:48 a.m. She stated the kitchen should have been maintained in a sanitary manner and the kitchen staff were responsible for cleaning the floor, which included under appliances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure:
1. Recommendations from PASRR Level II Determinations and PASRR Evaluation Reports were incorporated into a resident's assessment, care plan and transitions of care for 3 (#12, #24, #63) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR; and
2. The coding accuracy for Minimum Data Set assessments regarding PASRR Level II for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR.
The deficient practice had the potential to affect a census of 110 residents.
Cross Reference F641.
Cross Reference F644.
Findings:
1.
Resident #12
Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Disorder and Bipolar Type (05/06/2022).
Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following:
Recommended Lesser Services:
Training in Activities of Daily Living;
Training in Independent Living Skills; and
Crisis Intervention Plan/Safety Plan.
Recommended Specialized Services:
Outpatient Therapy (Individual); and
Outpatient Therapy (Group).
Review of Resident #12's Clinical Record revealed no documented evidence the facility created or implemented any of the following: Training in Activities of or Outpatient Therapy (Individual), Outpatient Therapy (Group).
Review of Resident #12's current Care Plan revealed no documented care plan for any of the following services: in Activities of Daily Living, Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, Outpatient Therapy (Individual), or Outpatient Therapy (Group).
Resident #24
Review of Resident #24's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Affective Disorder, Other Symptoms and Signs with Cognitive Functions and Awareness.
Review of Resident #24's OBH-PASRR Level II Summary and Determination Notice, dated 09/07/2023, revealed, in part, the following:
Recommended Lesser Services:
Training in Independent Living Skills; and
Crisis Intervention Plan/Safety Plan.
Recommended Specialized Services:
Outpatient Therapy (Individual).
Review of Resident #24's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
Review of Resident #24's current Care Plan revealed no documented care plan present for any of the following services; Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
Resident #63
Review of Resident #63's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Major Depressive Disorder (11/07/2019), Major Depressive Disorder Severe with Psychotic Symptoms (11/15/2019), and Paranoid Schizophrenia (03/16/2022).
Review of Resident #63's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated resident was cognitively intact.
Review of Resident #63's OBH-PASRR Level II Summary and Determination Notice, dated 11/29/2023, effective 12/08/2023 through 12/06/2024, revealed, in part, the following:
Recommended Lesser Services:
Training in Independent Living Skills; and
Crisis Intervention Plan/Safety Plan.
Recommended Specialized Services:
Outpatient Therapy (Individual).
Review of Resident #63's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
Review of Resident #63's current Care Plan revealed no documented care plan present any of the following services: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
An interview was conducted on 04/17/2024 at 12:20 p.m. with S1ADM. She stated she was not in charge of handling resident PASRRs, her social workers were. She stated once a resident was granted Level II PASRR, the facility was only required to give them medications and have them seen by the Behavioral Health Specialist. She reviewed Resident #12, #24 and #63's PASRR II Determinations and stated she had no idea what the services indicated as necessary were, so there was no way the facility could have implemented them. She stated she would speak with her social workers and see if they knew what any of the OBH identified interventions meant but she did not think they would because the facility had never done anything like this with a Level II.
An interview was conducted on 04/17/2024 at 9:50 a.m. with S5SSD. She stated the social workers were not responsible for handling and processing PASSR documents for the facility. She stated S1ADM handled everything to do with those. She stated she knew some PASRRs were kept in S1ADM's office, some were kept in the business office and some were located in some old binders she found in her office from the previous social worker. She stated the Form 142's were kept separate from the determinations and were located in S1ADM's office. She stated did not know which ones were kept where or why; she just knew they were in several locations throughout the facility. She stated she just located a more recent PASRR response with a level upgrade for one of the residents in the business office then found the same resident's Form 142 in S1ADM's office. She stated them being so difficult to locate was probably why the most up to date documents were not provided by S1ADM upon initial request. She confirmed S1ADM handled the PASSR documents and processed them once received, not the social workers.
2.
Resident #12
Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizoaffective Disorder, Bipolar Type (05/06/2022).
Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed the following in Section A1500 PASRR:
Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition with an entry of 0 (No).
Section A1510A: Serious Mental Illness Level II PASRR conditions was blank.
Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following:
Evaluation Placement Recommendations:
The individual has a serious mental illness and is recommended nursing home admission.
An interview was conducted on 04/18/2024 at 3:47 p.m. with S13MDSC. She confirmed she did not handle PASRRs and did not know who did. She stated she could not MDS code for a Level II PASRR if she was not provided with the documentation to know she should do so and confirmed she was not provided with the documentation for Resident #12, #24 and #63 or many other residents in the facility.
An interview was conducted on 04/18/2024 at 4:20 p.m. with S2DON. She confirmed she did not handle PASRR and did not know who did. She confirmed she would expect a system to be in place to ensure all residents received services and were MDS coded correctly for their diagnoses and PASRR status.
An interview was conducted on 04/18/2024 at 4:45 p.m. with S1ADM. She confirmed there could not be a system in place to ensure all residents received services and were MDS coded correctly for their diagnoses and PASRR status because she was not aware the facility was responsible for providing anything more than administering medications and having them seen by the Behavioral Health Specialist once a resident was granted a Level II PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#39) of 32 residents reviewed for advanced directives in the initial screening process.
Findings:
Review of Resident #39's Clinical Record revealed he was admitted to the facility on [DATE]. Further review of the quarterly MDS assessment with an ARD date of 01/31/2024 revealed he had a BIM's of 14, which indicated he was cognitively intact.
Review of Resident #39's Electronic Health Record Physician's Orders revealed the following:
Order date: 11/20/2020 - Code Status: Full Code
Review of Resident #39's Hard Chart revealed an Advanced Directive Form with DNR checked and signed by Resident #39, which indicated he did not want to be resuscitated if found with no pulse or respirations. A signed physician order dated, 04/30/2021, for Resident #39 confirmed a DNR code status.
On 04/16/2024 at 1:58 p.m., an interview was conducted with Resident #39. He stated in the event of an emergency he wished to remain a DNR code status.
On 04/16/2024 at 2:00 p.m., an interview was conducted with S6LPN. She stated in the event of an emergency she would refer to the hard chart to determine a resident's code status. She confirmed Resident #39's hard chart revealed he had a DNR code status and would not be coded in the event of an emergency. She confirmed Resident #39's electronic health record physicians order reflected he was a full code status. She stated all residents' hard chart and electronic health record should match to accurately reflect the resident end of life wishes and did not.
On 04/16/2024 at 2:05 p.m., an interview was conducted with S7LPN. She stated in the event of an emergency she would refer to the hard chart to determine a resident's code status. She stated all residents' hard chart and electronic health record should match to accurately reflect the resident end of life wishes.
On 04/16/2024 at 2:12 p.m., an interview was conducted with S2DON. She stated in the event of an emergency she would expect her nursing staff to refer to the hard chart to determine a resident's code status. She confirmed Resident #39's hard chart indicated DNR code status and the electronic health record reflected he was a full code status. She confirmed all residents' hard chart and electronic health record should match to accurately reflect the resident's end of life wishes and did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing catheter care for 1 (#12) of 3 (#12, #52 and #102) sampled residents reviewed for catheter care.
Findings:
Review of the facility's policy revised 03/2024, titled, Enhanced Barrier Precautions revealed, in part:
Policy:
It is the policy of this facility to implement enhanced barrier precautions (EBPs) for the prevention of transmission of multidrug-resistant organism.
Definitions:
-EBPs refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities.
Policy Explanation and Compliance Guidelines:
a. An order for enhanced barrier precautions will be obtained for residents with any of the following:
ii. indwelling medical devices (e.g., .urinary catheters .) .
3. Implementation of EBPs:
b. PPE for EBPs is only necessary when performing high-contact care activities .
-High-contact resident care activities include:
-Device Care or use: ( .Urinary catheters .)
Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Neuromuscular Dysfunction of Bladder and Paraplegia.
Review of Resident #12's current Physician Orders revealed an order for Enhanced Barrier Precautions (EBPs) with a start date of 01/16/2023.
On 04/17/2024 at 2:52 p.m., an observation was made of S9CNA providing catheter care for Resident #12. S9CNA was observed to clean Resident #12's catheter without wearing a gown.
On 04/17/2024 at 4:00 p.m., an interview was conducted with S9CNA. She stated Resident #12 was on EBPs. She confirmed she did not wear a gown during catheter care.
On 04/18/2024 at 5:33 p.m., an interview was conducted with S2DON. She stated Resident #12 had a suprapubic catheter and was on EBPs for direct contact care of the resident. She stated nursing staff should wear gloves and a gown when providing catheter care for Resident #12.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into resident's assessment, care planning and transitions of care for 3 (#12, #24 and #63) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101 ) reviewed for PASRR.
Findings:
Resident #12
Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Disorder and Bipolar Type (05/06/2022).
Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following:
Recommended Lesser Services:
Training in Activities of Daily Living;
Training in Independent Living Skills; and
Crisis Intervention Plan/Safety Plan.
Recommended Specialized Services:
Outpatient Therapy (Individual); and
Outpatient Therapy (Group).
Review of Resident #12's Clinical Record revealed no documented evidence the facility created or implemented any of the following: Training in Activities of or Outpatient Therapy (Individual), Outpatient Therapy (Group).
Review of Resident #12's current Care Plan revealed no documented care plan for any of the following services: in Activities of Daily Living, Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, Outpatient Therapy (Individual), or Outpatient Therapy (Group).
An interview was conducted on 04/18/2024 at 1:00 p.m. with S12LPN. He stated the only psychiatric services Resident #12 received is provided was a Psychology Nurse Practitioner visit once a month.
An interview was conducted on 04/18/2024 at 11:04 a.m., with S1ADM. She stated she did not have documentation of PASRR level II recommendations offered for Resident #12.
An interview was conducted on 04/18/2024 at 11:07 a.m. with S2DON. She stated she did not have documentation of PASRR level II recommendations offered for Resident # 12. She stated Resident #12's BHSF Form 142 document could not be provided.
An interview was conducted on 04/18/2024 at 11:08 a.m. with S5SSD. She stated she did not have documentation of PASRR level II recommendations offered for Resident #12.
Resident #24
Review of Resident #24's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Affective Disorder, Other Symptoms and Signs with Cognitive Functions and Awareness.
Review of Resident #24's OBH-PASRR Level II Summary and Determination Notice, dated 09/07/2023, revealed, in part, the following:
Recommended Lesser Services:
Training in Independent Living Skills; and
Crisis Intervention Plan/Safety Plan.
Recommended Specialized Services:
Outpatient Therapy (Individual).
Review of Resident #24's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
Review of Resident #24's current Care Plan revealed no documented care plan present for any of the following services; Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
Resident #63
Review of Resident #63's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Major Depressive Disorder (11/07/2019), Major Depressive Disorder Severe with Psychotic Symptoms (11/15/2019), and Paranoid Schizophrenia (03/16/2022).
Review of Resident #63's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated resident was cognitively intact.
Review of Resident #63's OBH-PASRR Level II Summary and Determination Notice, dated 11/29/2023, effective 12/08/2023 through 12/06/2024, revealed, in part, the following:
Recommended Lesser Services:
Training in Independent Living Skills; and
Crisis Intervention Plan/Safety Plan.
Recommended Specialized Services:
Outpatient Therapy (Individual).
Review of Resident #63's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
Review of Resident #63's current Care Plan revealed no documented care plan present any of the following services: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual).
An interview was conducted on 04/17/2024 at 9:45 a.m. with Resident #63. She stated she did not wish to stay at this facility and planned to go live in a group home or out in the community.
An interview was conducted on 04/17/2024 at 10:40 a.m. with S6LPN. She confirmed she was Resident #63's nurse and was very familiar with the services and care she received. She confirmed she had multiple psychiatric diagnoses and desired to eventually go live somewhere outside of a nursing home. She confirmed the resident did not leave the facility to participate in any outpatient therapy services and had never done so since she was her patient. She confirmed she was not aware of and had not received resident specific training for a Crisis Intervention Plan or a Safety Plan for Resident #63. She confirmed she never witnessed or assisted with providing Resident #63 any training in independent living skills.
An interview was conducted on 04/17/2024 at 1:30 p.m. with S1ADM. She confirmed the facility did not provide the services indicated in the individual PASRR Level II Determination Letters for Resident #12, #24 and #63 or any of the Level II residents currently in the facility; including a Crisis Intervention Plan/Safety Plan. She stated she thought the facility was only required to handle medication management and ensure the mental health specialist saw the Level II PASRR residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure the oxygen tubing and humidification bottles were changed in a timely manner for 2 (#80 and #99) of 3 (#50, #80, and #99) residents reviewed for oxygen therapy.
Findings:
Review of the facility's Policy titled, Equipment Cleaning and Change Out revealed the following, in part:
Policy: The following procedures have been developed emphasizing the importance of proper handling and processing of equipment to assure proper sterilization/clean equipment standards are followed to reduce possible nosocomial infections.
Procedure:
H. Nasal Cannulas .
1. Change on a designated day of the week and PRN.
Resident #80
Review of the Clinical Record for Resident #80 revealed she was admitted to the facility on [DATE] and had diagnoses which included Congestive Heart Failure.
Review of the current Physician Orders for Resident #80 revealed the following, in part:
Start date: 11/05/2020 Oxygen at 2 Liters via nasal cannula continuously
Review of Resident #80's MDS with an ARD of 05/02/2023 revealed, in part, she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she received oxygen therapy.
An observation was made of Resident #80 on 05/08/2023 at 9:00 a.m. She had oxygen in place via nasal cannula. Her oxygen tubing and humidification bottle were dated 04/30/2023.
An interview was conducted with Resident #80 on 05/08/2023 at 9:02 a.m. She stated she wore her oxygen via nasal cannula at all times.
An observation was made of Resident #80 on 05/09/2023 at 1:14 p.m. She had oxygen in place via nasal cannula. Her oxygen tubing and humidification bottle were dated 04/30/2023.
Resident #99
Review of the Clinical Record for Resident #99 revealed she was admitted to the facility on [DATE] and had diagnoses which included Centrilobular Emphysema, Chronic Diastolic Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease.
Review of the Physician Orders for Resident #99 dated May 2023 revealed the following, in part:
Start Date: 07/05/2023, Discontinue Date: 05/09/2023 Oxygen at 3 Liters via Nasal Cannula Continuously
Start Date: 05/09/2023 Oxygen at 2 Liters as needed
Review of Resident #99's MDS with an ARD of 02/14/2023 revealed, in part, she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she received oxygen therapy.
Review of the current Care Plan for Resident #99 revealed the following, in part:
Problem: I require oxygen therapy
Intervention: Change my tubing per protocol
An observation was made of Resident #99 on 05/08/2023 at 7:43 a.m. Resident #99's oxygen tubing and humidification bottle were dated 04/01/2023.
An interview was conducted with Resident #99 on 05/08/2023 at 9:22 a.m. She stated she utilized her oxygen via nasal cannula every night.
An observation was made of Resident #99 on 05/09/2023 at 11:14 a.m. Resident #99's oxygen tubing and humidification bottle were dated 04/01/2023.
An interview was conducted with S5LPN on 05/09/2023 at 11:24 a.m. She stated Resident #99 utilized her oxygen via nasal cannula every night. She stated the RN weekend supervisor should have changed oxygen tubing and humidification bottle weekly.
An observation was made of Resident #99's oxygen tubing and humidification bottle with S2DON on 05/09/2023 at 12:51 p.m. S2DON confirmed Resident #99's oxygen tubing and humidification bottle were dated 04/01/2023.
An interview was conducted with S2DON on 05/09/2023 at 12:53 p.m. He stated oxygen tubing and humidification bottles should have been changed weekly by the weekend RN Supervisor.

Based on interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure a Water Management Program was implemented to prevent the spread and growth of Legionella's and/or opportunistic waterborne pathogens. This had the potential to affect all of the 110 residents residing in the facility.
Findings:
A review of the facility's policy titled Legionella Surveillance and Water-Borne Pathogen Management Plan revealed the following:
It was the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections and developed the waterborne pathogen plan to ensure preparedness and appropriate action will be taken in the event of a confirmed or suspected case of hospital associated illness due to waterborne pathogens including Legionella within the facility.
1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems.
On 05/11/2023 at 9:50 a.m., an interview was conducted with S2DON. S2DON stated he was unaware if the facility monitored the water system for Legionella. S2DON stated he was unsure who was responsible for monitoring the water system for Legionella infection.
On 05/11/2023 at 10:00 a.m., an interview was conducted with S6MS. S6MS stated he had no knowledge of Legionella testing in the facility. S6MS confirmed the facility did not have a water management program at this time.
On 05/11/2023 at 11:00 a.m., an interview was conducted with S1ADM. She confirmed the facility's water was not monitored or tested for Legionella at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure reportable incidents were reported to the State Survey Agency as required. The facility failed to ensure:
1. An allegation of sexual abuse was reported within 2 hours after the allegation was made for 1 (#52) of 4 (#7, #30, #52 and #89) residents reviewed for abuse.
2. An incident of physical abuse was reported to the State Survey Agency for 1 (#7) of 4 (#7, #30, #52 and #89) residents reviewed for abuse.
Findings:
Review of the facility's policy titled, Abuse, Neglect, and Exploitation revealed the following, in part:
Policy: It is the policy of the facility to provide protections of the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.
Definition:
Sexual Abuse is non-consensual sexual contact of any type with a resident.
Physical Abuse includes, but is not limited to hitting, slapping, punching .
VII. Reporting/Response
A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified time frames:
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or
b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
1.
Review of the Clinical Record for Resident #52 revealed she was admitted to the facility on [DATE] and had diagnoses which included Multiple Sclerosis, Anxiety Disorder, and Functional Quadriplegic.
Review of the MDS with an ARD of 03/22/2023 for Resident #52 revealed, in part, she had a BIMS of 14, which indicated she was cognitively intact.
Review of the Nurses' Note for Resident #52 dated 04/21/2023 at 5:51 a.m. entered by S4LPN revealed the following, in part:
Resident #52 reported to the nurse during medication administration that she was pushed into her room by a resident, and he rubbed on her leg while she was in the wheelchair and touched her breast. Resident #52 reported the event on 04/20/2023 at 8:45 p.m.
Review of the Incident Investigation for Resident #52 dated 04/20/2023 at 8:20 p.m. revealed the following, in part:
Incident Type: Resident Contact
Report prepared by: S4LPN
Narrative of Incident and description of injuries: Resident #52 reported to nurse during medication administration that she was pushed into her room by a resident and he rubbed on her leg while in the wheelchair and touched her breast.
Review of the Incident Report submitted to the State Survey Agency for Resident #52 revealed the following, in part:
Occurred: 04/20/2023 at 9:35 p.m.
Discovered: 04/20/2023 at 9:39 p.m.
Entered: 04/21/2023 at 3:01 p.m.
Victim: Resident #52
Accused: Resident #89
Accused allegation: Sexual Abuse
An interview was conducted with S4LPN on 05/09/2023 at 2:05 p.m. She stated on 04/20/2023, Resident #52 reported to her the man that pushed her wheelchair into her room, rubbed on her leg and touched her breast. She confirmed the allegation made by Resident #52 was sexual abuse.
An interview was conducted with S3ADON on 05/09/2023 at 3:09 p.m. She stated on 04/20/2023, S4LPN notified her Resident #52 reported Resident #89 touched her inappropriately. She confirmed the allegation was sexual abuse. She stated she reported the allegation to S1ADM immediately.
An interview was conducted with S1ADM on 05/09/2023 at 3:17 p.m. She stated S3ADON notified her on the night of 04/20/2023 of the incident between Resident #52 and Resident #89. She confirmed the allegation was sexual abuse. She confirmed she did not report the incident to the State Survey Agency within 2 hours of the allegation.
2.
Review of Resident #7's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses which included Parkinson's Disease, Other Schizophrenia, Cognitive Communication Deficit, and Vascular Dementia, Unspecified Severity, with Behavioral Disturbance.
Review of Resident #7's Quarterly MDS with an ARD of 04/04/2023 revealed the resident had a BIMS of 3 which indicated severe cognitive impairment.
Review of the Nurses' Note for Resident #7 dated 02/06/2023 at 8:36 a.m. entered by S7LPN revealed the following, in part:
Summoned to television room by staff stating resident had been struck in the face by another resident.
Review of the Incident Investigation for Resident #7 dated 02/06/2023 at 8:36 a.m. revealed the following, in part:
Incident Type: Resident Contact
Report prepared by: S7LPN
Narrative of Incident and description of injuries: Reported to this nurse that resident was struck in the face by Resident #30.
An interview was conducted with S8CNA on 05/11/2023 at 10:38 a.m. S8CNA stated she witnessed Resident #30 walk up to Resident #7 while sitting in his gerichair and slapped him in the face. S8CNA stated Resident #30 hitting Resident #7 was abuse.
An interview was conducted with S1ADM on 05/11/2023 at 12:50 p.m. S1ADM confirmed she was aware of the incident between Resident #7 and Resident #30. S1ADM stated Resident #30 slapped Resident #7 on the face. S1ADM confirmed this was resident to resident abuse and was not reported to the State Survey Agency.