Indianola Rehabilitation And Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent a resident who was identified as having exit-seeking behaviors from leaving the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed for wandering/elopement risk (Resident #1).On 12/30/25 around 7:30 PM Resident #1 was able to gain access to an unlocked door and exited the building and was in the courtyard area, unattended and unsupervised for an undetermined amount of time. The temperature was 34 degrees at the time between 8:00 PM and 9:00 PM when staff revealed the resident was found and brought back inside the building.The elopement placed Resident #1, as well as other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death.The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 12/8/25 when Resident #1 began exhibiting exit seeking behaviors. The State Agency (SA) notified the facility's Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 1/12/26 at 4:30 PM and provided the IJ template to the Administrator.Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) existed at 42 CFR S483.25(d)(1)(2), Free of Accident Hazards/Supervision/Devices (F689), Scope and Severity J.The facility submitted an acceptable Removal Plan on 1/14/26, alleging all corrective actions to remove the IJ were completed on 1/13/26. The SA validated the Removal Plan on 1/14/26 and determined the IJ was removed on 1/14/26, prior to exit. Therefore, the scope and severity for F689 was lowered from J to D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include:Review of the facility policy titled Wander Management, Monitoring System & Resident Elopement Protocol, last revised 7/1/25, revealed the stated purpose was to monitor the safety of residents at risk for elopement and provide a system to alert staff that a resident may be attempting to leave the facility. The policy further stated all staff are responsible for ensuring resident safety and providing adequate supervision to maintain the safest environment possible.Record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses including personal history of unspecified dementia, muscle wasting and atrophy, protein calorie malnutrition, multisystem inflammatory syndrome, and osteoarthritis. Record review of the Brief Interview for Mental Status (BIMS) dated 11/12/25 revealed a score of 3, indicating Resident #1 was severely cognitively impaired.Record review of the Wander Data Collection dated 6/24/25 revealed Resident #1 was identified as high risk for wandering. Review of the Wander Data Collection dated 11/7/25 revealed the resident was identified as low risk for wandering. Review of the Wander Data Collection dated 12/31/25 revealed the resident was again identified as high risk for wandering.Record review of the Medication Administration Record (MAR) for October 2025 revealed a physician order for a wander bracelet related to dementia and exit-seeking behaviors, initiated on 6/24/25 and discontinued on 10/28/25.Record review of a Social Services Progress Note dated 12/8/25 at 10:04 AM revealed Resident #1 was agitated, sitting in the lobby doorway, yelling that he wanted to go home, tapping on the door, and required redirection by nursing staff.An interview with the Social Worker on 1/12/26 at 11:54 AM confirmed she authored the note and confirmed the resident exhibited exit-seeking behaviors. She stated additional interventions such as increased monitoring and a wandering assessment should have been implemented after the 12/08/25 incident but confirmed that increased monitoring and supervision was not put in place. She stated that on the night that the resident left the building and was outside on 12/30/25 could have been really bad and the resident could have frozen to death if not discovered.Record review of the Plan of Care (POC) Response History revealed that on 12/30/25 at 11:18 AM staff documented behavioral symptoms of wandering, marked that the resident had exhibited these behaviors previously, and documented the nurse was notified.An observation of Resident # 1 on 1/12/26 at 10:20 AM revealed resident was alert, sitting in his wheelchair propelling around the room. Resident #1 was asked if he had gone outside at night when it had been cold and he stated that he did one time can't remember when, but he wanted to meet his girlfriend. He stated he went around the yard and tried to come back in, but the door was locked. He stated he sat outside for a long time before someone opened the door. He stated he was shaking when he came back in, he was so cold.An observation of the courtyard and the exit door on 1/12/26 at 10:30 AM with the Administrator, revealed the door was secure, a code was required to open it, did not release after holding the handle down, and the entire courtyard is fenced and locked and there is a sidewalk path located in the middle of the courtyard. An interview with the Administrator on 1/12/26 at 11:30 AM revealed she was notified a little after 9:00 PM on 12/30/25 that Resident #1 had exited through the courtyard door. She instructed staff to apply a wander guard and initiate one-on-one supervision. She stated the Maintenance Director was contacted due to concerns the door's fire safety feature did not function properly and confirmed that sustained pressure on the door handle would cause the door to be released. An interview with the Director of Nursing (DON) on 1/12/26 at 11:56 AM revealed Registered Nurse (RN) #1 notified her that Resident #1 had exited the building and was returned inside. She stated she instructed staff to initiate one-on-one supervision and apply a wander guard. She confirmed she completed the incident report on 12/31/25 and did not come to the facility the night of the incident to begin an investigation.An interview with the Maintenance Director on 1/12/26 at 12:08 PM revealed he was contacted on 12/30/25 at approximately 9:13 PM and arrived at the facility at 9:53 PM. He stated sustained pressure on the door handle caused the door to release without activating the alarm. He stated he adjusted the magnet and the door functioned properly thereafter.A phone interview with Certified Nursing Assistant (CNA) #3 on 1/12/26 at 12:12 PM revealed that on 12/30/25 he was walking down the hall, happened to look out the courtyard door, and observed someone sitting outside. He stated it was unknown at the time if the individual was a resident. He immediately obtained another CNA, who identified the individual as Resident #1. They immediately brought the resident back inside. CNA #3 stated the resident was wearing a hat, shoes, and a flannel jacket, and was shivering, rubbing his hands together, and his hands appeared white or pale. He stated he did not hear any alarms sounding and confirmed it was dark outside, but the patio and courtyard lights were on.A phone interview with CNA #5 on 1/12/26 at 1:12 PM revealed she responded as staff were bringing Resident #1 back inside the building and she observed that holding the door handle down caused the door to release and open and the door did not alarm.An interview with CNA #2 on 1/12/26 at 3:10 PM revealed she was notified that Resident #1 was outside and confirmed the resident was shivering and stated that he was cold. She confirmed that she did not hear an alarm and believed the resident already had a wander guard due to his frequent exit-seeking behaviors.An interview with CNA #1 on 1/12/26 at 3:18 PM revealed she was assigned to Resident #1 on the night of 12/30/25. She stated she took residents out to the smokers' courtyard at approximately 6:20 PM and the door functioned normally, requiring a code to open the door and exit into the courtyard. She stated she returned a little after 7:00 PM and Resident #1 was still watching television in the lobby. She confirmed that she later began charting and completing rounds and, at nearly 9:00 PM, went to get Resident #1 for bed and observed the staff bringing him back inside the building around 9:00 PM. She stated the resident was shivering, rubbing his hands, and stated he was going home. She confirmed that she notified the nurse immediately and maintained one-on-one supervision from 11:00 PM to 7:00 AM.An interview with CNA #6 on 1/12/26 at 3:30 PM revealed she did not hear an alarm sounding. She stated she had been in the breakroom near the courtyard exit until approximately 8:30 PM and did not observe or hear anything unusual. She confirmed the resident exit-seeks daily.An interview with Licensed Practical Nurse (LPN) #1 on 1/13/26 at 12:00 PM revealed she was assigned to Resident #1 on 12/30/25 from 7:00 AM to 3:00 PM. She confirmed the resident was always exit-seeking and required frequent redirection. She stated she assumed the resident had a wander guard in place and confirmed the resident used a wheelchair for mobility.An interview with CNA #4 on 1/13/26 at 12:13 PM revealed she was assigned to Resident #1 on 12/30/25 on the day shift and confirmed the resident exhibited daily exit-seeking behaviors, including going room to room and pushing on doors. She stated she documented the behaviors and could not recall whether additional interventions were implemented.Record review of the Incident Report dated 12/30/25 at 09:00 (PM) revealed documentation that Resident #1 exited the facility through the smokers' courtyard door. The report documented that the resident was assisted back into the facility, checked for injury, placed on one-on-one supervision, a wander guard was applied, and maintenance was contacted to check and reset the door. The report was completed by the Director of Nursing (DON). Record review of the Maintenance Director's timesheet, door audits, and maintenance request log revealed no prior documented concerns related to the courtyard door.Record review of the Vital Sign Record revealed Resident #1's vital signs, including body temperature, were not obtained until 12/31/25 at 10:50 AM.Record review of local weather data revealed temperatures ranged from 32 to 34 degrees Fahrenheit between 8:00 PM and 9:00 PM on 12/30/25.Immediate Jeopardy (IJ) Removal PlanOn 1/12/2026 at 4:20 PM, the State Agency (SA) notified the Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the IJ templates. Facility respectfully submits this removal plan.Brief Summary of Events:On 12/30/2025 at 7:28 PM, Resident #1 exited the door leading to the facility courtyard. Resident #1 has a Brief Interview for Mental Status of 3. Resident #1 was seen by staff sitting on the patio area of the courtyard and brought back into the facility.Corrective Actions:On 12/30/2025 at 8:03 PM, Resident #1 was seen by the Certified Nursing Assistant (CNA) #3 sitting unattended in a chair on the patio of the facility located in the courtyard. He was knocking on the door trying to access the entrance back to the facility. CNA# 1 took him immediately to his room and alerted the charge nurse.On 12/30/2025 at 9:05 PM, Registered Nurse (RN) notified Director of Nursing (DON) that Resident #1 had exited the building and was found in the courtyard by CNA #3.On 12/30/2025 at 9:07 PM, DON notified the Administrator that Resident #1 exited the facility to the courtyard. DON told the Administrator that Resident #1 was back in the building. The Administrator instructed DON to have him 1:1 monitored the remainder of the night and to call the Maintenance Director to come and check the door. The administrator instructed DON that a head count of all residents needed to be done immediately.On 12/30/2025 at 9:11 PM, DON notified Maintenance to come back to facility and check the door.On 12/31/2025 at 8:15 A M, Resident #1 was assessed by nursing to no ill effects.On 12/30/2025 at 9:19 PM, DON spoke with CNA# 1. DON told CNA# 1 to stay with Resident #1 1:1 for the remainder of the night.On 12/30/2025 at 9:53 PM, Maintenance arrived in the building and found that door would open if handle was compressed longer than 10 seconds. Maintenance then adjusted bolt in door to disable the feature so that door would not open. All doors and windows checked.On 12/30/2025 at 10:13 PM, Maintenance called DON to notify her that the door had been corrected and would no longer open without code and room checks had been done and all residents were accounted for.On 12/31/2025 at 9:57 AM, Resident #1 was assessed as a wandering risk and a signaling device was placed on the right wrist of Resident #1 for monitoring. On 12/31/2025 at 10:30 AM, Social Services updated the Residents at Risk for Elopement in the Elopement Binder. Elopement Drills started 1/12/25 at 5:30 PM.On 1/12/2026 at 9:56 PM, the Administrator reported this incident to the Mississippi State Department of Health and Licensure.On 1/12/2026 at 10:00 PM, the Mississippi Attorney General's Office was notified of the incident.On 1/12/2026 at 5:30 PM, an Ad-Hoc Quality Assurance Performance Improvement (QAPI) was held to discuss this incident and findings from the State Surveyor.On 1/12/2026 at 11:00 PM, DON conducted an audit of Residents at Risk for Elopement to review wander risk care plans of those residents identified as at risk for wandering.On 1/12/2026 at 6:30 PM, in-services on Elopement, Resident's Rights, Proper Door Functioning, Abuse/Neglect/Reporting, and Notifying Staff of Observed Behaviors began for all staff. No staff will be allowed to work until Inservice has been completed.On 1/13/2026 at 10:30 AM, a revised Ad-Hoc QAPI was held to discuss this incident and findings from the State Surveyor.On 1/13/2026 at 8:30 AM, review of audit findings of Residents at Risk for Elopement was done with Administrator, DON, and ADON.Ombudsman was notified on 1/13/2026 at 12:10 PM.The facility alleges all corrective actions were completed on 1/13/26 and the IJ removed on 1/14/26.Validation:The State Agency (SA) validation of the Removal Plan was made on-site during the investigation through observations, record review and interviews on 1/14/26. The SA determined all corrective actions were completed on 1/13/26 and the IJ was removed on 1/14/26.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to ensure that a resident's call light was within reach, which limited the ability to request assistance as needed for two (2) of three (3) survey days. Resident #14
Findings include:
Review of the facility policy titled Answering the Call Light with a revision date of September 2022 revealed 5. Ensure that the call light is accessible to the residents .
An observation and interview with Resident #14 on 4/22/25 at 11:00 AM, revealed the resident sitting on the side of her bed. Her call light cord was hanging from the wall by the foot of her bed and laying on the floor. The call light was not in reach. Resident #14 revealed, I can't reach it, they don't put it up here where I can. It's always hanging down there.
An observation on 4/22/25 at 12:05 PM, and again at 3:09 PM, revealed the call light remains hanging from the wall, inaccessible to the resident
An observation and interview on 4/23/25 at 8:25 AM, revealed the call light hanging from the wall, inaccessible to the resident. Resident #14 revealed the call light has been there all night, stating I guess they think I don't need my call button where I can reach it.
During an interview and observation on 4/23/25 at 10:25 AM, Certified Nurse Aide (CNA) #2 confirmed Resident #14's call light was on the floor and inaccessible. She revealed the call light should have been placed on her bed where she could reach it. She stated, we are always supposed to make sure each resident's call light is where they can reach it.
In an interview on 4/23/25 at 10:30 AM, the Assistant Director of Nurses (ADON) confirmed that staff are expected to ensure call lights are always within residents' reach so they can request assistance. This is important for residents' safety and care.
During an interview on 4/24/25 at 8:40 AM, the Administrator confirmed that all residents are supposed to always have a call light accessible to them.
A review of Resident #14's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that include Osteoarthritis, Anxiety Disorder, and Convulsions.
Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1-21-2025 revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to promptly resolve resident grievances related to food quality and temperature for five (5) of nine (9) residents attending the Resident Council meeting. Residents #11, #14, #21, #25, and #46
Findings Include:
Review of the facility policy titled Filing Grievances/Complaints, revised 6/2024 revealed under, Policy Statement: Our facility will assist residents, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such request are made .
An interview with Resident #21 (Resident Council president) on 4/22/25 at 10:55 AM revealed they (the residents) have been discussing concerns with the food quality and temperature (cold food) in the previous monthly meetings.
During a Resident Council meeting held on 4/22/25 at 2:45 PM, Resident #11, #14, #21, #25, and #46 all agreed the main concern from the previous council meetings was the food and continued to be an ongoing problem. The residents verbalized the food was not good, and Resident #14 stated, It's garbage. Resident #11 stated, We may have one good meal once or twice a week. She explained that the vegetables were always mushy and overcooked. All the residents said they had discussed the food concerns in the Resident Council and also in the monthly food committee meeting. They verbalized that nothing gets done about it. Resident #14 revealed the dietary manager asked her about the food, and she told her, It's terrible. Residents #11 and #25 revealed they would like more variety of foods and explained the facility serves the same thing over and over. Resident #11 explained that they get too many carbohydrates in a day and sometimes get mashed potatoes and french fries at the same meal. She revealed the french fries were always served cold. She stated, The cold foods are not cold, and the hot foods are not hot. Furthermore, she revealed they were served tea with no ice and stated, I just try to eat enough to live. The residents verbalized they would like more tacos and stated they had discussed this with dietary, but this had not been implemented. Resident #46 revealed he used to get a sandwich for supper, and he liked that, but the facility cut that out. Resident #21 (Resident Council president) stated, The Easter Sunday meal was good, but we only have one Easter a year. He explained that all the other meals were poured out of a can. He stated, These people can't cook. They all agreed they would like to have more fresh fruit and vegetables. Resident #21 revealed that he had suggested having a CNA (certified nurse aide) that floated on the hall to help deliver trays faster. He explained that he believed the food was getting cold because staff got delayed in the rooms.
Record review of the Resident Council Minutes dated 1/07/25, 2/03/25, 3/03/25, and 4/07/25 revealed there was no documentation regarding resident food complaints.
An interview with the Activities Director (AD) on 4/23/25 at 8:10 AM revealed the residents had told her in previous Resident Council meetings the food was not good, and they were not satisfied. She revealed that she went and got the dietary manager to come and talk to the residents. She explained that she did not write anything up on the food complaints and allowed the dietary manager to write up the residents' concerns in her notebook. The AD revealed she was not aware of what the dietary department had done about the complaints.
Record review of the Food Committee Meeting Minutes dated 12/27/24 revealed under, How can we improve your dining experience? Change the menus to something interesting was indicated. Documentation lacked details identifying which residents made complaints or what actions were taken to address the concern.
Record review of the Food Committee Meeting Minutes dated 2/28/25 revealed under, What would you like to see instead? Less mashed potatoes, more diced potatoes were indicated. Documentation lacked details identifying which residents made complaints or what actions were taken to address the concern.
Record review of the Food Committee Meeting Minutes dated 3/28/25 revealed under, What would you like to see instead? Fresh fruits and vegetables were documented. Also revealed under, Are foods served at the proper temperature? No was indicated with additional comments, Resident asked could the facility purchase a heating cart. There was a lack of documentation to identify the residents that made complaints or what actions were taken to resolve the issues that were discussed.
An interview with the Administrator (ADM) on 4/23/25 at 12:15 PM revealed she was aware of some food concerns. She explained the residents wanted more of a variety of potatoes, so the kitchen has been changing up and doing roasted potatoes, au gratin potatoes, and others. She revealed that at one time the residents were complaining about the vegetables being too soft. The ADM explained that she went to the kitchen and found that staff were cooking the vegetables around 9 to 10 in the morning and then placed them on the steam table until they were served. She revealed they had tried multiple things to fix Resident #21's food concerns and tried to focus on what he liked. The ADM stated, I understand they all like different things. She confirmed she was aware of the complaints regarding cold food from time to time.
An interview with the Dietary Manager (DM) on 4/23/25 at 1:10 PM, revealed she goes to the monthly Resident Council meetings, and she has been writing down the resident food concerns. She explained that she documented the residents' concerns in a notebook and confirmed a grievance was not completed. She revealed they (the staff) did not have any documentation to prove the residents' food concerns were addressed or what action they took to correct and resolve their issues.
An interview with the Regional Dietary Manager (RDM) on 4/23/25 at 2:30 PM revealed she knew the residents had complained about cold food in a previous Resident Council meeting. She revealed she was unsure why the food complaints were not written up as a grievance. She acknowledged they (staff) did not have a paper trail to track what was done to resolve the residents' complaints regarding food.
An interview with the Administrator (ADM) on 4/24/25 at 8:44 AM confirmed that grievances should have been completed on the residents' food concerns so that all the staff were aware of the concerns and could work toward getting the concerns resolved.
Record review of the admission Record revealed the facility admitted Resident #11 on 10/03/24.
Record review of the Brief Interview for Mental Status (BIMS) dated 4/17/25 revealed a summary score of 15, which indicated Resident #11 was cognitively intact.
Record review of the admission Record revealed the facility admitted Resident #14 on 7/03/20.
Record review of the BIMS dated 4/23/25 revealed a summary score of 15, which indicated Resident #14 was cognitively intact.
Record review of the admission Record revealed the facility admitted Resident #21 on 6/08/15.
Record review of the BIMS dated 2/27/25 revealed a summary score of 15, which indicated Resident #21 was cognitively intact.
Record review of the admission Record revealed the facility admitted Resident #25 on 7/14/24.
Record review of the BIMS dated 1/31/25 revealed a summary score of 15, which indicated Resident #25 was cognitively intact.
Record review of the admission Record revealed the facility admitted Resident #46 on 5/03/21.
Record review of the BIMS dated 1/06/25 revealed a summary score of 15, which indicated Resident #46 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to provide a clean, home-like environment for one (1) of 68 resident rooms observed. Room A-21-W.
Findings included:
Record review of the facility policy, titled Cleaning and Disinfection of Resident-Care Items and Equipment reviewed 3/19/25 revealed Policy Statement, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations .
An observation on 4/22/25 at 10:50 AM, revealed that an oxygen concentrator was in use by the resident in room A-21-W. Three (3) dime-sized, light brown dried substances were visible on top of the concentrator, along with a two(2)-inch streak of a similar light brown substance down the front.
During an interview with Housekeeper #1 on 4/22/25 at 1:01 PM, she stated that housekeepers do not clean any medical equipment currently in use by residents, as they are concerned about interfering with the device's settings. She further explained that the Nursing Department is responsible for cleaning the oxygen concentrator.
In an observation of the oxygen concentrator in Room A-21-W and an interview with Registered Nurse (RN) #1 on 4/22/25 at 1:10 PM, she verified that the concentrator was soiled with formula from the resident's tube feeding. She stated that the concentrator should have been cleaned by nursing staff to prevent attracting pests, such as ants.
In an interview with the Director of Nursing on 4/23/25 at 11:15 AM, she stated that it was her expectation that nursing staff would clean the oxygen concentrator if it became soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #62
Record review of Resident #62's Care Plan Report revealed, I require staff assist with ADL self-care performance deficit related to right side hemiparesis, with contracture to right arm, impaired mobility. Goal: I will be neat, clean, and odor-free each shift. Under Interventions, Bathing/Showering: Bath daily. Total dependent x (times)1 staff with bathing. Personal Hygiene . Total dependent x 1-2 staff with hygiene/grooming.
An observation on 4/22/25 at 11:04 AM, and again at 3:21 PM, revealed Resident #62 with unkempt, slick-appearing hair. Her fingernails were approximately one-half (1/2) inch long, jagged, and with a brown substance underneath them.
An observation on 4/23/25 at 8:31 AM, revealed Resident #62 lying in bed, no change in her personal hygiene status.
During an interview and observation on 4/23/25 at 10:30 AM, the Assistant Director of Nurses (ADON) revealed that the nurses are responsible for trimming the residents' fingernails. She stated, I would say they are done once a month and as needed, but nothing is set in stone as to when it is to be completed. The ADON confirmed Resident #62's fingernails were long, jagged, and had a brown substance underneath them, and needed to be cleaned and trimmed. She revealed that the resident's hair looked greasy and needed to be washed and revealed that we expect each resident to be kept clean and presentable.
During an interview on 4/23/25 at 10:40 AM, the DON confirmed that while nurses are responsible for trimming fingernails, the Certified Nurse Aides (CNA's) are expected to clean under the fingernails and notify nursing staff when trimming is needed. She acknowledged that all aspects of personal hygiene for Resident #62 should have been done, and if it was not, then her care plan was not followed.
During an interview on 4/23/25 at 2:30 PM, the MDS Coordinator revealed she is responsible for developing the care plans for the residents, and they are individualized to address each resident's needs. She revealed Resident #62's ADL care plan addressed personal hygiene, which staff know includes her nail care and hair washing. She confirmed that if the resident was found to not be properly groomed and cared for, then her ADL care plan was not being followed, and it should have been.
A record review of Resident #62's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Hemiplegia, Hemiparesis, and Dementia.
Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a person-centered care plan for providing personal hygiene for two (2) of 30 sampled residents care plans reviewed. Resident #23 and Resident #62.
Findings Include:
Review of the facility policy titled Care Plans, Comprehensive Person-Centered, with a review date January 2023, revealed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .
Resident #23
Record review of the Care Plan Report for Resident #23 revealed: I require staff assist with Activities of Daily Living (ADL) self-care performance deficit r/t (related/to) Dementia with confusion/impaired mobility and cognition, contractures to extremities, last revised 3/14/25. Interventions listed included: Personal Hygiene .Nail care as needed.
An observation on 4/22/25 at 10:45 AM, revealed Resident #23's fingernails were long, approximately one-half (1/2) inch in length, with a brown substance under every nail bed.
An interview with the Minimum Data Set (MDS) Nurse, on 4/23/25 at 10:45 AM, confirmed that Resident #23's ADL care plan had not been implemented in relation to personal hygiene. She stated the purpose of the comprehensive care plan is to direct staff on the resident-specific care needed.
An interview with the Director of Nursing (DON) on 4/24/25 at 8:34 AM, confirmed that staff did not follow Resident #23's the ADL care plan.
Record review of the admission Record revealed the facility admitted Resident #23 on 2/09/22 with medical diagnoses that included Dementia and Contracture, unspecified joint.
Record review of Resident #23's MDS with an Assessment Reference Date (ARD) of 3/06/25 revealed Section GG-Functional Abilities coded Dependent for Personal Hygiene.
Record review of Task: GG - Personal Hygiene form for Resident #23 from 4/10/25 through 4/22/25 revealed no documentation of refusals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Resident #62
On 4/22/25 at 11:04 AM and again at 3:21 PM, observations revealed Resident #62 with unkempt hair that had a wet appearance. Her fingernails were long and jagged, reaching approximately one-half (1/2) inch past the fingertips with a brown substance underneath.
An observation on 4/23/25 at 8:31 AM revealed Resident #62 lying in bed with no change in appearance.
During an interview and observation on 4/23/25 at 10:15 AM, CNA #2 revealed that she was responsible for giving Resident #62 her bed bath, which was supposed to include washing her hair and cleaning underneath her fingernails. She stated, I took a towel and went over the resident's hair this morning, but I did not wash her hair, and I tried to clean underneath her fingernails. She confirmed the resident had a brown substance under her fingernails and revealed that her hair was dirty, and she should have washed it.
During an interview and observation on 4/23/25 at 10:30 AM, the Assistant Director of Nurses (ADON) confirmed Resident #62's fingernails needed to be cleaned and trimmed and her hair looked greasy and needed washing. She stated that it was her expectation that each resident would be kept clean and presentable.
During an interview on 4/23/25 at 10:40 AM, the DON confirmed that all aspects of personal hygiene for Resident #62 should have been done. She revealed it is both the nurses and the CNA's responsibility.
A record review of Resident #62's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Hemiplegia, Hemiparesis, and Dementia.
A record review of the MDS Section GG- Functional Abilities with an ARD of [DATE], revealed the resident is Dependent for Personal Hygiene.
Based on observation, staff interview, record review, and facility policy review, the facility failed to provide personal hygiene for two (2) of 30 sampled residents. Resident #23 and Resident #62.
Findings Include:
Review of the facility policy titled Activities of Daily Living (ADL), Supporting with a revision date of March 2018, revealed: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene .
Resident #23
An observation on 4/22/25 at 10:45 AM revealed Resident #23's fingernails were approximately one-half (1/2) inch in length past the fingertip and each nail had a brown substance underneath.
An observation on 4/23/25 at 10:37 AM revealed no change in Resident #23's fingernails.
Record review of the Minimum Data Set (MDS) for Resident #23, with an Assessment Reference Date (ARD) of March 6, 2025, revealed Section GG-Functional Abilities coded Dependent for Personal Hygiene.
An interview with Licensed Practical Nurse (LPN) #1, on 4/23/25 at 10:38 AM, confirmed that Resident #23's fingernails were too long and nasty. She stated it appeared they had not been trimmed or cleaned in a while and confirmed they needed to be. She revealed that improper nail care could lead to a break in the skin that could increase the risk of infection.
An interview with the MDS Nurse on 4/23/25 at 10:45 AM, revealed, after reviewing the last 30 days of the Progress Notes for Resident #23, no documentation was found regarding nail care or refusals.
Record review of the Progress Notes for Resident #23 revealed no documentation of refusals for personal hygiene care or nail care from dates 3/22/25 through 4/22/25.
An interview with Certified Nursing Assistant (CNA) #1 on 4/24/25 at 8:30 AM, regarding Resident #23's fingernail care, revealed: He does not refuse any type of ADL care.
An interview with the Director of Nursing (DON) on 4/24/25 at 8:34 AM revealed that the facility's expectation is for nursing staff is to keep Resident #23's fingernails trimmed and cleaned.
Record review of the admission Record revealed the facility admitted Resident #23 on 2/09/22 with medical diagnoses that included Dementia and Contracture, unspecified joint.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication cart was kept locked and attended for one (1) of three (3) survey days.
Findings Include:
Review of the facility policy titled Storage of Medications unrevised, revealed under, Policy Statement: The facility stores all drugs and biologics in a safe, secure, and orderly manner. Additionally revealed, 9. Unlocked medications carts are not left unattended.
On 4/22/25 at 10:11 AM and again at 1:20 PM, an unlocked medication cart was observed parked in front of the A Hall nurses' station with no staff nearby or in sight.
An interview with Registered Nurse (RN) #1 on 4/22/25 at 1:28 PM, confirmed she left the medication cart unlocked and unattended. She revealed the cart should never be left unlocked and explained that a resident could get medication out and overdose. She acknowledged the facility had one wanderer on the hall that could get into the cart and take something.
An interview with the Administrator (ADM) on 4/22/25 at 2:38 PM confirmed the medications carts must be locked anytime a nurse stepped away. She acknowledged the risk and revealed that anybody that wanted to take something from the cart could and stated, There is a large potential there for an incident to occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and facility policy and procedure review, the facility neglected to provide an environment free from abuse/neglect for Resident #1. Certified Nursing Assistant (CNA) #1 did not report to anyone that Resident #1 hit his head during resident care. This resulted in a serious right eye injury with fractures to his orbital bones which remained untreated and unassessed by the facility staff for several hours after the injuries to Resident #1 were discovered for one (1) of 27 residents reviewed for abuse and neglect. Resident #1
Findings include:
Record review of the facility policy and procedure titled Abuse Prohibition Policy, reviewed 5/17/24 revealed . Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress . Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions .
On 7/30/24 at 11:30 AM, an interview with the Administrator (ADM) and the Director of Nurses (DON) revealed the local police had gone to the emergency room (ER) and completed their police report and talked to the resident at the ER. The Attorney General (AG) had been to the facility on Monday. The ADM stated that the local police had come to the facility to follow up on the situation on 7/29/24 and indicated to her they felt Resident #1 had been hit by someone at the facility. The ADM stated that the incident occurred on 7/27/24 2024, during the 7:00 AM - 3:00 PM shift. The ADM stated she obtained a statement from CNA #1, and he denied hitting the resident. CNA #1 stated that Resident #1 hit his head on the bedside table. The ADM stated the DON was contacted by Licensed Practical Nurse (LPN) #1 that Resident #1's eye was swollen shut and the area around his eye was black prior to leaving for dialysis on 7/24/24 at approximately 11:00 AM. Resident #1 initially told LPN #1 on 7/29/24 at 11:00 AM, that he and CNA #1 were boxing, and he got the black eye. The ADM stated CNA #1 did not report the incident of Resident #1 hitting his head on the bedside table to anyone. The ADM stated the DON was contacted on Saturaday, 7/27/24 at approximately 11:15 AM via telephone but did not come to the facility to investigate the incident on 7/27/24 so there was no incident report or documentation assessing the injuries of Resident #1 for that day.
Interview on 7/30/24 at 2:18 PM, with LPN #2 revealed that she was the 3:00 PM - 11:00 PM nurse supervisor for the second shift on 7/27/24. She stated she did not receive a report form the first shift nursing supervisor of any incidents that occurred with Resident #1. LPN #2 stated that at approximately 3:15 PM, LPN #1 told her that something happened between CNA #1 and Resident #1 and that Resident #1 had received a black eye. LPN #1 told LPN #2 that the DON had been contacted and that Resident #1 was going to be sent to the local ER for evaluation after dialysis. LPN #2 stated that at approximately 4:00 PM, Resident #1 returned from dialysis and this was the first time that she had seen Resident #1. His right eye was swollen shut and was dark purple and black with large bruises and a small amount of blood noted to the nose. LPN #2 asked Resident #1 what had happened, and he said, we had a little tussle, Resident #1 did not tell LPN #2 who the CNA was or call the CNA by name. Resident #1 was transported to the local ER by the facility van driver at approximately 4:30 PM. LPN #2 stated that at approximately 8:30 PM on 7/27/24 the facility van driver returned to the facility alone because Resident #1 had been sent via ambulance from the local ER to a hospital in another city for overnight observation and further testing.
Interview on 7/30/24 at 3:32 PM, with RN #3 from the local ER revealed that on 7/27/24 at approximately 5:00 PM, she saw Resident #1 in the ER where she was working as the ER nurse. She stated that Resident #1 arrived at the ER alone with a female facility van driver. Resident #1 was noted to have a large swollen dark bruised black eye with blood on his shirt and blood drops on his pants, and both nostrils of his nose contained blood. She stated that Resident #1 told her that he had gotten punched in the eye but did not want to talk about it. RN #3 stated that she immediately called the facility DON, and she stated that an investigation was underway to try to determine what had happened. RN #3 stated that she also called the local Police Department, Adult Protective Services, and the State Agency. RN #3 stated that approximately 1 hour after he was seen in the ER his two (2) daughters came to the ER but Resident #1 only stated that he got punched and did not want to talk about it anymore. The local Police Department came to the local ER and talked to Resident #1 at approximately 8:00 PM. Resident #1 was transferred for overnight observation and further testing via ambulance to an out-of-town hospital. RN #3 reported that the local ER had received a call earlier in the day around lunchtime (approximately 12:15 PM) from the on-call Nurse Practitioner (NP) who reported to the ER that she had received a call from the facility DON after Resident #1 had been sent out to dialysis. The DON reported to Nurse Practitioner (NP) that Resident #1 had obtained a black eye and bloody nose sometime during patient care the morning of 7/27/24 at around 8:00 AM. The NP stated that Resident #1 was sent out to dialysis before she was notified at 12:15 PM. The NP instructed the facility staff to bring Resident #1 to the local ER as soon as he returned from dialysis. Resident #1 completed dialysis and arrived at the local ER at approximately 5:00 PM.
Interview on 7/30/24 at 3:49 PM, with the Attorney General (AG) Investigator revealed that he was in the process of obtaining a copy of the local Police report. He stated that the local ER had contacted the local Police to come to the ER and complete a Police report. The AG stated that as soon as he received the Police Report and gathered more information, he would make his conclusions as to what had occurred. The AG stated that CNA #1 had denied he hit Resident #1.
Interview on 7/30/24 at 3:57 PM, with LPN #1 revealed she was the facility unit nurse on 7/27/24 for the 7:00 AM - 3:00 PM shift. LPN #1 stated that CNA #2 told her that Resident #1 was cutting up and resisting care. LPN #1 went to Resident #1's room to see what was going on and CNA #1 was giving Resident #1 a bath. CNA #1 told LPN #1 everything was fine and that he had things under control. LPN #1 did not see the Resident's face at that time. At approximately 9:00 AM, LPN #1 saw Resident #1 walking down the hall with his walker. LPN #1 stated He appeared fine. I thought I saw a small blister under his right eye, but he did not have any swelling or bruising at that time. At approximately 10:30 - 10:45 AM, LPN #1 passed by the lobby and saw Resident #1 sitting in a chair waiting for dialysis to come pick him up and at that time his right eye was swollen shut and he had dark purple and black bruising around his right eye with some small amount of blood noted to his nose. LPN #1 asked him what had happened, and he said, we were wrestling, I got hit when we were wrestling. He never called any names as to who had hit him. LPN #1 immediately called the DON, and she told LPN #1 to get a statement from CNA #1 and to get CNA #1 out of the building on suspension until an investigation could be completed. LPN #1 stated that she should have written a nursing note and put information in the medical record of Resident #1 immediately after the incident was reported to her, but she honestly thought that RN Supervisor #1 had completed the paperwork.
Interview on 7/30/24 at 4:00 PM, with the daughter of Resident #1 revealed that she had been called by LPN #1 on 7/27/24 at approximately 12:00 PM after her dad had been sent to dialysis. LPN #1 told her that her dad had been injured during care that morning and had received a black eye. Resident #1 told the family that he was horsing around and wrestling with a friend. The daughter stated that after dialysis the facility transported Resident #1 to the local ER. Resident #1 had fractures to his orbital bones around his right eye and bruises on his arm and a bloody nose. The daughter stated that Resident #1 had blood on his clothes at dialysis and at the ER. Resident #1 was transported via ambulance to another out-of-town hospital for further evaluation.
Interview, on 7/30/24 at 4:20 PM, with CNA #1 revealed that on 7/27/24 at approximately 8:00 AM, CNA #1 discovered that Resident #1 needed to be cleaned up. CNA #1 attempted to deliver care and Resident #1 resisted and was cussing and swinging his arms about. Resident #1's bedside table was to the left of his bed and the window was to the right of his bed. CNA #1 stated Resident #1 was telling him to go on and leave him alone and that he did not want CNA #1 cleaning him up. Resident #1 was swinging his arms about, and CNA #1 told Resident #1 I am not here to hurt you, and I am here to help you. CNA #1 stated that he did not ask another staff to assist him with Resident #1. He stated that he thought he could handle the situation all by himself. He stated that he had left the door to Resident #1's room open. CNA #1 stated that he had been in-serviced and trained to leave the room when a resident was resisting care and get another staff to come in with him after the resident had calmed down, but he did not do that because Resident #1 calmed down on his own. CNA #1 stated Resident #1 did hit his head on the bedside table where CNA #1 had his basin of bath water sitting, but he stated that he was not hurt and that he was okay. CNA #1 stated that because Resident #1 was not hurt, he continued to deliver care. CNA #1 stated that he did not report to anyone that Resident #1 had hit his head until he gave a written statement to LPN #1 several hours later when Resident #1 was discovered to have a black eye. CNA #1 stated that he did not hit Resident #1 and that he loved his residents and would never hurt anyone. CNA #1 stated that he assumed that Resident #1 had either hit himself in the eye or that he hit his head on the bedside table.
Interview on 7/30/24 at 6:15 PM, with the facility van driver revealed that she was called about noon on 7/27/24, by the DON and asked to come to the facility after dialysis and pick up Resident #1 and take him to the local ER for evaluation and x-rays. The van driver waited with Resident #1 at the ER until the local ER stated they were sending Resident #1 to an out-of-town hospital. The facility van driver stated that Resident #1 had a swollen, bruised right eye and his nose started bleeding at the ER. The facility van driver stated that she did not ask Resident #1 about the incident.
Observation and interview on 7/30/24 at 6:30 PM, with Resident #1 revealed that he was sitting alone in a chair in the lobby at the front of the facility. Resident #1 had a large swollen shut black right eye with some thick, white substance noted to the corners of the eye and along the eyelash area. Resident #1 stated that he was not able to open his right eye at this time. Resident #1 stated: I got into a little altercation with a friend. Resident #1 refused to disclose the name of his friend and stated they had worked it all out between them and that everything was okay.
Interview on 7/31/24 at 9:30 AM, with CNA #2 revealed she was working on the same unit on 7/27/24 as CNA #1. CNA #2 revealed she heard loud yelling coming from Resident #1's room. The door was opened. I heard CNA #1 tell Resident #1 he was not trying to hurt him, he was trying to give him a bath. Resident #1 told CNA #1 to go on and leave him alone and to get out of his room. CNA #2 stated CNA #1 never asked for any help with Resident #1. CNA #2 stated CNA #1 should have left the room until Resident #1 calmed down and he should have asked someone to help him, but he didn't.
An interview on 7/31/24 at 12:16 PM, with the dialysis Facility Administrator (RN #4) revealed that she was working at the dialysis clinic on 7/27/24 when Resident #1 was there for dialysis. She stated that the van driver came into the dialysis clinic and asked the staff to come and help with the man from the nursing home because something was wrong. The private company van driver got Resident #1 off the van, and they brought him into the dialysis clinic with blood on his face and hands and clothes and a swollen black right eye. Resident #1 told the dialysis staff that he had been in a wrestling match with another patient at the facility by the name of (gave the first name of CNA #1). The dialysis nurse called the nursing home and talked to a lady that stated that she was an RN at the facility named (name of RN #2). RN #5 wanted to make sure that the facility knew that Resident #1 had been sent to dialysis with an injury to his right eye and a bloody nose. The dialysis staff called the physician, and he gave instructions to have Resident #1 evaluated and x-rayed at the local ER.
Record review of the dialysis clinic notes dated 7/27/24 at 1:33 PM, signed by RN #4 revealed Resident #1 arrived to dialysis today with his right eye swollen shut, a bloody nose, blood on his hands and pants. When questioned what happened, he stated he was wrestling with another patient named (name of CNA #1) at the nursing home. RN #4 contacted the nursing home and spoke with RN #2 who stated the patient was combative with a CNA during his bath prior to dialysis. The dialysis physician was notified via telephone, gave approval to start treatment, hold heparin, and wanted Resident #1 to get an x-ray post-dialysis at the hospital to ensure there are no fractures. This information was communicated to the nursing home and Resident #1's family.
Record review of a handwritten statements for LPN#1 revealed there was a verbal exchange between CNA #1 and Resident #1 at approximately 8:00 AM or 9:00 AM on 7/27/24. The statement revealed that at approximately 10:50 AM prior to leaving the facility for dialysis she discovered that Resident #1 had an eye injury. LPN #1 documented in her statement .swelling and bruising was noted . around 10:50 to resident's right eye. DON was notified.
Record review of the local hospital Final Radiology Report dated 7/27/24 at 4:27 PM revealed .Exam: CT Head Without Contrast .Clinical Indication Injury or trauma .Impression: Significant right orbital fracture partially imaged with intraorbital air and severe appearing proptosis .
Record review of the local hospital Final Radiology Report dated 7/27/24 at 5:15PM revealed .IMPRESSION: 1. Comminuted and depressed right orbit floor fracture. Comminuted and medially displaced right orbit medial wall fracture. Small amount of intraorbital air. Marked proptosis. Thickened edematous appearance of the right inferior rectus muscle also with some gas immediately adjacent to possibly within the muscle fibers. Tiny bone fragments in close proximity to the right inferior rectus muscle. Cannot definitely exclude an element of intramuscular hemorrhage. However, no significant retrobulbar hemorrhage. 2. Age indeterminate nasal bone fracture. 3. Hemorrhage in the right maxillary sinus.
Record review of the local police department Incident Report revealed Event Info: Date Reported: July 27, 2024, Time Reported: 20:01 (8:01 PM) . Date of Occurrence Range: 7/27/24 Time of Occurrence Range: 19:55-20:10 (7:55-8:10 PM Call Type: Assault- Victim was assaulted at (Proper name of nursing home facility) by an employee. Employee was trying to dress the victim when the victim began cussing and acting up. Victim has Dementia. Victim was transported to (local ER) where x-rays showed a fractured orbital. Victim was transported to (another city) to see a specialist. Classification: Completed Class: Vulnerable Person Abuse or Neglect Subclass: Abuse. Name type: Suspect Name (name and address and telephone number of CNA #1). Narrative . (Proper name of daughter) stated she received a call from the facility about 11:13 AM and was informed their father had been assaulted. Instead of the facility sending Resident #1 to the hospital it was stated that he was taken to dialysis with a very bad swollen right eye.Resident #1 stated that CNA #1 an employee at the facility is the person that caused his injury . The staff on duty during the shift had not reported the injury at all. The x-ray of Resident #1's face showed his orbital is fractured .
Record review of a handwritten statement by CNA #1 dated July 27, 2024 revealed This morning when I went to bathe (Proper name of Resident #1), he started cursing and swinging. I asked him to stop and let me clean him. But he continued to swinging and curse. I notified the nurse that he was fighting and refusing care. During his outburst he hit his head, and his eye was swollen. I notified the nurse. I had went in several times to clean him, and I even asked (Proper name of CNA #2) to come into the room with me.
Record review of the handwritten statement by LPN #1 revealed At approximately 9:00 AM, this nurse (Last name of LPN #1) was called to the resident's room because the resident was being combative and refusing care. Upon entering the resident's room, the resident was noted to be lying in bed on his right side facing the window and the aide was giving the resident a bath. The resident was noted to be calm and did not appear to be in distress. After resident stated that he was alright, this nurse exited the room. There was no bruising or swelling noted at this time. Swelling and bruising was noted around 10:50 to the resident's right eye. DON was notified. Signed by LPN #1 and dated July 28, 2024.
Record review of a handwritten statement dated 7/29/24 by LPN #2 revealed, On the evening of 7/27/24 I was working the 3:00p- 11p shift as the supervisor when (Proper name of Resident #1) returned to the facility from dialysis. I ask him . why his eye was swollen, he stated that him and his CNA had a 'little tussle.' I ask him what he meant by a 'little tussle.' He stated that he really did not think that the CNA hit him or did anything to him, he stated, 'I might have hit myself.' .
Record review of a typed statement by facility Administrator (ADM) dated 7/28/24 at 10:52 AM revealed, (Proper name of CNA #1) informed the Administrator that (Proper name of Resident #1) was refusing care, so he sent for (Proper name of LPN #1) . CNA) #1 stated Resident #1 had risen in the bed, swung, and was fighting, and he hit his head on the over-bed table he had at bedside with the bath water on it. CNA #1 stated Resident #1 never complained of pain or said he was hurt. He finally calmed down and he was able to clean him up, dress him, shave him, and trim his hair with no issues. Resident #1 then walked up front prior to going to dialysis. LPN #1 asked Resident #1 what happened per CNA #1. Resident #1 replied, 'I have been down there fighting and did it to myself.' CNA #1 stated he never closed the door to Resident #1's room for his privacy because the smell was so bad. That is the only thing he did wrong was not providing privacy.
Record review of the Minimum Data Set (MDS) dated [DATE], for Resident #1 Section C revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Resident #1 was intact cognitively and had no cognitive impairment.
Record review of the admission Record revealed Resident #1 had been admitted to the facility on [DATE] and again on 4/16/23 with diagnoses that included Type 2 Diabetes Mellitus and Heart Failure.

Based on interview, record review and facility policy and procedure review the facility failed to implement the Activities of Daily Living (ADL) care plan when Certified Nursing Assistant (CNA) #1 did not notify the charge nurse supervisor when a resident was resisting care. This failure resulted in Resident #1 receiving fractures to his orbital bones during an altercation with CNA #1 during care for one (1) of 27 residents reviewed. Resident #1.
Findings include:
Record review of the facility policy titled, Care Plans, Comprehensive-Centered with a reviewed date of January 2023 revealed Policy Statement: A comprehensive, person-centered care plan .is developed and implemented for each resident. Policy Interpretation and Implementation .8. The comprehensive, person-centered care plan will: .g. Incorporate identified problem areas h. Incorporate risk factors associated with identified problems 10. Identifying problem areas and their causes, and developed interventions that are targeted and meaningful to the resident .11 a. When possible, interventions address the underlying sources (s) of the problem area (s), not just addressing only symptoms or triggers .
Record review of the care plan with a date initiated of 2/23/24 revealed Focus: I have inappropriate behaviors and at risk for injuries and complications. I yell at staff and resist care .Interventions: Monitor behaviors .Notify charge nurse, supervisor .Notify physician and RR (Resident Representative) .Redirect as needed
Interview on 07/30/24 at 11:30 AM, with the Director of Nursing (DON) and the Administrator (ADM) revealed Resident #1 was discovered to have a black eye and a nosebleed on 07/27/24 at approximately 10:40 AM after he had received care from CNA #1 on 07/27/24 at approximately 8:00 AM-9:00 AM. The DON revealed there was no documentation CNA #1 notified the charge nurse supervisor or obtained help from additional staff when Resident #1 resisted care.
During an interview on 07/30/24 at 3:57 PM, Licensed Practical Nurse (LPN #1) revealed CNA #1 never reported to anyone that Resident #1 hit his head during patient care earlier that morning on 07/27/24 at approximately 8:00 AM to 9:00 AM. LPN #1 confirmed that CNA #1 did not follow protocol for Residents with behaviors or that were resisting ADL care. LPN #1 stated that CNA #1 should have called for another staff to assist him and walked away and left the room after the resident became resistant to care. LPN #1 stated that CNA #1 never asked for help with Resident #1 after he became resistant to ADL care. LPN #1 stated that Resident #1 received injuries of a swollen black eye and some bleeding to his nose that occurred during ADL care with CNA #1. LPN #1 stated that she should have assessed Resident #1, and she should have documented the events of the incident of Resident #1, but she did not.
Interview on 07/30/24 at 4:20 PM, with CNA #1 revealed that during patient care on 07/27/24 at approximately 8:00 AM Resident #1 became resistant and began yelling and swinging his arms about during bath time. CNA #1 stated that Resident #1 hit the right side of his head on the bedside table that was positioned on the left side of Resident #1's bed. CNA #1 confirmed that he did not report the incident or notify the nurse because Resident #1 was not hurt and did not issue any complaints of pain. CNA #1 confirmed he did not obtain other staff to assist when Resident #1 was resisting care or notify the nurse or nurse supervisor.
Interview on 07/31/24 at 11:02 AM, with the Minimum Data Set (MDS) nurse, Registered Nurse (RN) #6 revealed that the ADL care plan was not appropriately followed for Resident #1. RN #6 stated that CNA #1 should have obtained an additional staff member to assist with the ADL care of Resident #1 after he became resistant and should have reported Resident #1 was resisting care to the Charge Nurse/Supervisor. RN #6 stated that all the staff are trained to leave the room and to allow a Resident time to calm down, and to obtain an additional staff member to come and assist with ADL care, when a resident exhibits behaviors. RN #6 stated CNA #1 did not follow protocol and did not implement the care plan for Resident #1.