Every finding on record at Badger Prairie HCC

Based on interview and record review, the facility did not ensure that all alleged violations involving misappropriation of resident funds/personal property are reported immediately to the administrator of the facility, the State agency, and to other officials, including local law enforcement, in accordance with State law through established procedures for 1 of 1 supplemental residents (R27) reviewed for abuse. Facility did not report R27's allegation of a staff member hitting her/physical abuse to local law enforcement.Evidenced by:Facility policy, title Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Property, or Injuries of Unknown Origin, and Mandatory Reporting of a Crime, dated 7/22/25, includes: Any employee, manager, agent, volunteer, or contractor of the facility must report any reasonable suspicion of a crime committed against a resident of the facility to both law enforcement and the state agency.Facility policy, titled Nursing Home Reporting, undated, includes: Immediately protect the resident, call Administrator, notify law enforcement. Must call even if resident or family prefer not to. When to notify law enforcement: If events that cause the allegation involve abuse or result in serious bodily injury. If there is reasonable suspicion of a crime: murder, rape, assault, robbery, drug diversion, identity theft, fraud. If there has been nonconsensual sexual contact. If there has been a resident to resident willful action that results in physical injury, mental anguish, or pain. Call Police Immediately but no later than two hours. If the events that caused allegation do not involve abuse and do not result in serious bodily injury. If there is suspicion of neglect exploitation mistreatment or misappropriation of property. If there are requests from residents/ family to report to police. call police or use police department reporting no later than 24 hours.R27 admitted to the facility on [DATE] with the following diagnoses: Paranoid schizophrenia (mental illness with paranoia and delusions), dementia, depression, and anxiety.R27's Nurse Notes, dated 8/27/25, include: 1:25 PM Resident accusatory 1 time asking CNA, Are you going to hit me like you did this morning? Reported to nurse manager. Self transferred 6 times, kept getting stuck and unable to move further. No other behaviors noted this shift.(It is important to note the allegation by R27, that a staff member hit her.)Facility Self Report, dated 8/27/25, includes:Wednesday, 8/27/25, at 12:45 PM RN C (Registered Nurse) informed me (Nurse Manager E). during nursing report at 12:30 PM CNA D (Certified Nursing Assistant) reported that R27 accused her of hitting her. I immediately visited the neighborhood, removed CNA D from the floor, at 12:55 PM. DON B (Director of Nursing) was notified of allegations. Now in my office, CNA D provided a statement of events that occurred. She stated the incident occurred around 10:30 AM. CNA D said R27 was in a pleasant mood earlier, but when she approached to assist, R27 asked, Are you here to hit me again? CNA D responded, No, I would never do that. I'm here to help you with your cares. When asked CNA D stated she reported the incident to the nurse immediately. I confirmed with the nurses on duty, who stated the report was received at 12:30 PM. CNA D was asked to leave the facility pending an investigation. CNA D departed the facility immediately. At approximately 2:12 PM R27's group sheet was updated to require two CNAs for all cares. At 3:19 PM an education reminder was sent out to all staff to report incidents immediately to their supervisor. At approximately 2:30 PM I (Nurse Manager E) visited R27 in her room. She was calm, drinking a pepsi, and not in distress. She described her day as good but noted her CNAs were rough with her, though she could not recall who or what happened. When asked if she was harmed, she first said no, then yes, but could not provide details and changed the subject to her sister's visit. I reassured her of our commitment to safe care and encouraged her to reach out if she recalled more. At 3:00 PM Social Worker F followed up with R27, finding her in her room, sitting in a recliner, drinking a soda, in a positive mood, and mentioning it's always a good day when her sister visits. When asked about her care, R27 said it was good but described her morning CNAs as not so good, without clarifying why. When asked if she was having trouble remembering or was nervous, she said yes but couldn't explain what happened with the CNA despite prompting. At 3:56 PM CNA D was placed on paid administrative leave pending the investigation. At 4:00 PM the floor nurse conducted a comprehensive skin assessment, finding R27 alert, with a 2x2 cm dark purple bruise on her left calf that did not appear new or suspicious. R27 reported right hip pain and has a diagnosis of primary generalized osteoarthritis and other chronic pain, but no redness or bruising was noted. Her range of motion was intact and strong in all four extremities. She showed no distress and her vital signs were stable. During the assessment, the nurse asked R27 is she was hit. R27 denied being hit. At 5:20 PM, I notified R27's guardian about the allegation and our follow up actions. At 5:30 PM, I notified the Medical Director of the allegations of abuse. On Thursday, August 28, 25 a nursing order was placed to chart an internal progress note monitoring R27's psychosocial well being; conducted every shift for three days. On Thursday, August 28, 25 Social Worker F conducted a climate survey asking residents the following questions: Do you have any concerns about your care, do you have any concerns about staff and so you feel safe at this facility. On Tuesday, September 2, 25 the floor nurse conducted an additional comprehensive skin assessment concluding the integument was intact, not with standing the bruise noted to the left calf. CNA D statement: Good morning, up and shower. Bathroom after breakfast, stuck in bathroom, started to sit, CNA D pulled resident up and back onto toilet. Stood back up, to remove pants. Resident went to the bathroom, up back onto chair. Toileted again around 10:30 ish. Resident was walking in room, CNA D came into assist with resident. Resident stated, Are you back in here to hit me again? CNA D said, No, I would never do anything like that. Resident replied with a look. CNA D assisted resident to bathroom. Resident made no further comments regarding being hit. Activities of Daily Living went on as usual. Nurse Manager E statement: At approximately 2:30 PM Writer went to speak with R27. R27 was in her room sitting at her recliner having a pepsi. R27 did not appear to be in any distress. Writer asked how her day went and she replied, Really good. Writer asked how things were going with her CNAs, she stated they were going well, but no sooner stated, They were rough with me today. Writer asked who they were and if she could elaborate on what occurred. Writer asked if she could explain what had happened and she replied, I can't remember. R27 began talking about her sister visiting and asked if I had any siblings. Writer assured R27 that our goal is to provide safe care giving and if at any time she had remembrance of what may have occurred, to reach out as to discuss further. Writer also stated I will come to visit later this evening. Social Worker F statement: Writer was asked to check in with R27 following a reported allegation. Resident was in her room sitting in her recliner drinking soda. Resident was in a positive mood stating, It is always a good day when (sister) visits. Writer asked resident how her care has been, to which she responded, Good. Writer asked how things have been with core morning CNA, who reported resident's allegation against her. R27 responded, Not so good but was unable to clarify why. R27 would say 1 to 3 words and become quiet. Writer asked if she was having trouble remembering or if she was nervous to discuss it, which R27 replied, Yes. R27 was unable to vocalize what had happened with CNA and did not respond to prompting. R27 appeared drowsy and stated she was feeling tired because she had a busy morning and had been outside. Writer asked if resident would prefer to rest, which she agreed to. During conversation, resident had significant hand tremors and often brought her hand to her forehead and said, I can't when asked a question. She appeared to be drowsy and kept her eyes closed for most of the interaction, which not typical when speaking with writer.On 9/10/25 at 1:52 PM DON B (Director of Nursing) indicated the facility did not notify local law enforcement of R27's allegation of staff hitting her. DON B indicated the policy states, When to notify law enforcement: If events that cause the allegation involve abuse. DON B indicated a concern of a staff member hitting a resident is an allegation of abuse. DON B indicated the facility should have called local law enforcement per facility policy and because local law enforcement is one of the residents' resources.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse by a resident (R1.) This affected 3 (R2, R3, and R11) of 6 residents reviewed for abuse. R1 was observed hitting 3 residents (R2, R3, and R11) on 3 separate occasions; R1 struck R11 in the head 4 times with a pillow, R1 struck R3 in the back with his shoe, and R1 struck R2 across her face with the insole of his shoe. The facility failed to protect residents from physical abuse. Using the reasonable person concept a resident would be saddened and distressed after being hit in their home. Evidenced by: The facility's policy titled Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Property or Injuries of Unknown Origin, and Mandatory Reporting of a Crime dated 1/24/23, states in part, .II. Policy: Each resident has the right to be free from abuse, neglect, mistreatment, exploitation, misappropriation of resident property .Residents must not be subjected to the preceding by anyone, including but not limited to, facility staff, other residents, consultants .All alleged violations will be reported to the administrator or designee, Director of Nursing, and the nurse manager immediately, thoroughly investigated and measures implemented to prevent further incidents. Incidents that meet state and federal criteria will be reported to the Division of Quality Assurance (DQA) and the Office of Caregiver Quality (OCQ) immediately. Immediately is defined as not later than 2 hours, if the alleged violation involves abuse or results in serious bodily injury, or 24 hours, if the alleged violation does not involve abuse and does not result in seriously bodily injury. A written report filed within 5 working days of the incident . V. Procedures: A .6. Neighborhood treatment teams shall identify residents whose personal histories render them at risk for abusing other residents, and develop intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessing these interventions on a regular basis .B. Identification, Investigation, Protection, and Reporting: It is the policy of [facility name] that reports of abuse as defined above are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened. The investigation will begin immediately, once informed of an event .The Investigation will include: .3. What happened: a. Residents' statements .b. Peer statements .d. Involved staff and witness statements of events (written or verbal statements documented), staff or witnesses that were in the area at the time of the incident .10. Root cause analysis of the incident 11. Conclusion based on findings . Example 1: R1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Dementia with agitation, Major Depressive Disorder, Anxiety Disorder, and cognitive communication deficit. R1's most recent MDS (Minimum Data Set) dated 5/9/23, states that R1 is rarely/never understood. R1's MDS also indicates that he requires supervision and set up assist for locomotion on the unit. R11 was originally admitted to the facility on 12/ 28/22 with diagnoses to include dementia, non-traumatic brain dysfunction, anxiety disorder, and cirrhosis. R11's most recent MDS dated [DATE] states that R11 has a BIMS (Brief Interview of Mental Status) of 99, indicating that he was unable to complete the interview. The MDS also indicates that R11 requires extensive assist of 2 staff members for bed mobility and transfers and is completely dependent on staff for locomotion on the unit. R1 has documented behaviors of being physically aggressive with staff and wandering into peers' rooms. Documentation is as follows: April 2023 - R1 was physically aggressive with staff for 36 out of 90 shifts. R1 wandered into peers' rooms 67 out of 90 shifts. May 2023 - R1 was physically aggressive with staff for 33 out of 90 shifts. R1 wandered into peers' rooms 67 out of 90 shifts, with one shift not documented on. June 2023 - R1 was physically aggressive with staff for 40 out of 90 shifts. R1 wandered into peers' rooms 58 out of 90 shifts, with nine shifts not documented on. July 2023 - R1 was physically aggressive with staff for 30 out of 93 shifts. R1 wandered into peers' rooms 68 out of 93 shifts, with three shifts not documented on. August 2023 - R1 was physically aggressive with staff for 7 out of 23 shifts. R1 wandered into peers' rooms 15 out of 23 shifts, with one shift not documented on. It is important to note that the facility is not documenting R1's behaviors when he is physically or verbally aggressive towards other residents. On 4/24/23, R1 hit R11 with a pillow several times. R1's nurse's notes on 4/24/23 at 8:44 PM state in part, Resident was delusional, accusatory, and physically and verbally aggressive early in the shift. Resident was accusing staff of abusive towards an individual. Resident became agitated when staff attempted to reassure. Per CNA (Certified Nursing Assistant,) resident grabbed a pillow and hit another resident sitting in a Broda chair four times. Resident attempted to kick a staff while writer was trying to redirect the resident. When writer was trying to provide reassurance, the resident was verbally abusive towards the writer .Staff allowed the resident to wander on his own and resident eventually settled . R1's nurse's notes on 4/24/23 at 10:50 PM state in part, Per CNA, around 1615 (4:15 PM) resident became agitated and was wandering around the living room. Resident unexpectedly pulled a pillow from another resident (victim) who was sleeping in the Broda chair. Resident began hitting the other resident with the pillow four times . R11's nurse's notes on 4/24/23 at 11:12 PM state in part, Resident was the victim of the assault that occurred on the living room at 1615 (4:15 PM.) Another resident hit the resident with pillow four times unprovoked . R11's nurse's notes on 4/24/23 at 11:12 PM (second entry) state in part, Resident was drowsy for most of the shift, with intermittent restlessness. However, resident was under supervision t/o (throughout) the shift. Between 1635-1645 (4:35 PM - 4:45 PM), resident was restless in his Broda chair. Redirection provided, with minimal effect. Writer gave PRN (as needed) lorazepam (Ativan) PO (by mouth.) A minute later, writer was behind the Broda chair and got distracted by another resident when the resident got up quickly from his chair. Writer attempted to help the resident but when the resident took a step his feet got tangled with the blanket. Resident then fell on the carpet .Resident reported pain and was agreeable to PRN. Writer gave PRN morphine PO (by mouth), with good effect . Of note, a dependent person would likely be saddened and distressed when someone enters their living space unprovoked and hits them repeatedly. R11 became restless and subsequently had a fall after the incident. It is important to note that there is no documentation indicating that the facility implemented any interventions to R1's care plan to ensure that other residents were kept safe from R1. Example 2: R3 was originally admitted to the facility on [DATE] with diagnoses that include dementia, major depressive disorder, personality disorders, and anxiety disorder. R3's most recent MDS dated [DATE] states that R3 has a BIMS of 9 out of 15, indicating that he is moderately cognitively impaired. R3's MDS also indicates that he requires extensive assist from 2 staff members for bed mobility and transfers, and that he requires limited assistance from 2 staff members for locomotion on the unit. On 5/11/23, R1 struck R3 with his shoe. R1's nurse's notes state, in part: 5/11/23 at 1:06 PM - Resident was day 5 without BM (Bowel Movement.) Resident very restless, agitated, and aggressive to staff during cares. Writer administered PRN suppository around 09 am. Around 0930 staff found him using room D115's bathroom. Resident was sitting on his recliner did not say anything and appears to be not care Resident has a Lg (large) BM in D115's bathroom. Resident was restless and agitated around 10:30 AM. Staff must monitor closely to prevent altercation. PRN risperidone administered around 10:40 AM and was effective. Resident calm down later but kind of more relax and touched One time to female staff and one time to male resident at room D113 holding from the back and putting his head over the shoulder. Staff must intervene, educated as he is redirect able [sic] . 5/11/23 at 6:41 PM - Writer notified that R1 was finished with his meal, sitting at dining spot. CNA near him was assisting another resident and told R1 to finish his milk. R1 became reactive and struck CNA in the face. CNAs assisted R1 away form [sic] the dining area and back to a recliner in the living room. R1 appeared calm, staff turned away and went back to attending to residents in the dining area. R1 quickly removed a shoe and got up and went to another resident who was sitting eating his dinner and came up behind him and struck his left shoulder with his shoe. The other resident was very surprised, fearful, had not been talking or involved with R1 or the CNA during the previous incident .His shoes were kept off, and he has another RN (registered Nurse) providing 1:1 for the time being .RN reports increased restlessness and agitation on the PM (evening) shift . 5/11/23 at 8:55 PM - Resident aggression: Staff reported that resident was upset when asked to finish his drinks during his meal and threw his silverware on the floor. Resident then proceed toward the staff who was feeding resident (R3) at the time. Resident hit the staff in the face; staff redirected him and sat him on recliner in living room. Resident once again proceeded toward staff and this time he hit the resident (R3) with his shoe in the back/shoulder area. Staff intervened before resident hit his peer again. Resident (R3) has no apparent injury but c/o (complained of) pain on back when lifting his shirt up . R3's nurse's notes state, in part: 5/11/23 at 9:48 AM - Resident was struck by another resident in his left back shoulder when he was having dinner. Staff intervene and remove another resident from him before struck again. Writer and nurse supervisor assessed resident and found no apparent injury. Resident c/o (complained of) pain on the area that was struck. Resident was able to describe the situation and sound worried at the time . Of note, a dependent person would likely be saddened and distressed if someone enters their living space unprovoked and hits them. R3 expressed pain, fear, and was very surprised with being hit. On 8/8/23 at 8:18 AM, Surveyor interviewed R3. Surveyor asked R3 if he remembered being hit with a shoe? R3 stated yes, he whopped me alongside my head and back. Surveyor asked R3 how it made him feel? R3 stated that it made him feel helpless. Surveyor asked R3 if it hurt when the other resident hit him? R3 stated yes. Surveyor asked R3 if he was afraid the other resident was going to hit him again? R3 stated yes. On 8/8/23 at 8:37 AM, Surveyor interviewed CNA L. Surveyor asked CNA L to explain the events of the incident between R1 and R3. CNA L stated that R1 hit R3 with his shoe, and that R3 didn't do anything to R1. CNA L stated that R1 wanders around the unit and goes into other resident's rooms. Surveyor asked CNA L what interventions were implemented after the incident? CNA L reported that they took R1 to his room, called the nurse, and then he came back out into the common area. CNA L stated that they had to make sure that R1 did not go near R3. Example 3: R2 was admitted to the facility on [DATE] with diagnoses to include dementia, bipolar disorder, major depressive disorder, generalized anxiety disorder, and borderline personality disorder. R2's most recent MDS dated [DATE] states that R2 has a BIMS of 14 out of 15, indicating that she is cognitively intact. R2's MDS also states that she requires supervision and set up assistance for bed mobility, transfers, and locomotion on the unit. It is important to note that during this survey, R2 was observed to be either in a reclining chair, or in her bed. R2 was not observed to be wandering the unit. On 6/10/23, R2 was struck repeatedly in the face by R1. R1's nurse's notes state, in part: 6/10/23 at 2:48 PM - Writer was alerted by charge nurse that during writer's break, there was an incident between R1 and R2. Upon further investigation with CNA staff and staff member who witnessed the incident, writer learned that R1 hit R2 in the face 3-4 times using an insole from his shoe. Per CNA, R1 had been wandering around the unit prior to this in an agitated manner, and followed R2 in an aggressive manner after hitting her .Current plan of action is to have 1:1 staff on the PM shift for safety and for R1 to no longer have shoes (will have grippy socks or possibly lightweight slippers instead) . 6/10/23 at 10:28 PM - Resident aggressive with cares. Per intervention d/t (due to) resident altercation, resident not allowed to wear shoes. Resident somehow found the shoes. When staff attempted to take the shoes, resident became agitated and aggressive towards the staff . 6/19/23 at 2:36 PM - In the morning around 0900 (9:00 AM) resident softly touched peer (R2) on her shoulder from behind . R2's nurse's notes state, in part: 6/10/23 at 2:41 PM - .Writer then assessed R2. R2 was upset following the incident, crying, and repeatedly stating a man hit me in the face and get me away from him .Writer provided PRN trazodone to resident for agitation . 6/10/23 at 8:30 PM - Resident drowsy/sleeping majority of the shift, up only with meal and toileting. 1:1 supervision this shift. Per staff, resident confused and tearful. During COVID screening, resident reported about dying in one hour d/t her oxygen de-sating. O2 (oxygen) 95%. Resident perseverating on wanting to see the doctor or nurse for everything especially discomfort from her lips and mouth. During HS (bedtime) medication, resident was moaning and crying. Resident reports lips and mouth pain . 6/11/23 at 1:58 PM - Resident agitated and anxious this shift .PRN lorazepam was administered at 12:00 with her scheduled medications. PRN lorazepam had minimal effects . Of note, a dependent person would likely be saddened and distressed to have someone enter their living space unprovoked and hit them. The facility implemented 1:1 supervision at the time of the incident and removed R1's shoes, but it is important to note that the facility allowed R1 to keep his shoes, per his guardian's request and just removed the insoles, and did not provide extended supervision to prevent further incidents; this is R1's second attack using his shoes. On 8/7/23 at 3:34 PM, Surveyor observed R1 in the TV (television) area with his shirt off, leaning over the back of a recliner that another resident was sitting in. On 8/7/23 at 3:36 PM, Surveyor observed R1 standing at the counter, irritable, talking, and fidgety. R2 is also sitting at the counter; R1 was approximately 4 feet away from R2. On 8/7/23 at 3:37 PM, Surveyor observed R1 to move behind R2's recliner chair at the counter. R2 began calling out, staff took R2 to her room. R1's CNA Kardex states NO SHOES WITH INSOLES ON THE HOUSEHOLD (may wear when leaving NBHD (neighborhood) with wife or for activities.) Surveyor observed R1 to be wearing his black tennis shoes throughout the survey, unable to visualize whether there were insoles inside them. On 8/8/23 at 8:37 AM, Surveyor interviewed CNA L. Surveyor asked CNA L to explain the incident between R1 and R2. CNA L stated that R1 was wandering around the unit and kept taking his shoes and socks off. CNA L reported that they tried to get R1 to put his shoes back on, and then R1 tried to go into another resident's room to urinate, CNA L stated that R1 shoved her and then went and sat down. CNA L reports that at that time, she went to get another resident out of someone's room, R1 took off his shoes off and hit R2, R2 was sitting in the recliner. CNA L stated that R1 was still trying to hit R2 after she intervened, but she was standing in the way, so he just hit her. Surveyor asked CNA L if the facility provided education to staff after the incident? CNA L stated that she was not aware of any education provided. Surveyor asked CNA L what interventions were implemented for R1 after the incident? CNA L stated that they were to provide 1:1, R1 and R2 are not to be close together, R1 is not to have shoes on, and if R1 is agitated, staff are to try to get him to his room. On 8/8/23 at 10:05 AM, Surveyor interviewed CNA M. Surveyor asked CNA M what interventions are in place for R1? CNA M reported that they are to supervise him when he's wandering, make sure he's not going into other residents' rooms, make sure other residents aren't getting too close to him, and to monitor his demeanor. Surveyor asked CNA M if R1 was allowed to wear shoes? CNA M stated yes, he just can't have insoles. On 8/8/23 at 10:45 AM, Surveyor interviewed SN I (Supervisory Nurse.) Surveyor asked SN I what the facility's process was for a resident-to-resident altercation? SN I stated that they protect and separate the residents, get help if needed, and report it immediately; CNAs are to report it to the first nurse they see or call the charge nurse and start an investigation immediately. SN I stated that depending on the severity and intent, they would call law enforcement and that they need to report it to the SA (State Agency) within 2 hours and have 5 days to complete. Surveyor asked SN I if she could explain why there wasn't a report sent to the SA regarding R1's resident to resident altercation on 4/24/23? SN I stated that she was unaware of the incident. Surveyor asked SN I if the incident should have been investigated? SN I stated yes. Surveyor asked if the incident should have been reported to the SA? SN I stated that she didn't know. Surveyor asked SN I if there was documentation of the interventions that were implemented for R1 after each incident? SN I stated that they should keep R1 away from other residents and monitor. Surveyor asked SN I if there was any documentation of the monitoring? SN I stated they do not have formal documentation of monitoring. Surveyor asked SN I what interventions were implemented after the incident between R1 and R3? SN I reported that they moved R3 to another household, they provided 1:1 supervision for R1. Surveyor asked SN I if the 1:1 supervision was long term? SN I stated that she didn't know. Surveyor asked SN I about interventions implemented after the incident with R1 and R2. SN I stated that she had told staff that R1 was to not have any shoes, due to this being his second attack with his shoes, staff removed the shoes. SN I reported that R1's wife was not pleased with the removal of the shoes and wanted him to always wear shoes, so they were given back. Surveyor talked with SN I about the incident on 6/19/23 where R1 touched R2 on the shoulder. Surveyor asked SN I how R1 was able to get close enough to touch R2? SN I stated that she did not know. On 8/8/23 at 2:38 PM, Surveyor interviewed DON B (Director of Nursing.) Surveyor asked DON B about the interventions implemented after each of R1's resident-to-resident altercations. DON B stated that she didn't have anything to add if Surveyor spoke with SN I. R1 has a history of aggressive behaviors including striking other residents. The facility failed to protect and ensure residents are free from abuse.

Based on observation, interview, and record review, the facility did not ensure that every resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, and did not ensure that the resident can exercise his or her rights without interference. This has the potential to affect a pattern of residents residing in the facility. R4 voiced concern of not having her own phone to make and receive calls without interference. Staff report screening incoming phone calls to residents. Staff report screening visitors prior to visiting the residents. This is evidenced by: The facility admission form entitled, [NAME] of Rights, revision date of 3/7/19, states in part: . you have rights guaranteed to you by state and federal laws. Your rights strongly emphasize individual dignity, self-determination, promoting your independence and enhancing your quality of life. You have the right to exercise all of your rights free from interference, coercion, discrimination or reprisal . Privacy . to private and unrestricted visits with any person of your choice, in person and by telephone . Grievances . to contact the Ombudsman to advocate on your behalf, free from discrimination of reprisal, if you feel any of your rights have been violated . Access . to contact your Ombudsman, or the State survey agency, or any advocate or agency of your choosing . The facility policy entitled, Denial of Resident's Rights, dated 2/28/23, states in part: . Purpose: To assure that resident rights are only withdrawn, suspended, or compromised for cause, after review by the Administrator of the facility. Rights may be denied when medically or therapeutically contraindicated, as documented in the resident's treatment record by behavior health specialist or MD (Medical Doctor). The resident or resident representative shall have the opportunity to have the decision to deny rights reviewed . Procedure . 5. Should the resident or resident representative disagree with the denial of rights, he/she may file a grievance or contact an advocate or outside agency for the purpose of challenging the right(s) denial. The Social Worker or designee may assist the resident and/or resident representative in this process. 6. The treatment team will work with the resident, so he/she can regain the denied right(s). The plan to regain denied rights will be reflected in the resident's interdisciplinary plan of care. 7. The treatment team will review the rights denial at the quarterly MDS (Minimum Data Set) meeting and/or monthly staffing and reinstate the right as soon as possible . R4 is a long-term resident of the facility in a locked unit. R4 was admitted to the facility on [DATE]. R4 has the following diagnosis of schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood, and behavior). R4's most recent quarterly MDS dated [DATE], scored 99 on her Brief Interview of Mental Status (BIMS) which indicates R4's cognitive status is severely impaired. R4's Care Plan, dated 8/5/22 with an effective date of 2/9/23, states: R4 is diagnosed with schizoaffective disorder, major depressive disorder-recurrent and a personal history of suicidal behavior . Interventions include . Phone Use: Has access to a modified phone with a specific plan for how staff assist her in making calls . (Note: The care plan does not indicate visitation screening or preferences.). R4's Certified Nursing Assistant (CNA) care plan states, in part: . When phone request, staff to dial using special phone set up-see detailed plan in chart or charting room, may not make long distance calls without calling card- Contact only for phone use . R4's Phone plan states, in part: .R4 has a modified phone so she can receive calls, but not make outgoing calls without staff assistance. This is due to history of making inappropriate phone calls, scheduling unnecessary appointments, changing insurance plans, and monopolizing neighborhood phone. ~Upon request for use of the phone, ask R4 who she wants to call. If she says she is calling social security, insurance agency, police, a place she wants to call to purchase items or doctor's office- tell her you cannot assist her with making these calls . She is not allowed to receive calls from these entities as well. Inform them to contact R4's guardian instead . ~Acceptable calls to make/receive are to an attorney, family, friend, guardian, or support programs . ~Ask her for the number and name of the person she wants to call. If she does not tell you the name of the person, tell her you cannot complete the call . ~If R4 receives a phone call, ask who the caller is. If it is an acceptable caller, transfer the call to R4's extension. If it is not an acceptable caller, simply say she is not available, and either hang up, or transfer to a nurse . ~Once she is done with the call, the phone should be returned to the sunroom area outside of R4's room. It is not to be kept in her room . ~When the phone is returned, make sure the box/tape are still secure in case she is attempting to take it apart and make calls . R4's Monthly Documentation Charting Record from her chart states, in part: Did R4 ask to make any inappropriate phone calls this shift (Y or N)? QSH (every shift) . ~3/1/23-3/31/23: 1- yes, 72- no, 20- no documentation, out of 93 opportunities ~4/1/23-4/30/23: 1- yes, 86- no, 3- no documentation, out of 90 opportunities ~5/1/23-5/30/23: 1- yes, 85- no, 4- no documentation, out of 90 opportunities ~6/1/23-6/30/23: 0- yes, 88- no, 2- no documentation, out of 90 opportunities ~7/1/23-7/31/23: 0- yes, 89- no, 4- no documentation, out of 93 opportunities R4's facility created Denial of Rights form, dated 6/6/23, states, in part: . The right or rights which are checked below are being denied at this time because: Due to calling 911 inappropriately and changing your insurance plan without legal authority to do so . Staff to dial the phone and transfer call to modified phone. See phone plan. Staff will work with you so you can regain the right(s), which has been withdrawn. This denial will be reviewed by the treatment team at least quarterly to consider if it is still necessary to deny the right(s) . The resident refusal to sign, dated 5/24/23. The guardian signed on 6/6/23. On 8/7/23 at 3:28 PM, Surveyor observed a lime green colored 8.5 x 11 sign on the wall at the entrance of the locked unit, next to a wall phone that states: Please identify yourself AND who you are here to see. Of note, Surveyor had to pick up the phone and tell the staff that answered I was a surveyor and what resident Surveyor was going to see to enter the locked unit. Residents are allowed the right and access to visitors, including State Agency, and should not be required to identify one's self. On 8/7/23 at 1:29 PM, Surveyor interviewed R4. Surveyor asked R4 if she can make phone calls. R4 indicated she must get the staff to make a call because her phone is covered in cardboard and tape so she cannot make the call herself. R4 further indicated that if she does not tell the staff who she is calling, the staff will ask her who she is calling. R4 then informs the staff who she plans to call and the phone number. Surveyor asked R4 how she receives phone calls, she replied that the staff come to her room and tell her who is on the phone and then ask if she would like to talk to them. R4 indicated that if she agrees to the caller, she must go outside her room to get the phone in the hallway because the staff will transfer the call to that extension. R4 indicated she then takes the phone into her room and when she is finished, she puts the phone back out into the hallway. Surveyor asked R4 how she feels about the phone plan, R4 stated: I am in a prison, and I am not important. Surveyor asked R4 what makes her feel sad, R4 stated: the condition that I am in, basically no phone, staying in this room all the time, all I have is this TV. I'm scared I am not going to get out of here. On 8/7/23 at 10:49 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C the phone policy for residents. RN C indicated she typically asks who is calling and offer the resident the phone. Surveyor asked RN C the reasoning the caller is being asked to identify themselves, she replied it was for the facility records and that maybe the caller is somebody the resident does not want to speak to. RN C further indicated they let the resident know who is calling and the resident can choose yes or no if they want to speak to the caller. Surveyor asked RN C how a resident can make a call, she indicated the residents can use the mobile phone if the phone use is not care planned or monitored. Surveyor asked RN C to explain the visitor procedure, she indicated visitors do a COVID-19 (Coronavirus disease of 2019) screening, then the visitor calls from the phone outside the locked unit, identify themselves, and who they are here to see. RN C further explained she then asks the resident if they would like the visitor, and then will let the visitor in. Surveyor asked RN C if a resident has ever declined a visitor, she indicated no resident has declined a visitor to her knowledge. Surveyor asked RN C if there has been any education of phone or visitor procedures, she said there was not anything formal but had taken upon herself today to call and ask the social worker for clarification of R4's phone plan. RN C further explained that she was advised by the social worker that staff should be asking the name of the caller and the resident they want to speak to. On 8/8/23 at 1:37 PM, Surveyor interviewed RN C again. Surveyor asked RN C the steps taken if a visitor declines to identify themselves, she indicated that has not happened to her before. RN C further indicated there is a sign at the unit entrance that says to identify themselves, the visitors must identify themselves with the front desk staff and then she would refer the visitor to her manager. On 8/7/23 at 2:24 PM, Surveyor interviewed RN D. Surveyor asked RN D the phone policy for residents. RN D indicated he asks who they are and for which resident, RN D then asks resident if they would like to speak with the caller and will transfer the phone if agreed by the resident. Surveyor asked RN D to explain the visitor procedure, he indicated the visitors sign in for the COVID-19 screening, call when they are outside the unit, identify themselves, and who they want to see. Surveyor asked RN D the reasoning to identify themselves, he indicated the visitor did not have to as the visitor's name is at the front desk. Surveyor asked RN D if there has been any education of phone or visitor procedures, he indicated there was a couple of months ago for R4. RN D further indicated the staff are supposed to check R4's care plan as it was modified recently. On 8/7/23 at 3:12 PM, Surveyor interviewed CNA F (Certified Nursing Assistant). Surveyor asked CNA F the phone policy for a resident, she indicated they ask who is calling and for which resident, then go to the resident and ask if they want to speak with the caller. Surveyor asked CNA F how a resident can make a phone call, she indicated they get the mobile phone and dial the number for the resident. Surveyor asked CNA F the procedure for visitors, she indicated the visitors check in at the front desk and then the visitor calls when they are at the front door of unit, identify themselves and who they are visiting. Surveyor asked CNA F the procedure if a visitor does not identify themselves, she indicated she would get a nurse. Surveyor asked CNA F about R4's phone policy, she indicated that the staff make the calls for her and then transfer the call to her phone. Surveyor asked CNA F why R4's phone keypad is covered, she indicated so R4 cannot make any calls herself. Surveyor asked CNA F if R4 is physically able to make calls herself, she indicated R4 has the ability. Surveyor asked CNA F if R4 has voiced concerns with the phone plan, CNA F indicated R4 was saying this was socialism and communism and gets upset with the phone policy. On 8/8/23 at 8:40 AM, Surveyor interviewed Scheduler G. Surveyor asked Scheduler G if she covers the front desk, she indicated she did until the morning receptionist comes in. Surveyor asked Scheduler G the process for visitors, she indicated the visitor comes to the front entryway door and picks up the phone that rings to the desk. Scheduler G continued to explain the visitors identify themselves, who they are visiting, and are to be screened for COVID-19. Surveyor asked Scheduler G the visitor process at the locked units, she indicated the visitors must check in with the staff, they identify themselves and who they are visiting to get in. Surveyor asked Scheduler G the reasoning for calling the unit to be let in, she indicated some residents didn't want visitors or something might be in place for a specific resident. On 8/8/23 at 8:54 AM, Surveyor interviewed SW E (Social Worker). Surveyor asked SW E the visitor process. SW E indicated the visitors pick up the phone at the entrance that rings to the staff or charge nurse, the visitor needs to state who they are, who they are visiting, and the number of people in their party. SW E further indicated the receptionist or staff will buzz the visitors in and they proceed to the COVID-19 screening. Surveyor asked SW E the process for visitors for locked units, she indicated there is a phone on the wall, the visitor states their name and who they are visiting, the staff person then meets them at the door to open the door manually. Surveyor asked SW E if screening resident visits by asking a visitor to identify themselves and who they are visiting is a violation of resident right, she indicated she did not believe so. Surveyor asked SW E if R4 has a care plan to screen for visitors, she indicated R4 does not and that it is standard to screen for everyone in the building and everyone needs to identify themselves due to previous offenders and restraining orders. We need to make sure who is coming is appropriate. Surveyor asked SW E the process of incoming phone calls, she indicated the call comes into the nurse, the nurse can transfer to a mobile phone, and then give the phone to the resident. Surveyor asked SW E if the staff ask who is calling, she indicated yes as that it is a courtesy and is not necessarily required unless it is care planned and is also preventative for a scam or a telemarketer. Surveyor asked SW E the incoming phone process for R4, SW E stated: the person needs to ask who is calling in case it is an entity that is an insurance agent calling her, then either say she is not available, and the phone call is then transferred to the nurse. This has only happened once or twice. Surveyor asked SW E if screening resident calls by asking who the caller is and who they are calling for is a violation of resident rights, she indicated she did not believe so. Surveyor asked SW E if dialing a phone number for a resident is a violation of their privacy, she indicated no, they are assisting them to make the call they wish. Surveyor asked SW E if R4 has loss some of her human rights, she indicated no and that R4 has all her rights except the phone modification. Surveyor asked SW E if the resident has a right to make and receive calls, she indicated yes. On 8/8/23 at 11:24 AM, Surveyor interviewed Receptionist H. Surveyor asked Receptionist H the process for visitors, she indicated the visitor calls from the entryway and identifies themselves, who they are here to see. Surveyor asked Receptionist H if she asks who the visitor is, she indicated she does not because she looks at the COVID-19 screening form and looks at her cheat sheet. Receptionist H further indicated that R4 does have a person on the cheat sheet she wishes to not visit. Surveyor asked Receptionist H the process if the visitor's name was not on the COVID-19 form, she indicated she will ask for name and call the nurse manager if the visitor still refuses. Surveyor asked Receptionist H the process for incoming calls, she indicated that callers identify themselves, she transfers the caller to the unit, and the staff would screen the calls at that point. On 8/8/23 at 11:30 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B the visitor process for the locked units, she indicated the signage on the wall informs the visitor to call and identify themselves and who they are visiting and then the staff let them in. Surveyor asked DON B if a visitor must identify themselves, she indicated technically no, but it is helpful. Surveyor asked DON B if it is a violation of a resident right to screen phone calls, she indicated screening phone calls should not be happening, and it is situational. Surveyor asked DON B the process for the ombudsman to visit a resident, she indicated there was nothing different, an ombudsman has the right to visit. The facility has a process in which visitor must identify themselves and who they are visiting additionally the facility has a process in which they screen resident calls. This process violates the resident right to have a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, and did not ensure that the resident can exercise his or her rights without interference.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse are reported 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, to the administrator of the facility and to other officials for 1 of 3 allegations reviewed for abuse. R1 was observed hitting another resident with a pillow. The facility did not report this event to the State Agency. This is evidenced by: The facility's policy titled Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Property or Injuries of Unknown Origin, and Mandatory Reporting of a Crime dated 1/24/23, states in part .II. Policy: Each resident has the right to be free from abuse, neglect, mistreatment, exploitation, misappropriation of resident property .Residents must not be subjected to the preceding by anyone, including but not limited to, facility staff, other residents, consultants .All alleged violations will be reported to the administrator or designee, Director of Nursing, and the nurse manager immediately, thoroughly investigated and measures implemented to prevent further incidents. Incidents that meet state and federal criteria will be reported to the Division of Quality Assurance (DQA) and the Office of Caregiver Quality (OCQ) immediately. Immediately is defined as not later than 2 hours, if the alleged violation involves abuse or results in serious bodily injury, or 24 hours, if the alleged violation does not involve abuse and does not result in seriously bodily injury. A written report filed within 5 working days of the incident . R1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Dementia with agitation, Major Depressive Disorder, Anxiety Disorder, and cognitive communication deficit. R1's most recent Minimum Data Set (MDS) dated [DATE], states that R1 is rarely/never understood. R1 has documented behaviors of being physically aggressive with staff and wandering into peers' rooms. In April 2023, R1 was physically aggressive with staff for 36 out of 90 shifts, R1 wandered into peers' rooms 67 out of 90 shifts. R1's nurse's notes on 4/24/23 at 8:44 PM state in part, Resident was delusional, accusatory, and physically and verbally aggressive early in the shift. Resident was accusing staff of abusive towards an individual. Resident became agitated when staff attempted to reassure. Per CNA (Certified Nursing Assistant), resident grabbed a pillow and hit another resident sitting in a Broda chair four times. Resident attempted to kick a staff while writer was trying to redirect the resident. When writer was trying to provide reassurance, the resident was verbally abusive towards the writer .Staff allowed the resident to wander on his own and resident eventually settled . R1's nurse's notes on 4/24/23 at 10:50 PM state in part, Per CNA, around 1615 (4:15 PM) resident became agitated and was wandering around the living room. Resident unexpectedly pulled a pillow from another resident (victim) who was sleeping in the Broda chair. Resident began hitting the other resident with the pillow four times . Of note, using the reasonable person concept, a resident would be saddened and distressed if they were hit with an object unprovoked in their own home. On 8/8/23 at 10:45 AM, Surveyor interviewed SN I (Supervisory Nurse.) Surveyor asked SN I what the facility's process was for a resident-to-resident altercation. SN I stated that they protect and separate the residents, get help if needed, and report it immediately; CNAs are to report it to the first nurse they see or call the charge nurse and start an investigation immediately. SN I stated that depending on the severity and intent, they would call law enforcement and that they need to report it to the SA (State Agency) within 2 hours and have 5 days to complete. Surveyor asked SN I if she could explain why there wasn't a report sent to the SA regarding R1's resident to resident altercation on 4/24/23? SN I stated that she was unaware of the incident. Surveyor asked SN I if the incident should have been investigated? SN I stated yes. Surveyor asked if the incident should have been reported to the SA? SN I stated that she didn't know. On 8/8/23 at 2:38 PM, Surveyor interviewed DON B (Director of Nursing.) Surveyor asked DON B if the incident on 4/24/23 regarding R1 should have been investigated? DON B stated that depending on the severity, yes, it should have been investigated. Surveyor asked DON B if she would have expected that it would have been self-reported to the SA? DON B stated it should have been reported to the charge nurse, care coordinator, nurse manager, but the nurse didn't report it to anyone until the next shift arrived. Surveyor asked DON B, based on a reasonable person concept, should the incident have been reported to the SA? DON B stated yes. On 8/8/23 at 3:15 PM, Surveyor interviewed RN J (Registered Nurse.) Surveyor asked RN J about the resident-to-resident altercation involving R1 on 4/24/23. RN J reported that R1 was agitated and has a history of behaviors. RN J stated that R1 was wandering and went around the Broda chair and removed a pillow from behind the head of the victim and proceeded to hit him four times with the pillow in the head. Surveyor asked RN J what the size of the pillow was? RN J stated that it was a standard sized bed pillow. It is important to note that Surveyor received an email on 8/9/23 at 12:20 PM from DON B written by SN K. SN K reported that she was made aware of the resident-to-resident altercation around 10:00 PM and that the following day (4/25/23) she continued to follow up with staff and residents. At no time did the facility submit a report to the State Agency regarding this incident. Cross Reference F600

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 1 of 3 abuse investigations. R1 was observed hitting another resident with a pillow. The facility did not thoroughly investigate the incident. Evidenced by: The facility's policy titled Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Property or Injuries of Unknown Origin, and Mandatory Reporting of a Crime dated 1/24/23, states in part .II. Policy: Each resident has the right to be free from abuse, neglect, mistreatment, exploitation, misappropriation of resident property .Residents must not be subjected to the preceding by anyone, including but not limited to, facility staff, other residents, consultants .All alleged violations will be reported to the administrator or designee, Director of Nursing, and the nurse manager immediately, thoroughly investigated and measures implemented to prevent further incidents .V. Procedures: .B. Identification, Investigation, Protection, and Reporting: It is the policy of [facility name] that reports of abuse as defined above are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened. The investigation will begin immediately, once informed of an event .The Investigation will include: .3. What happened: a. Residents' statements .b. Peer statements .d. Involved staff and witness statements of events (written or verbal statements documented), staff or witnesses that were in the area at the time of the incident .10. Root cause analysis of the incident 11. Conclusion based on findings . R1 was admitted to the facility on [DATE] with diagnoses that include: Alzheimer's Disease, Dementia with agitation, Major Depressive Disorder, Anxiety Disorder, and cognitive communication deficit. R1's most recent Minimum Data Set (MDS) dated [DATE], states that R1 is rarely/never understood. R1 has documented behaviors of being physically aggressive with staff and wandering into peers' rooms. In April 2023, R1 was physically aggressive with staff for 36 out of 90 shifts, R1 wandered into peers' rooms 67 out of 90 shifts. R1's nurse's notes on 4/24/23 at 8:44 PM state in part, Resident was delusional, accusatory, and physically and verbally aggressive early in the shift. Resident was accusing staff of abusive towards an individual. Resident became agitated when staff attempted to reassure. Per CNA (Certified Nursing Assistant), resident grabbed a pillow and hit another resident sitting in a Broda chair four times. Resident attempted to kick a staff while writer was trying to redirect the resident. When writer was trying to provide reassurance, the resident was verbally abusive towards the writer .Staff allowed the resident to wander on his own and resident eventually settled . R1's nurse's notes on 4/24/23 at 10:50 PM state in part, Per CNA, around 1615 (4:15 PM) resident became agitated and was wandering around the living room. Resident unexpectedly pulled a pillow from another resident (victim) who was sleeping in the Broda chair. Resident began hitting the other resident with the pillow four times On 8/8/23 at 10:45 AM, Surveyor interviewed SN I (Supervisory Nurse). Surveyor asked SN I what the facility's process was for a resident-to-resident altercation, SN I stated that they protect and separate the residents, get help if needed, and to report it immediately; CNAs are to report it to the first nurse they see or call the charge nurse and start an investigation immediately. Surveyor asked SN I if the incident should have been investigated, SN I stated yes. On 8/8/23 at 2:38 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the incident on 4/24/23 regarding R1 should have been investigated, DON B stated that depending on the severity, yes, it should have been investigated. On 8/8/23 at 3:15 PM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J about the resident-to-resident altercation involving R1 on 4/24/23, RN J reported that R1 was agitated and has a history of behaviors, RN J stated that R1 was wandering and went around the Broda chair and removed a pillow from behind the head of the victim and proceeded to hit him four times with the pillow in the head. Surveyor asked RN J what the size of the pillow was, RN J stated that it was a standard sized bed pillow. It is important to note that Surveyor received an email on 8/9/23 at 12:20 PM from DON B written by SN K. SN K reported that she was made aware of the resident-to-resident altercation around 10:00 PM and that the following day (4/25/23) she continued to follow up with staff and residents. SN K's documentation indicates that residents were interviewed the next day but there is no documentation that other staff, including the CNA (Certified Nursing Assistant that was present during the altercation, were interviewed. There is no evidence that the investigation was started immediately, and that the facility completed a thorough investigation.

Based on observation and interview the facility did not ensure food was prepared in a clean and sanitary environment in accordance with professional standards for food service safety. This has the potential to affect all 110 residents. -Floor stand mixer was found to have dried food particles on the undercarriage and splatter guard. -Medium stand mixer was found to have dried food particles on the undercarriage and splatter guard. -Countertop stand mixer was found to have dried food particles on the undercarriage. -Pans were stacked while wet following dishwashing and placed into storage. This is evidenced by Example 1 FDA (U.S. Food and Drug Administration) Food Code 2022 documents at section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . On 5/16/23 at 10:30 AM and on 5/17/23 at 4:00 PM, Surveyor observed a floor stand mixer with a visible brown dried substance splattered on the undercarriage and splatter guard, a medium stand mixer with a dried white substance splattered on the undercarriage and splatter guard, and a countertop stand mixer with a dried white substance on the undercarriage of the stand mixer. On 5/17/23 at 4:00 PM, Surveyor interviewed FSS O (Food Services Supervisor). Surveyor and FSS O inspected the three mixers. When inspecting the floor stand mixer FSS O indicated that the undercarriage and splatter guard doesn't look as clean as it should, and the brown dried substance was brownie batter that was prepared using the mixer the day before. FSS O, indicated that undercarriage of the medium mixer and splatter guard was not clean, and the dried white substance splattered was whipped cream that was prepared yesterday. FSS O indicated that the bottom side of the head unit of the countertop stand mixer was not clean and had dried food on it. On 5/18/23 at 3:00 PM Surveyor requested a mixer cleaner policy from FSS O this was not provided to Surveyor by the end of survey. FSS O indicated that they train staff on the cleaning process, including the shield around the mixers. Surveyor asked if the facility had a cleaning schedule for the mixers. FSS O indicated that the mixers are cleaned after they are used. On 5/18/23 at 3:46 PM, Surveyor interviewed and requested a mixer cleaner policy and schedule from FSM N (Food Service Manager). FSM N was unable to provide a mixer cleaning policy or schedule. FSM N indicated that staff at each workstation is supposed to be cleaning their assigned workstations top to bottom after every shift, and that supervisor is responsible inspecting workstations following each shift. FSM N indicated that this process is outlined in the job routines of kitchen staff. Example 2 FDA Food Code 2022 documents at section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; . On 5/15/23 at 10:10 AM Surveyor observed FS P (Food Service) removing pans dripping with water from the dishwasher rack following the dishwashing cycle and stacking them FS P placed the wet stacked pans on a cart and placed pans on a storage shelf. Surveyor and FS P examined pans, pans were still damp and dripping. FS P indicated the pans should be dry when stacked. On 5/18/23 at 3:00 PM Surveyor interviewed FSS O (Food Service Supervisor). FSS O indicated that dishes including pans are to be air dried and not stacked wet, stacking dishes wet can cause bacteria to grow. It's not something you do. 45695 Example 3 On 5/15/23 at 11:44 AM, Surveyor observed FS C (Food Service) taking temperatures of lunch foods prior to serving. FS C walked to the sink, removed her gloves, rinsed her hands in water, used paper towel to dry her hands, and then returned to the serving table to start putting on a pair of gloves. Surveyor asked FS C if she used soap when washing her hands, she indicated no and advised she should have used soap. Example 4 On 5/17/23 at 8:37 AM, Surveyor observed a plastic spoon in the brown sugar container with the cover on the container. Surveyor interviewed CNA D (Certified Nursing Assistant) and indicated the spoon should not be in the brown sugar.

Based on interview and record review the facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for 3 of 25 residents (R65, R7, and R8) reviewed for code status of total sample of 32 and 1 of 1 supplemental resident (R97). R65's code status preference form documents CPR (Cardiopulmonary Resuscitation, Full Code status) and his code status order is DNR (Do Not Resuscitate), these do not match. R7's code status does not match in the medical record and DNR form is not signed by legal representative. R8's code status preference form is not signed by the resident or legal representative. R97's code status preference form documents No CPR, and his code status order is Full code, these do not match. This is evidenced by: The Facility's Policy and Procedure entitled CPR (Cardiopulmonary Resuscitation)/DNR (Do Not Resuscitate) dated [DATE], documents, in part: .C. CPR status will be reviewed with resident/guardian quarterly and as needed. D. The CPR/DO-NOT-Resuscitate order will be written by the attending physician after the resident and/or legal decision maker have been made aware of the risks and benefits associated with each of these options. E. The physician's orders are the official location for CPR/DNR status. No separate lists shall be kept. No notation on the outside of the charts will be used .A. Assigning Code Status at Admission: 1. Before admit, the admissions coordinator/clerk will: a. Provide facility's CPR Do-Not-Resuscitate Information Sheet, facility's CPR/Do Not Resuscitate Directive, and the State of WI Emergency Care Do Not Resuscitate Order forms to legal decision maker as part of the admission packet. b. Obtain a written decision about code status from legal decision maker on the appropriate forms before admission .2. At the time of admission, the admitting nurse will: a. Consult the facility's Admission CPR/Do Not Resuscitate Advanced Directive Form signed by resident/legal decision maker and enter the correct code status in EHR (electronic health record) under physician's orders . It is important to note that the above policy does not delineate whether the physician orders are those electronic in the EHR or those paper orders in the hard chart. The ADMISSION CPR/Do Not Resuscitate Directive form is in the EHR (Electronic Health Record) under Advance Directives. Physician Orders in the hard chart are under the Physician Orders tab and are copied onto pink paper. Electronic Physician Orders are found in the EHR under Physician Orders. EMERGENCY CARE DO NOT Resuscitate ORDER (DNR) form is in the hard chart under the Advance Directive tab. It is important to note, only DNR residents use this form. Example 1 R97 admitted to the facility [DATE]. R97's ADMISSION CPR/Do Not Resuscitate Directive form documents No CPR- Do Not Resuscitate (comfort care will be provided), dated [DATE]. R97's pink physician order sheets in hard chart documents FULL CODE, dated [DATE]. R97's electronic physician order documents FULL CODE. R97's EMERGENCY CARE DO NOT Resuscitate ORDER (DNR) form documents DNR, dated [DATE]. Example 2 R65 admitted to the facility [DATE]. R65's ADMISSION CPR/Do Not Resuscitate Directive form documents CPR with notation * pending physician recommendation of DNR, dated [DATE]. R65's pink physician order sheets in hard chart documents DNR, dated [DATE]. R65's electronic physician order documents DNR. R65's EMERGENCY CARE DO NOT Resuscitate ORDER (DNR) form documents DNR, dated [DATE]. Example 3 R8 admitted to the facility [DATE]. R8's ADMISSION CPR/Do Not Resuscitate Directive form documents No CPR- Do Not Resuscitate (comfort care will be provided), this document is not signed or dated. R8's pink physician order sheets in hard chart documents DNR, dated [DATE]. R8's electronic physician order documents DNR. R8's EMERGENCY CARE DO NOT Resuscitate ORDER (DNR) form documents DNR, dated [DATE]. On [DATE] at 12:06 PM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J where a residents' code status would be found, in the event of an emergency (i.e., a code (when a resident is in cardiopulmonary arrest requiring a team of providers to rush to the specific location and begin immediate resuscitation efforts)); RN J stated she would look in the hard chart under the physician order tab. Surveyor asked RN J who completes the code status paperwork with residents upon admission, RN J said that the resident usually comes with an order on admission. Surveyor asked RN J if the forms should be signed and dated, RN J stated I would think so. Surveyor asked RN J if a resident changes his/her mind about code status and wants it changed, who is responsible for this task; RN J explained that the CCC (Clinical Care Coordinator) might be, but she would pass this request onto administration so that the correct people are alerted. On [DATE] at 12:37 PM, Surveyor interviewed RN, IP K (Infection Preventionist). Surveyor asked RN, IP K where a residents' code status would be found, in the event of an emergency (i.e. a code), RN, IP K stated there are multiple places and multiple people would be looking but the quickest and easiest would be in the nurse's station charting room where the DNR bracelets hang, or in the hard chart under the advance directives tab for the form, or is you're logged into your computer, then in the edocs (electronic documents) under advance directives. Surveyor asked RN, IP K who completes the code status paperwork with residents upon admission, RN, IP K said the CCC and/or SW (Social Worker). Surveyor asked RN, IP K if the forms should be signed and dated, RN, IP K stated yes, if the resident is responsible for themselves then they should sign and if they are activated then their legal representative should sign. Surveyor asked RN, IP K if a resident changes his/her mind about code status and wants it changed, who is responsible for this task, RN, IP K said CCC or Social Worker. On [DATE] at 12:43 PM, Surveyor interviewed RN, NM L (Nurse Manager). Surveyor asked RN, NM L where a residents' code status would be found, in the event of an emergency (i.e., a code), RN, NM L stated number one spot is always the electronic physician orders, but you could also look in the hard chart under the advance directive tab or in the edocs in the EHR. Surveyor asked RN, NM L who completes the code status paperwork with residents upon admission, RN, NM L said the Social Worker (SW). Surveyor asked RN, NM L if the forms should be signed and dated, RN, NM L stated yes, by both the Physician and the Resident/Legal Representative. Surveyor asked RN, NM L if a resident changes his/her mind about code status and wants it changed, who is responsible for this task, RN, NM L said nursing must communicate this to the Physician, then the Physician will have a conversation with resident and family, then SW generates paperwork. On [DATE] at 1:15 PM, Surveyor interviewed SSD M (Social Service Director). Surveyor asked SSD M where a residents' code status would be found, in the event of an emergency (i.e., a code), SSD M stated electronic Physician Orders as these are up to date. Surveyor asked SSD M who completes the code status paperwork with residents upon admission, SSD M said these forms go out prior to admission to the legal decision maker, sometimes they are emailed back in sometimes they are mailed, or hand delivered; if they are choosing DNR there are two forms; our preference form and the State DNR form, if choosing full code then just the preference form. Surveyor asked SSD M if the forms should be signed and dated, SSD M stated yes, signatures and dates should be there, that's our error. Surveyor asked SSD M if a resident changes his/her mind about code status and wants it changed, who is responsible for this task, SSD M said they can change their mind at any time, we have a conversation around the code status change request and discuss what that means, the Physician change is the official order change and clerically there are a number of pieces to getting this changed depending on which way it is being changed but we (Social Services) complete the majority of the change. Surveyor asked SSD M if the facility's preference form is ever re-done, SSD M stated no, that form is only done upon admission, it is not re-done even if there is a change in code status, but the form is archived in the chart for historical reference. On [DATE] at 4:06 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B where do you expect your nurses to locate a residents' code status, in the event of an emergency (i.e., a code), DON B stated I expect them to find that under the Physician Orders in the computer. Surveyor asked DON B should the code status preference forms be signed and dated, DON B said they are supposed to be yes. Surveyor asked DON B if code status should be accurate and match in all places that it is documented, DON B said it should be yes 45695 Example 4 R7 was admitted into the facility on [DATE]. On [DATE], Surveyor reviewed R7's records: R7's Physician Order summary located in R7's chart, dated [DATE]-[DATE], order date [DATE] . Full Code. Note: The physician order summary are pink copies located in R7's blue medical record at the nurse's station. Surveyor requested the Advance Directive and was provided the in-house form entitled, CPR/Do Not Resuscitate Directive with the box checked CPR and signed by the legal representative on [DATE]. R7's Physician order dated [DATE] states, DNR/No Intubation. R7's blue chart contains a form entitled, Emergency Care Do Not Resuscitate Order that is signed by the physician on [DATE] and no signature is present on the form from the legal guardian. R7's hospital facility discharge summary, dated [DATE], states in part; Code status: No CPR/No intubation. R7's hospice facility admission note start date of [DATE] states in part; .Advance directives discussion and execution . Patient has a completed State DNR Order . Note: The State DNR completed form was not provided to the Surveyor prior to exit. R7's Nursing progress note dated [DATE], states in part; . Code status changed at [hospital name] to DNR/ No Intubation- will clarify with guardian for continuation of this decision. On [DATE] at 12:56 PM, Surveyor interviewed RN H (Registered Nurse). Surveyor asked RN H where she would look for a code status, she indicated if she had the computer up, she would look in the computer by pulling up the physician order. RN H further indicated if the computer was not up or on, she would pull the blue chart and go to the section of the physician orders and look at the pink page with the physician order of the code status that would be on the front page. Surveyor then demonstrated to RN H the computer says to not perform CPR and the pink physician orders says to perform CPR. RN H indicated she would look at the advance directives tab in the blue chart. After viewing the Advanced Directives, RN H indicated the guardian did not sign and that she would call the guardian. Surveyor asked if R7 had a guardian, she indicated yes. On [DATE] at 12:58 PM, Surveyor interviewed RN I. Surveyor asked RN I if she would perform CPR on R7. RN I indicated she would not perform CPR on R7 because she has had a talk with the guardian in the past indicating the guardian was kind of agreeing with us and was going to confirm with her brother. On [DATE] at 3:52 PM, Surveyor interviewed FM G (Family Member). Surveyor asked FM G if she has signed any paperwork regarding R7's code status. FM G indicated she did not sign anything and is hesitant to have the conversation with R7 stating, I don't know if she should be resuscitated at this point. I really don't know; I haven't discussed anything with her. FM G further indicated that she would like to have a discussion with R7's siblings and has not had a discussion yet of R7's code status.

Based on observation, interview and record review, the facility did not ensure it maintained 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 for 4 of 21 hand hygiene opportunities (R96 and R64). R96 and R64 was observed during wound care, where the RN (Registered Nurse) did not consistently follow professional standards of practice for hand hygiene. Staff did not complete hand hygiene per professional standard of practice. This is evidenced by: The facility policy entitled, Hand Hygiene, Employees, undated, states in part: . All staff shall utilize good hand hygiene techniques at all times, including following the removal of gloves or other personal protective devices . B. Hand Wash Methods 1. Soap and Water Hand Wash Method . b. Use adequate amount of soap from soap dispenser only . c. Lather well, using friction, clean under nails for at least 20 seconds, all surfaces of hands, and under/around fingernails . V. Procedure . C. Other Aspects of Hand Hygiene . 7. Change gloves and wash hands. Reapply clean gloves if moving from a contaminated body site to a clean body site . Example 1 On 5/18/23 at 8:49 AM, Surveyor observed Hospice RN F (Registered Nurse) complete wound care on R96's lower extremities. - Hospice RN F removed the old dressings on the left leg with gloved hands and used some scissors to cut off the soiled dressing. The scissors were placed on the clean wound supply barrier after use. The soiled gloves were removed, and new gloves were applied. The wound care continued to the right leg. The scissors were used to remove the soiled dressing and after the dressing was removed, the scissors were placed on the clean supply barrier and the gloves discarded. (Note: Hospice RN F did not perform hand hygiene after removing soiled gloves and did not sanitize scissors prior to placing them on the clean barrier.) - After the soiled dressings were removed, Hospice RN F removed her gloves and discarded them. Hospice RN F then went into R96's bathroom and obtained washcloths and used the sink to wet the washcloths. (Note: Hospice RN F did not perform hand hygiene after removing soiled gloves.) - Hospice RN F cleaned R96's legs with the washcloths and placed them on the clean supply barrier touching clean wound supplies. (Note: Hospice RN F placed soiled wet linen touching clean, unused dry wound supplies.) - Hospice RN F picked up a handheld mirror with soiled gloved hands and used the mirror to see the posterior wounds on R96's bilateral lower extremities, and then placed the mirror back on the clean supply barrier. Hospice RN F used the marker with soiled gloved hands to write down measurements on one occasion and a bare hand on another occasion during wound care. (Note: Hospice RN F contaminated the mirror and the marker with soiled gloves and placed them onto the clean barrier. During another opportunity, Hospice RN F used the mirror and marker with bare hands without sanitizing the marker and the mirror prior to use.) - Hospice RN F removed her soiled gloves and proceeded to obtain clean medical supplies from R96's drawer. (Note: Hospice RN F did not perform hand hygiene prior to touching R96's drawer.) - Hospice RN F picked up the soiled scissors, disinfected them and used the scissors to cut clean new wound dressings. After use, placed the scissors on the same contaminated location on the clean barrier. The scissors were picked up and reused multiple times as well as the mirror. (Note: Hospice RN F placed sanitized scissors on the contaminated area of the barrier and reused the scissors several occasions to cut clean dressings. The soiled mirror was placed on the clean barrier.) Example 2 On 5/15/23 at 12:19 PM, Surveyor observed CNA D (Certified Nursing Assistant) serving a resident lunch and then went to the sink to wash his hands. CNA D started the water, placed his hands under the water and then used paper towel to dry his hands. CNA D then went to return to assist residents with lunch. Surveyor asked CNA D if he used soap to wash his hands, he stated he did not use soap and should have used soap. Example 3 On 5/15/23 at 12: 28 PM, Surveyor observed CNA E assisting a resident with lunch and then went to the sink to wash his hands. CNA E started the water, placed his hands under the water, obtained soap, and washed for approximately 5 seconds, and then used paper towel to dry his hands. CNA D then went to return to assist residents with lunch. Surveyor asked CNA D how long hands should be washed, he indicated about 30 seconds and that he washed his hands for about 10 seconds. On 5/18/23 at 4:06 PM, Surveyor interviewed DON B (Director of Nursing) regarding wound care and hand hygiene. DON B indicated that hand hygiene should be performed after removing gloves, hands should be washed with soap, and hands should be washed for 15-20 seconds. DON B further indicated that during wound care, there should not be contact of clean wounds supplies with soiled linens because everything would be contaminated. 30992 Example 4 R64 was admitted to the facility 12/21/22. R64's diagnoses include, in part, pressure injury right hip - unstageable, paraplegia, mild neurocognitive disorder, intracranial injury and cauda equina syndrome. On 5/18/23 at 9:37 AM, Surveyor observed RN Q (Registered Nurse) and RN Sup R (Registered Nurse Supervisor) change R64's dressing to his unstageable pressure injury to his right hip. Surveyor observed RN Q cleanse the pressure injury with Dial soap and a moistened gauze pad, pat dry. RN Q removed her gloves and applied new gloves. RN Q did not sanitize her hands in between glove changes per standards of practice. RN Q then proceeded to pack R64's pressure injury with iodosorb. RN Q removed gloves and applied new gloves. RN Q applied a dressing to R64's pressure injury. RN Q did not sanitize her hands in between glove changes per standards of practice. On 5/18/23 at 9:55 AM, Surveyor spoke with RN Q. Surveyor asked RN Q, when should you wash/sanitize your hands. RN Q stated, when entering a room, before cares, after cares, when completing wound care when removing gloves. RN Q stated if hands are heavily soiled she would wash hands with soap and water. RN Q stated she receives regular education regarding handwashing. Surveyor asked RN Q, should you have used hand sanitizer in between glove changes. RN Q stated, Yes. On 5/18/23 at 3:52 PM, Surveyor spoke with RN Sup R (RN Supervisor). Surveyor asked RN Sup R, when should staff wash hands. RN Sup R stated, upon entering room, leaving room, prior to contact with resident or bodily fluids, and assisting with meals. Surveyor asked RN Sup R, when should staff wash/sanitize hands during a dressing change. RN Sup R stated, staff should remove gloves, sanitize, and reapply gloves. RN Sup R added, basically every time staff remove gloves they need to sanitize their hands and if their hands are visibly soiled they should use soap and water. Surveyor asked RN Sup R, why is it important for staff to wash/sanitize their hands following glove changes. RN Sup R stated, RN Q did the cleaning with the Dial soap and water, but she was still touching other surfaces. RN Sup R stated this is important for infection prevention. On 5/18/23 at 4:49 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor described the dressing change above to DON B and lack of hand washing/sanitizer in between glove changes. DON B stated the general concept is to wash hands when changing gloves and that should not have happened.

Based on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization having the potential to affect the census of 110 residents (R). This is evidenced by: The facility policy, entitled Preventative Care Protocol, dated 11/29/22, states, in part: . I. Vaccinations: . A. Pneumococcal Vaccine: 1.Please refer to https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo/downloads/pneumo-vaccine-timing.pdf for administration guidelines. B. Trivalent or Quadrivalent Influenza Vaccine: Annually per recommendation of Medical Director . The facility policy does not address the following for the Influenza and Pneumococcal immunizations: *Resident/resident representative to receive education regarding the benefits and potential side effects of the immunizations. *Resident is offered an influenza immunization October 1 through March 31 annually unless contraindicated or resident has been immunized. *Each resident is offered a pneumococcal immunization unless contraindicated or resident has been immunized. *Resident/resident representative has the choice to refuse immunizations. *The resident's medical record includes at a minimum: Resident/resident representative was provided the education regarding the benefits and side effects of the immunizations and the resident either received the immunizations or did not receive the immunizations and reasons. On 5/17/23, at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding the pneumococcal policy. Surveyor reviewed the State Owner's Manual (SOM) on requirements for a pneumococcal and influenza policy with DON B and asked if their policy included those requirements for a pneumococcal and influenza vaccine policy. DON B indicated no; the facility needs a more detailed policy.

Based on observation, interview, and record review, the facility did not ensure correct use of a bed rail, by not following manufacturer's recommendations and specifications for 6 of 6 residents (R78, R81, R86, R5, R37, R75) utilizing bed rails. The facility failed to assess residents R78, R81, R86, R5, R37, and R75 for the risk of entrapment when using bed rails and the facility did not review the risks and benefits and obtain informed consent prior to the instillation of bed rails. This is evidenced by: Manufacturer's instructions for the facility's beds include but are not limited to: Warning: Entrapment with assist devices may cause injury or death. To help prevent entrapment you should follow the FDA's (Food and Drug Administration) Entrapment Guidance and your healthcare provider's recommendation to chose a bed, mattress and accessories that are appropriate for the specific resident. In addition, you should ensure the mattress fits the bed frame and assist device snugly, follow the manufacturer's instructions for all medical devices and accessories, and monitor the patient frequently. If the assist device is placed incorrectly, it may pose an entrapment risk to your resident. DANGER! Risk of Death or Injury Patient entrapment with the bed side rails may cause injury or death. Proper patient assessment , and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, mattress thickness, size and density could increase the risk of entrapment. -Visit the FDA website at http://www.fda.gov to learn about the risk of entrapment . Review A Guide to Bed Safety, published by the Hospital Bed Safety Workgroup, located at www.invacare.com. Use the link located under each bed rail product entry to access this bed safety guide. - Refer to the Bed Rail Entrapment Risk Notification Guide included with your mattress for further information. DANGER! Risk of Injury or Damage An increased risk of patient entrapment may occur over time due to mattress compression. - Periodically monitor gaps between the bed, mattress, and /or bed rail. Where gaps occur, patient entrapment is possible and the mattress should be replaced. Caution! - make sure that the distance between the surface of the mattress and top of the side rail is at least 8.7/2220mm. Danger! Risk of Death, Injury Or Damage Conditions such as restlessness, mental deterioration and dementia or [CONDITION(S)] disorders (uncontrolled body movement), sleeping problems, and incontinence can significantly impact a patient's risk of entrapment. Pediatric patients or patients with small body size may also have an increased risk of entrapment. - monitor patients with these conditions frequently. 1. Resident 78 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R78's quarterly Minimum Data Set, (MDS) dated [DATE], indicated that their brief interview for mental status (BIMS) score was 10 which indicates the resident is moderately cognitively impaired. It also indicates that R78 is independent with bed mobility and requires no set up or physical help from staff. Observations on 03/14/22 at 2:30 PM revealed that R78 has two bilateral vertical grab bars on her bed. Record review of R78's medical record on 03/14-16/2022 did not reveal any assessment for the risk of entrapment with bedrail use, and did not reveal and review of the risks and benefits or consent for the use of bed rails with the resident's representative. Interview with Clinical Care Coordinator (CCC) G on 03/15/22 at 3PM: Surveyor asked if the facility assesses bed rails or gaps in between mattresses and the bed rails. CCC G stated that the facility does not measure or inspect the residents' beds as part of a risk of entrapment assessment. CCC G indicated they would only do that if it was necessary, but has not had to do that yet. Surveyor requested further information related to bed rail use. Interview with DON B on 03/16/22 at 12:22 PM: We don't have any risks and benefits statements, or side rail assessments for the risk of entrapment. DON B indicated bed rails are put on when needed. If a resident dies or moves and vacates a bed, a team of staff comes in and looks at the bed at that time to make sure it functions properly. 2. R81 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 03/14/22 at 1:03 PM revealed that R81 has bilateral half side rails on each side of her bed. R81's quarterly Minimum Data Set, (MDS) dated [DATE], indicated that their brief interview for mental status (BIMS) score of 4 which indicates the resident is severely cognitively impaired. It also indicates that R81 requires the assistance of 1 for bed mobility and requires oversight, encouragement, or cueing help from staff. Record review of R81's medical record on 03/14-16/2022 did not reveal any assessment for the risk of entrapment with bedrail use, and did not reveal and review of the risks and benefits or consent for the use of bed rails with the resident's representative. Interview with DON B on 03/16/22 at 12:22 PM: We don't have any risks and benefits statements, or side rail assessments for the risk of entrapment. DON B indicated bed rails are put on when needed. If a resident dies or moves and vacates a bed, a team of staff comes in and looks at the bed at that time to make sure it functions properly. 3. Record review identified R86 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R86's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed R86 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R86 had a severe cognitive impairment. The MDS also indicated R86 had one fall with major injury since admission, and R86 was assessed as at risk for falls. On 03/14/22, at 02:34 PM, Surveyor observed half-rails on both sides of the upper half of R86's bed. R86's conversation was very confused, and was not able to say if he used them for repositioning. Surveyor noted the rail on the right side of the bed was wobbly when grabbed. On 03/15/22, at 02:46 PM, Surveyor interviewed Clinical Care Coordinator (CCC) I, who stated they did not do a safety risk assessment for R86's side rails, because he came to them from a different facility where he was using side rails. CCC I stated R86 came with orders for the rails, so they didn't do a safety assessment for risk of entrapment with the rails. CCC I stated they just let the doctor know R86 was using the rails, and obtained orders for them. CCC I stated the risks and benefits were not discussed with R86's representative, and a consent form was not obtained for the rails. Surveyor reviewed R86's medical record. There was no order for side rails identified on the record. R86's comprehensive care plan and group sheet did not identify that R86 had side rails on the bed. Surveyor did not identify a safety risk assessment, or assessment for risk of entrapment with use of the side rails. Surveyor did not identify review of risks and benefits with use of the side rails, or a consent for use of the side rails from R86's representative. On 03/16/22, at 7:21 AM, Surveyor interviewed Director of Nursing (DON) B, who stated a safety risk assessment should be done prior to the implementation of bed rails. DON B stated staff would put an Interdisciplinary Progress Note in the medical record that explained the rationale for the bed rails, and what was tried prior to the implementation of the rails. DON B stated they had a policy for the implementation of restraints/bed rails. DON B was not sure how they documented the risk/benefits discussion and consent with the resident or their representative, and stated would need to check the policy. DON B stated the rails would be listed on the group sheet. Surveyor reviewed the facility Policy and Procedure Subject: Restraint Device Use. The policy stated, in part: .Definition .Restraints can include and are not limited to: 1. Bed rails of any length .Evaluation of need for restraint/device. 1. Other less restrictive alternatives will be explored before restraints or devices are applied .4. If no lesser restrictive alternatives meet the resident's needs, the nurse should complete restraint assessment, inform legal decision-maker, obtain MD order . On 03/16/22 at 9:00 AM, Surveyor noted the Certified Nursing Assistant (CNA) group sheet now included Bilateral side rails to aid in turning/repositioning for R86. On 03/16/22, at 11:04 AM, Surveyor interviewed CCC I who stated they did not do a safety risk assessment, or risk of entrapment assessment before side rails were installed on R86's bed. CCC I stated they did not have any documentation of other measures tried prior to implementation of the bed rails. CCC I stated they did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CCC I stated that the rails may have been on the bed from the previous resident, and they missed getting everything assessed and just left them on the bed for R86. 4. On 03/14/22 at 11:10 am, Surveyor observed R5 to have an air mattress with two side rail/grab bars in place, one on each side of his bed. Record review of R5's medical record on 03/14-16/2022 did not reveal any assessment for the risk of entrapment with bedrail use, and did not reveal and review of the risks and benefits or consent for the use of bed rails with the resident's representative. On 03/16/22 at 12:33 pm, Surveyor interviewed DON B who indicated that there is no assessment for entrapment of the resident and could not find anything for preventative maintenance of the beds and bedrails either. 5. On 03/14/22 at 11:10 am, Surveyor observed R37 to have two side rail/grab bars in place, one on each side of her bed. R37's quarterly Minimum Data Set (MDS) assessment, dated 03/15/22, showed a brief interview for mental status (BIMS) score of 99 which indicates severe cognitive impairment. Record review of R37's medical record on 03/14-16/2022 did not reveal any assessment for the risk of entrapment with bedrail use, and did not reveal any review of the risks and benefits or consent for the use of bed rails with the resident's representative. On 03/16/22 at 12:33 pm, Surveyor interviewed DON B who indicated that there is no assessment for entrapment of the resident and could not find anything for preventative maintenance of the beds and bedrails either. 6. On 03/14/22 at about 11:00 am, Surveyor observed R75 has a half bed rail on the right side of her bed. R75's quarterly Minimum Data Set (MDS) assessment, dated 01/18/22, showed a brief interview for mental status (BIMS) score of 15. Record review of R75's medical record on 03/14-16/2022 did not reveal any assessment for the risk of entrapment with bedrail use, and did not reveal any review of the risks and benefits or consent for the use of bed rails with the resident's representative. On 03/16/22 at 12:33 pm, Surveyor interviewed DON B who indicated that there is no assessment for entrapment of the resident and could not find anything for preventative maintenance of beds or bedrails.

Based on observation, interview, and record review the facility did not perform regular inspections of all bed frames, mattresses and bed rails, if any, as a part of a regular maintenance program for 6 of 6 sampled Residents (R): R78, R81, R86, R5, R37, R75 The facility did not regularly inspect all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify any possible areas of entrapment for R78, R81, R86, R5, R37, and R75. This is evidenced by: 1. Resident 78 (R78) was admitted to the facility with diagnoses including dementia with behavioral disturbance, major depressive disorder, anxiety disorder, and muscle weakness. Observations on 03/14/22 at 2:30 PM revealed that R78 has two bilateral vertical grab bars on her bed. Record review of R78's medical record on 03/14-16/2022 did not reveal any regular maintenance program for R78's bed frame, mattress, and bed rails. 2. R81 was admitted to the facility with diagnoses including [CONDITION(S)], dementia, major depression, coronary artery disease, chronic pain, and [CONDITION(S)]. Observations on 03/14/22 at 1:03 PM revealed that R81 has bilateral half side rails on each side of her bed. Record review of R81's medical record on 03/14-16/2022 did not reveal any regular maintenance program for R81's bed frame, mattress, and bed rails. Interview with DON B on 03/16/22 at 12:22 PM: We don't have any preventative maintenance program for residents beds, mattresses, and bed rails. 3. Record review identified R86 was admitted to the facility on [DATE] with diagnoses including, in part: history of traumatic subdural hemorrhage with loss of consciousness, dementia, and cognitive impairment. R86's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed R86 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R86 had a severe cognitive impairment. The MDS also indicated R86 had one fall with major injury since admission, and R86 was assessed as at risk for falls. On 03/14/22, at 02:34 PM, Surveyor observed half-rails on both sides of the upper half of R86's bed. R86's conversation was very confused, and was not able to say if he used them for repositioning. Surveyor noted the rail on the right side of the bed was wobbly when grabbed. On 03/15/22, at 10:28 AM, Surveyor interviewed Janitor L about the facility process for bed rails. Janitor L reported they get a work order from the staff if a resident needs bed rails attached to their beds. Janitor L reported they install the rails, making sure they are the correct bars for the type of bed, and that they are installed correctly. Janitor L stated they do not do any measurements, or go back for any routine maintenance of the rails once they are installed. 4. Observations on 03/14/22 at 11:10 am included R5 to have an air mattress with two side rail/grab bars in place one on each side of his bed. Record review of R5's medical record on 03/14-16/2022 did not reveal any regular maintenance program for R5's bed frame, mattress, and bed rails. 5. Observations on 03/14/22 at 11:15 am included R37 to have two side rail/grab bars in place one on each side of her bed. Record review of R37's medical record on 03/14-16/2022 did not reveal any regular maintenance program for R37's bed frame, mattress, and bed rails. 6. Observations on 03/14/22 at about 11:20 am tour of the facility, Resident (R) R75 had a half bed rail on the right side of her bed. Record review of R75's medical record on 03/14-16/2022 did not reveal any regular maintenance program for R75's bed frame, mattress, and bed rails. On 03/16/22, at 12:23 PM, Surveyor interviewed Director of Nursing (DON) B, who stated they did not have a schedule for preventative maintenance done by the facility for use of bed rails. DON B stated the maintenance staff provide the appropriate rails for the bed when requested, and the janitorial staff install the rails. DON B stated there was no scheduled follow up assessments for routine maintenance of the rails.

Based on record review and interview, the facility did not consult with and notify Resident (R) 79's physician when severe weight loss occurred for 1 of 5 Residents reviewed for nutrition. R79 had a severe weight loss of greater than 10% over six months and greater than 5% in one month. The facility did not consult or notify R79's physician of the severe weight loss. This is evidenced by: Review of R79's medical record document current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE], documented in Section K0300 titled, Weight Loss, as R79 as having weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and is not on a physician prescribed weight loss regimen. Review of the MDS Care Area assessment dated [DATE], Registered Dietitian (RD) H documented: Resident triggers due to eating a Mechanical soft diet, with recent, significant weight loss, and BMI of 26, indicating he's mildly overweight. Recent weight loss is related to household quarantine triggering his paranoia around eating, drinking and taking medications. His household is now off quarantine. Will not refer. Will proceed with weight maintenance goals On 03/15/22, Surveyor reviewed R79's documented weights. On 02/06/2022, the resident weighed 171 lbs. On 03/14/2022, the resident weighed 160 pounds which is a -6.43 % Loss in one month. On 12/12/2021, the resident weighed 187.4 lbs. On 03/14/2022, the resident weighed 160 pounds which is a -14.62 % Loss in three months. On 09/12/2021, the resident weighed 187.2 lbs. On 03/14/2022, the resident weighed 160 pounds which is a -14.53 % Loss in six months. Review of dietary note dated 02/03/22: .Half portions at lunch/dinner due to persistent weight gain R79's weight of 172# is down significantly from his weight in December, of 187#. Weight loss is due to increased paranoia related to his household quarantine. Paranoia includes not eating or drinking, spitting out medications, and reporting that he's scared. BMI of 26 indicates he's mildly overweight. he has a weight loss goal of 165-175#. Will modify weight loss goal to a weight maintenance goal. Review of R79's medical record did not document a physician consult or notification of the occurring severe weight loss. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/16/22 at 12:10 p.m., Surveyor interviewed Director of Nursing (DON) B and RD H asking about physician notification of R79's severe weight loss. RD H indicated the weight loss was related to increased paranoia and was on weight loss program and is now moved on a maintenance goal. DON B indicated the physician was not notified of the weight loss. DON B indicated the nursing staff would notify the physician by doctor's communications book or by email. There is a physician in the building Monday - Thursday to be able to communicate concerns. DON B indicated RD H would also get an email notifying of the weight loss. At 2:20 p.m., DON B indicated the facility policy does not have specific guidelines for physician update of weight changes. The residents that need specific guidelines for weights are care planned. We are now in the process of updating the policy.

Based on observation, interview, and record review, the facility did not develop and implement a behavior care plan with targeted behaviors and non-pharmacological interventions for a resident receiving multiple [CONDITION(S)] medications. This occurred for 1 of 22 Residents (R) reviewed for care planning, (R86) Findings include: Record review identified R86 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R86's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed R86 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R86 had a severe cognitive impairment. The MDS also identified R86 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R86's medical record identified physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (antidepressant) 20 milligrams (mg) daily for depression; order date 11/04/21. [MEDICATION(S)] (antipsychotic) 0.5 mg daily for psychotic disorder; order date 11/03/21. [MEDICATION(S)] 1.25 mg daily at 8 PM for psychotic disorder; order date: 11/03/21 [MEDICATION(S)] 0.25 mg PRN (as needed) for agitation or hallucinations related to psychotic disorder; order date 03/09/22. On 03/14/22, at 12:08 PM, Surveyor observed R86 sitting quietly at a table in the dining room area. On 03/14/22, at 12:34 PM, Surveyor observed staff set up lunch at the table in front of R86. R86 appeared to have difficulty hearing the staff member, and asked what several times. R86 proceeded to eat independently. On 03/15/22, at 10:28 AM, Surveyor observed R86 seated in a recliner in the common area of the neighborhood. R86 got up from the recliner, and began walking down the hallway in the opposite direction of R86's room. A staff member asked R86 if R86 needed to use the rest room, and redirected R86 to the bathroom in R86's room. R86 was cooperative and easily redirected. Surveyor reviewed R86's comprehensive care plan, and group sheet (Certified Nursing Assistant (CNA) care plan). No problems, goals, or interventions were identified related to behaviors, depression, psychotic disorder, agitation, or hallucinations. Surveyor reviewed the behavior monitoring documentation for the past two months on R86's medical record, and identified the only targeted behavior being monitored was wandering behaviors. On 03/15/22, at 2:07 PM, Surveyor interviewed Clinical Care Coordinator (CCC) I, who reported R86 was receiving the scheduled and PRN antipsychotic medication for anxiety and agitation. When asked if the staff was monitoring R86 for those behaviors, CCC I stated the staff was only monitoring R86 for wandering behaviors. CCC I stated there were no targeted behaviors for anxiety, agitation, or psychotic behaviors being monitored. On 03/15/22, at 2:15 PM, Surveyor interviewed CNA N, who stated R86 occasionally wandered, but was easily redirected. CNA N stated a couple of months ago, R86 returned from a hospital stay on a new medication. They noted R86 was more irritable and anxious at that time, but those behaviors had stopped. CNA N stated they were only monitoring wandering behaviors, and no other behaviors that CNA N was aware of. On 03/16/22, at 8:58 AM, Surveyor interviewed CNA P, who reported R86 did not have much for behaviors, mostly just wandered on the neighborhood. CNA P stated once in a blue moon R86 had some anxiety or agitation, but was very easily redirected. CNA P stated R86 was very hard of hearing, and CNA P thought that might contribute to R86's anxiety or agitation. CNA P stated for the most part R86 was very pleasant and easy to work with. On 03/16/22, 11:07 AM, Surveyor interviewed CCC I who stated they did not have a behavior care plan with targeted behaviors they were addressing with the antipsychotic medications. CCC I also stated there were no non-pharmacological interventions for staff to try when behaviors occurred prior to utilizing the antipsychotic medications. CCC I stated there should be a behavior care plan with targeted behaviors, and non-pharmacological interventions for this resident. On 03/17/22, at 9:46 AM, Surveyor reviewed with Director of Nursing (DON) B that there was no behavioral care plan with targeted behaviors, and non-pharmacological interventions prior to the use of antipsychotic medications for R86. Informed DON B that CCC I stated this behavior care plan was missing for R86. Informed DON B that CCC I stated she was adding a behavior care plan with targeted behaviors to R86's comprehensive care plan yesterday after we spoke. DON B stated R86 should have had a behavioral care plan with targeted behaviors and non-pharmacological interventions due to the use of antipsychotic medications.

Based on interview and record review, the facility did not ensure that PRN (as needed) orders for anti-psychotic drugs were limited to 14 days. The facility did not ensure that the residents were evaluated for appropriateness by the prescribing practitioner before renewing those anti-psychotic medications. This occurred for 2 of 6 residents (R) reviewed for unnecessary medications. (R86 and R42.) Findings include: Example 1: Record review identified R86 was admitted to the facility on [DATE] with diagnoses including, in part: history of traumatic subdural hemorrhage with loss of consciousness, dementia, and cognitive impairment. R86's quarterly Minimum Data Set (MDS) assessment, dated 01/28/22, showed R86 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R86 had a severe cognitive impairment. The MDS also identified R86 had a diagnosis of anxiety disorder and depression. The MDS indicated R86 received antipsychotic medication. Review of R86's medical record identified physician orders for the following medication: [MEDICATION(S)] (anti-psychotic medication) 0.25 milligrams (mg) PRN (as needed) for agitation or hallucinations related to psychotic disorder; order date 03/09/22. The original order date was 11/03/21. Review of the paper chart identified multiple paper written orders to renew the PRN [MEDICATION(S)] every 14 days since admission to the facility. On 03/15/22, at 2:07 PM, Surveyor interviewed Clinical Care Coordinator (CCC) I, who reported R86 had the PRN [MEDICATION(S)] order for anxiety and agitation. CCC I stated it was renewed every two weeks by a telephone order from the attending physician. CCC I stated they did review a resident's [CONDITION(S)] medications monthly as a team to determine the need to continue those medications. When asked if the physician was evaluating the resident every 14 days before renewing the PRN [MEDICATION(S)], and providing a rationale for continuing it, CCC I stated, No. CCC I stated they just send the request for renewal of the orders to the physician, the physician signs it and sends it back. CCC I stated they are not providing the physician with any rationale for continuing the PRN anti-psychotic medication, such as the resident's behaviors, number of times the PRN medication was used, and it's effectiveness, when they make the request for renewal. On 03/15/22, at 2:07 PM, Surveyor interviewed Registered Nurse (RN) J about R86's behaviors. RN J stated R86 mostly had behaviors of wandering, but was easily redirected. RN J stated R86 very rarely had behaviors of anxiety or agitation, and when that happened, staff was able to redirect and calm R86. RN J stated it was very rare that R86's behavior would get bad enough to require a PRN anti-psychotic medication. On 03/15/22, at 2:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA) N, who stated R86 occasionally wandered, but was easily redirected. CNA N stated a couple of months ago, R86 returned from a hospital stay on a new medication. They noted R86 was more irritable and anxious at that time, but those behaviors had stopped. CNA N stated they were only monitoring wandering behaviors, and no other behaviors that CNA N was aware of. On 03/16/22, at 8:58 AM, Surveyor interviewed CNA P, who reported R86 did not have much for behaviors, mostly just wandered on the neighborhood. CNA P stated once in a blue moon R86 had some anxiety or agitation, but was very easily redirected. CNA P stated R86 was very hard of hearing, and CNA P though that might contribute to R86's anxiety or agitation. CNA P stated for the most part R86 was very pleasant and easy to work with. On 03/17/22, at 9:46 AM, Surveyor reviewed the above information with Director of Nursing (DON) B, who stated they do have a process for updating the physician when they are renewing the PRN anti-psychotics every 14 days. DON B would look for documentation of this for R86's renewal of the PRN [MEDICATION(S)] every 14 days. No additional information was received. Example 2: R42 was admitted to the facility on [DATE] with diagnoses including, in part, [CONDITION(S)] disease, vascular dementia with behavioral disturbance, anxiety disorder, and major depressive disorder. R42's quarterly MDS assessment, dated 12/21/21, showed R42 had a BIMS score of 00. This indicated R42 had a severe cognitive impairment. Under the Mood/Behaviors section of the MDS, no hallucinations or delusions were noted. The MDS also indicated that no physical behaviors, no verbal behaviors, and no behaviors of rejection of cares occurred during the assessment period. The medical record identified the following physicians order: [MEDICATION(S)] (anti-psychotic medication) 5 mg, give 1/2 tablet (2.5 mg) twice per day PRN for agitation related to vascular dementia. The order had a start dated of 03/09/22, and a stop date of 03/23/22. Surveyor observed multiple paper written orders for renewal of this medication every 14 days on the paper chart. On 03/15/22, at 2:07 PM, Surveyor interviewed Registered Nurse (RN) J about R42's behaviors. RN J stated R42 had behaviors of swearing, swatting at staff, and resisting cares. RN J stated R42's behaviors were much improved. RN J stated staff knew how to work with R42, and it was very rare that R42's behavior would get bad enough to require a PRN anti-psychotic medication. On 03/16/22, at 10:15 AM, Surveyor interviewed CNA K, who reported R42's behaviors had gotten much better since admission. CNA K stated R42's main behaviors were swearing, and occasional swatting at staff, especially during cares. CNA K stated R42 would also spit at times. CNA K stated R42 was usually very pleasant and easy to work with. CNA K stated since they scheduled pain medications before cares, R42 was much better, and less resistant to cares. CNA K stated it was extremely rare that R42's behaviors would ever be severe enough to require a medication to control it. On 03/16/22, at 11:07 AM, Surveyor interviewed CCC I, who stated R42 had orders for the PRN [MEDICATION(S)] since admission to the facility because R42 was receiving hospice care. CCC I stated they did monthly team reviews for behaviors with residents on [CONDITION(S)] medications, but that it was without a psychiatrist at this time, and had been for the past several months. Surveyor asked if the physician evaluated R42 every 14 days before renewing the PRN [MEDICATION(S)], and if the physician provided a rationale for continuing it. CCC I stated, no, they just sent the request for renewal of the orders, and the physician signed it and sent it back. CCC I stated they did not providing the physician with any rationale for continuing the PRN anti-psychotic medication when they sent the request for renewal. On 03/17/22, at 9:41 AM, Surveyor interviewed DON B about the renewal of R42's anti-psychotic medication every 14 days without physician evaluation or rationale. DON B stated they did have a process for updating the physician for renewal of PRN anti-psychotic medications. DON B would look for documentation for R42's renewals of the PRN [MEDICATION(S)] every 14 days. Surveyor reviewed with DON B the behavior documentation and interviews with staff that did not show the need or rationale for renewal of the PRN anti-psychotic medication beyond 14 days. DON B agreed that it had probably been renewed unnecessarily.

The facility did not prepare food in accordance with professional standards for food service safety for 1 of 1 observations. Surveyor observed staff touch food with contaminated gloves while preparing ready to eat food . This is evidenced by: On 03/15/22 at 12:30 PM, Surveyor observed Certified Nursing Assistant (CNA) F cut up a resident's food, take off rubber gloves, put another pair of rubber gloves on, deliver food to a resident, take off rubber gloves, put on new pair of rubber gloves, unlock cupboard and make a sandwich for Resident (R) 5 with same rubber gloves on, then remove the rubber gloves, put on new pair, with no hand sanitizer in between changing rubber gloves. On 03/16/22 at 12:50 PM, Surveyor interviewed Director of Nursing (DON) B and asked for a policy on preparing ready to eat foods, she indicated there was not one. Surveyor told DON B of the above observations and asked if the steps taken were appropriate. DON B indicated No, she did it all wrong - everything.

Based on observation and interview, the facility did not ensure infection prevention and control was provided in a safe and sanitary manner to help prevent the development and transmission of communicable disease and infections for 1 Resident (R) 16 of 1 residents observed during wound care. R16 received wound care with facility staff using contaminated wash clothes to clean the wound. This is evidenced by: Review of R16's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wash with soap and water and pat dry, 2. Apply [MEDICATION(S)] and gauze to each site, 3. Cover each site with [MEDICATION(S)] border dressing for wound care. On 03/17/22 at 8:51 a.m., Surveyor observed Register Nurse (RN) M and RN O provide wound care to R16. RN O washed hands in R16's bathroom sink. RN M washed hands in R16's bathroom sink and put four wash clothes into the bottom of the sink and let water run over the wash clothes. RN M applied gloves and took the wash clothes and squeezed the excess water out and put them on the tray table with the dressing change supplies. RN M removed the old dressing from the left knee. RN O wet gauze and cleaned the area and went to change gloves then R16 pulled the blanket onto the cleansed wound. RN O cleansed the area again with a wet gauze and dried the area with gauze. RN O asked RN M to stand near R16 to ensure the blankets don't touch the area. RN M was standing near R16 and R16 moved the blanket back over the clean wound. RN M took the contaminated wet washcloth and cleansed the wound. RN O dried the wound with gauze and applied [MEDICATION(S)] to the wound bed and applied a fold gauze and applied [MEDICATION(S)]. On 03/17/22 at 9:36 a.m., Surveyor interviewed RN M asking if the four wash clothes that were put into the bottom of the sink to get wet would be contaminated since they were sitting right on the bottom of the sink. RN M indicated she had rinsed out the wash clothes. Surveyor asked even rinsing the wash clothes out with water and squeezing the water out and putting them on the tray table if the the wash clothes would still be contaminated from being on the bottom of the sink. RN M indicated the washcloths would be contaminated and will keep that in mind they should not be on the bottom of the sink. On 03/17/22 at 11:43 a.m., Surveyor interviewed Director of Nursing (DON) B and reviewed wound care observations and asked if it is appropriate to place wash clothes on the bottom of the bathroom sink. DON B indicated the wash clothes should not have been used and will do education immediately.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 109 residents. The facility did not ensure the main kitchen's dishwasher was reaching the appropriate temperature. Dietary staff was observed touching resident food after touching multiple other objects. Findings include: Example 1 The facility's main kitchen uses a high temperature dishwashing machine for prefatory pots and pans. The facility monitors the internal temperature of the dishwasher with test strips once per day. The test strips have a dark blue band on the end and the strips read, Pass when blue bar turns orange, 180F. Additionally, kitchen staff document the external digital readout of the dishwasher temperature twice daily. The facility's main kitchen does not have a policy or procedure regarding dishwasher temperatures and testing. On 3/10/20 at 9:44 AM, Surveyor observed dishwashing being conducted in the facility's main kitchen. Surveyor reviewed the temperature log and found historical daily test strips for the month of February and March. Only 10 test strips between February 1 and March 10 had completely turned orange in accordance with the test strip manufacturer guidelines, indicating the dishwasher had reached the appropriate temperature on 10 days. In addition, the external digital gauge documentation shows, in February and March of 2020, the wash temperature failed to reach 150 degrees Fahrenheit on 3 occasions and the rinse temperature failed to reach 180 degrees Fahrenheit 25 times. On 3/10/20 at 9:50 AM, Surveyor interviewed DM E (Dietary Manager) regarding the dishwasher temperature monitoring. DM E stated she had not been contacted by any staff in regards to the dishwasher not operating correctly. DM E stated that staff probably did not allow the dishwasher to warm up before testing the temperature and documenting the external digital gauge. DM E also stated that if staff get an unacceptable reading from the dishwasher gauge or test strip, they are expected to attempt a second time and if the reading is still not either 150 degrees Fahrenheit wash temperature and/or 180 degrees Fahrenheit rinse temperature, a supervisor should be notified immediately. Example 2 On 3/10/10 at 12:20 PM Surveyor observed FSH F (Food Service Helper) serving lunch for residents on the F unit. Surveyor observed FSH F pick up baked sweet potatoes with his gloved hands, set the potato on the serving plate, pick up a knife to cut the sweet potato, then pick up a slice of baked ham with the same gloves and place the ham on the serving plate and cut the slice of ham. FSH F was wearing the same gloves and was observed touching the handles of multiple serving utensils, trays cards, beverge containers, bread bag, the refrigerator door handle, packets of butter and serving plates. FSH F served multiple residents food after touching multiple objects as indicated above on unit without changing his gloves and touching food with gloved hands. On 3/10/20 Surveyor interviewed FSH F about observations of FSH F touching the resident's food with his gloved hands and touching other items during food service. FSH F stated that he should not have touched the ham or sweet potatoes with his gloved hands and should have used utensils to serve the ham and potatoes. On 3/12/20 at 2:58 PM Surveyor interviewed DM E (Dietary Manager) about staff touching resident's food with gloves hands when serving meals. DM E stated that there was not a specific policy for this, but that staff should have used utensils for contact with resident food, not gloved hands.

Based on interview and record review the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 5 of 5 unnecessary medication review residents Resident (R33, R35, R44, R46, R52) of a total sample of 25. R33, R35, R44, R46 and R52 did not have drug regimen reviews monthly. This is evidenced by: The Facility's Policy and Procedure entitled Medication Regimen Review dated 2/25/2020 documents, in part: .A licensed pharmacist will review the resident Medication regimen including the resident chart at least once a month .B. The consultant pharmacist will perform a monthly medication regimen review on each resident unless the resident condition/risk will indicate a more frequent schedule that is individualized and communicated between the facility clinical staff and the Pharmacy Consultant . Example 1 R33 admitted to the facility 10/9/14. R33 is missing monthly drug regimen reviews from the Consultant Pharmacist for March 2019, October 2019 and February 2020. Example 2 R35 admitted to the facility 12/17/19. R35 is missing monthly drug regimen review from the Consultant Pharmacist for February 2020. Example 3 R44 admitted to the facility 6/17/19. R44 is missing monthly drug regimen review from the Consultant Pharmacist for October 2019 and February 2020. Example 4 R46 admitted to the facility 9/12/12. R46 is missing monthly drug regimen review from the Consultant Pharmacist for October 2019 and February 2020. Example 5 R52 admitted to the facility 4/4/19. R52 is missing monthly drug regimen review from the Consultant Pharmacist for October 2019 and February 2020. On 3/12/2020 at 10:21 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor had requested pharmacy reviews for March 2019, October 2019, and February 2020. DON B came back and stated our Pharmacist had a medical leave so there is no review for February 2020. Surveyor asked DON B how often should the pharmacy reviews be completed, DON B stated there should be one for every month, some are at the end of month before. On 3/12/2020 at 3:23 PM, Surveyor interviewed Consultant Pharmacist O. Surveyor asked Consultant Pharmacist O if she knew why there are not pharmacy reviews for R33, R35, R44, R46 and R52 for the months list, Consultant Pharmacist O replied that she was on a medical leave in February but is unsure about March and October or 2019. Surveyor asked Consultant Pharmacist O if anyone covers for her when she is unavailable, Consultant Pharmacist O stated no.

Based on observation and interview, the facility did not allow all residents to make choices regarding aspects of their lives that are significant to them and did not allow 1 resident (R5) of 25 sampled residents to make a food choice during a meal. On 3/10/2020 at 12:20 PM, R5 requested another piece of meat for lunch. Nursing staff told her she wasn't allowed to have second helpings. R5 was admitted on [DATE] with [DIAGNOSES REDACTED]. R5's admission MDS (Minimum Data Set) on 11/23/19, measures her cognitive ability as severely impaired and is not interviewable. R5's care plan dated 2/18/2020 documents as one of R5's delusional behaviors that she complains about staff denying her food. R5's care plan does not document restrictions on food. R5's physician orders [REDACTED]. R5's physician orders [REDACTED]. On 3/10/2020 at 12:20 PM, R5 was eating lunch. The lunch menu consisted of ham, sweet potato and cauliflower. R5 had finished eating her ham slice. R5 asked CNA G (Certified Nurse Assistant) if she could have more ham. CNA G said You know you don't get seconds! R5 made no response. On 3/10/2020 at 12:45 PM, Surveyor spoke with CNA G. Surveyor asked CNA G why R5 could not have another slice of ham. CNA G said I think it's because of her weight gain. On 3/10/2020 at 12:30 PM, R5 was sitting at the table with one half of sweet potato and cauliflower left. R5 asked CNA H if she could have a piece of ham. CNA H said no, you don't get seconds. R5 made no response. On 3/10/2020 at 12:50 PM, Surveyor spoke with CNA H. Surveyor asked CNA H why R5 could not have a piece of ham. CNA H said she wasn't sure, she just knew R5 could not have second helpings. On 3/11/2020 at 1:05 PM, Surveyor spoke with RD J (Registered Dietician). RD J said she was not aware of any food restrictions for R5. RD J said each resident should have what they want to eat and no resident should be denied a second helping of food. On 3/12/20 at 9:42 AM, Surveyor spoke to DON B (DON). DON B said residents can have additional food if their diet order does not have a restriction and it is in the resident goals of care.

Based on interview and record review the facility did not develop a comprehensive person-centered care plan for 3 sampled residents (R35, R86 and R65) of 25 reviewed for person centered care plans. R35 does not have a care plan for hospice services. R86 does not have a care plan for significant weight loss The facility failed to create an individualized, patient specific care plan that addressed R65's pain, pharmacological, and non-pharmacological interventions. This is evidenced by: The Facility's Policy and Procedure entitled Care Plans dated 1/28/20 documents, in part: 3. Include interventions/approaches/instructions needed to provide effective and resident centered care including but not limited to ADL (Activity of Daily Living) care needs, transfers, ambulation, communication, dietary .4. Address resident's health and safety concerns to prevent decline or injury including by not limited to .comfort care needs .3. Includes person-centered goals that are measurable objectives and timeframes to meet resident's medical, nursing and physical care needs as well as mental and psychosocial needs that are identified in the comprehensive assessment .4. Is developed with 7 days after completion of the comprehensive assessment and developed by an interdisciplinary team that includes but is not limited to: Attending Physician, RN (Registered Nurse)/CCC (Clinical Care Coordinator), CNA (Certified Nursing Assistant), Dietician, Social Worker . Example 1 The Facility and Hospice contract dated 2/14/17 documents, in part: .(i) Plan of Care means a written care plan established, maintained reviewed at minimum every 15 days .The Plan of Care shall reflect the participation of Hospice, Facility and the Hospice Patient and family to the extent possible. Specifically, the Plan of Care includes: (i) an identification of Hospice Services, including interventions for pain management and symptom relief, needed to meet such Hospice Patient's needs and the related needs of Hospice Patient's family; (ii) a detailed statement of the scope and frequency of such Hospice Services; (iii) measurable outcomes anticipated form implementing and coordinating the Plan of Care; (iv) drugs and treatment necessary to meet the needs of the Hospice Patient; (v) medical supplies and appliances necessary to meet the needs of the Hospice Patient; and (vi) the IDT's (interdisciplinary team) documentation of the Hospice Patient's or representative's level of understanding, involvement and agreement with the Plan of Care. Hospice and Facility shall jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy and is responsive to the unique needs of Hospice Patient and his or her expressed desire for hospice care. The Plan of Care shall identify which provider is responsible for performing the respective function that have been agreed upon and included in the Plan of Care. R35 is a newer admission to the facility. R35 has the following Diagnosis: [REDACTED]. Per R35's medical record states she was admitted to the facility on Hospice Services. R35's medical record does not include a Hospice care plan. On 3/12/2020 at 12:55 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R35 should have a hospice care plan, DON B said it should be under the Hospice tab in the chart. No care plan for R35 was located. Example 2 R86 is a long term resident of the facility who was recently hospitalized from [DATE] through 1/29/2020. R86 has the following Diagnosis: [REDACTED]. Per R86's weight record: 12/1/19= 154.4 12/9/19= 159.2 12/15/19= 155.8 12/22/19= 155.6 12/29/19= 157.4 1/5/20= 160.2 2/9/20= 138.6 2/16/20= 144.6 2/23/20= 140.2 R86's weight from January to February indicate a 21.6 pound/13.48% weight loss. R86's meal intake during survey was: 3/10/20- Breakfast=75%, Morning Snack= 0, Lunch= 0, Afternoon Snack= 0, Supper= 0 3/11/20- Breakfast= 0, Morning Snack=not recorded, Lunch= 0, Afternoon Snack= not recorded, D= 90% 3/12/20- Breakfast= 0 Per 86's Progress Notes: 2/12/20 nursing note documents, in part: .current weight 138.6, 140.2 on 2/2/20 and 160.2 on 1/5/20, lost weight since he returned from hospital, hospital stay= 1/13-1/29, email sent to Registered Dietician . 2/28/20 nutrition note documents, in part: .add magic cup supplement to lunch meal . 3/10/20 psychiatrist note documents, in part: .R86 not eating well, looked much thinner than I remember from prior hospitalization .became suspicious once began talking about eating . On 3/12/2020 at 10:46 AM, Surveyor interviewed RN Q. Surveyor asked RN Q if she could explain R86's eating and weight loss, RN Q explained around the end of January he was in the hospital and lately not eating, stating I can't afford this. Often R86 will wipe tables thinking he's working for his food. He won't always eat meals but will usually will accept a snack. R86 has always had a history of [REDACTED]. Surveyor asked RN Q if R86 had a care plan for weight loss, RN Q looked and then stated no. On 3/12/2020 at 12:22 PM, Surveyor interviewed RD J (Registered Dietician). Surveyor asked RD J what she could share with Surveyor about R86's weight loss, RD J explained that R86 always had an underlying paranoia regarding spitting in food or poisoning food. Surveyor asked RD J if R86 should have a care plan for weight loss, RD J stated I don't do care plans on everybody, maybe a stabilization one for R86 I could do. On 3/12/2020 at 1:06 PM, Surveyor interviewed RN S. Surveyor asked RN S if R86 should have a care plan for weight loss, RN S replied that the weight loss is related to his hospitalization , that the Dietician had been notified, the staff are monitoring his intake and his paranoia, and are continuing his diet as ordered. Example 3 R65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R65's MDS dated [DATE] indicates the following: Section C - BIMS (Brief Interview of Mental Status) is 12 of 15 indicating R65 moderate impairment of cognition. Section J indicates that R65 has frequent pain that limits her activities, and rates pain at a 10 on a 0-10 scale. R65's signed physician orders [REDACTED].=10 mg PO weekly on Thursday Shift 2 (day shift) for RA ([MEDICAL CONDITION] Arthritis), [MEDICATION NAME] 0.6 mg PO QD (every day) for CPPD (Calcium [MEDICATION NAME] deposition). R65's MAR (Medication Administration Record) shows: Pain scale: y=yes, N= no QAM/PM (every morning, afternoon). On 3/10/2020 at 11:04 AM, Surveyor interviewed R65. Surveyor asked R65 if she was having pain. R65 stated that she has crippling arthritis and that she is having pain in her stomach; Surveyor observed R65 holding her left abdominal area and crying while speaking with R65. Surveyor reported pain to LPN N (Licensed Practical Nurse). On 3/11/2020 at 8:49 AM Surveyor interviewed CNA K (Certified Nursing Assistant). Surveyor asked CNA K if R65 complains of pain, CNA K stated that R65 sometimes complains of pain in her knees or foot. Surveyor asked CNA K how often R65 complains of pain, CNA K replied once in a while, not every day. Surveyor asked CNA K what do you do if R65 complains of pain, CNA K states that she asks R65 if she wants pain medication and then she tells the nurse. Surveyor asked CNA K if they use any non-pharmacological interventions for R65's pain, CNA K stated that they added padding to the EZ Stand Lift to help with R65's knee pain and that she can wear compression gloves for her hand pain. On 3/12/2020 at 9:04 AM Surveyor interviewed RN L (Registered Nurse). Surveyor asked RN L if R65 ever complains of pain, RN L stated that if R65 has pain, she will be able to tell you; I don't remember ever giving her any PRN (as needed) medications. Surveyor asked RN L if she performs a pain assessment on R65, RN L stated yes, it is done every shift. Surveyor asked if R65 has any non-pharmacological interventions that are effective for her, RN L states she gets scheduled Tylenol and has only used a PRN 2 times in the last 2 months. Surveyor asked RN L if she knows what R65's pain goal is, RN L stated I don't think she has a pain goal. On 3/12/2020 at 10:03 AM Surveyor observed cares. R65 did not demonstrate non-verbal signs of pain, nor did she report pain to staff while they were providing cares. On 3/12/2020 at 10:24 AM Surveyor interviewed R65. Surveyor asked R65 if she was having pain, R65 reported that she was having terrible pain in her back due to her wheelchair. Surveyor asked R65 if she could rate her pain on a 0-10 scale and R65 stated 10. Surveyor asked R65 if she had a pain goal, R65 became slightly agitated at this time, so the interview ended. On 3/12/2020 at 10:31 AM Surveyor called LPN N. Surveyor asked LPN N if she did a pain data collection on R65 when she reported pain on 3/9/2020, LPN N stated that she asks R65 if she is having pain and then gives her the scheduled medication. Surveyor asked LPN N if she does data collection prior to administering PRN medications, LPN N stated that they ask about pain, chart where it is; since we know her so well, it would be a behavior so then we provide her with an alternative activity. Surveyor asked how would a staff member that is not familiar with R65 and her behaviors know if R65's complaints of pain is actual pain or a behavior, LPN N stated that they probably wouldn't know but could ask a CNA or another staff member. Surveyor asked LPN N if R65 complains of pain every day, LPN N stated no, the scheduled medications usually takes care of it, but she cries pretty much every day. Surveyor asked LPN N if crying and reports of pain listed as behaviors anywhere, LPN N stated no, the CNAs typically document on that. R65's behavior tracking from 2/12/2020 to 3/12/2020 does not indicate that staff is monitoring crying or complaints of pain as target behaviors. On 3/12/2020 at 1:55 PM Surveyor interviewed DON B, RN C, and RN M. Surveyor asked DON B and RN C what is the expectation for monitoring residents with chronic pain, RN C stated that they would have a pain scale that is individualized depending on their ability to answer questions, would be evaluated with the MDS, usually have a scheduled pain medication, and non-medication intervention. Surveyor asked RN M if she would expect a patient with chronic pain to have a care plan that addresses pain. RN M reviewed R65's care plan with Surveyor and stated yes, it's not in here. Surveyor asked RN M how would staff that is unfamiliar with R65's behaviors know if her complaints of pain is actual pain or behaviors, RN M and RN C stated that R65 does some moaning often and that staff are able to distinguish pain from behaviors. Surveyor asked if the moaning, crying, and reports of pain should be tracked in the behavior monitoring, RN M stated it's hard to determine if they are behaviors or pain. Surveyor shared R65's most recent MDS Section J with DON B and RN M which indicates R65 rated her pain at a 10, DON B stated the Social Worker fills out this section and she will call her to confirm. DON B reported back to Surveyor that the Social Worker stated the MDS was completed with the Social Work intern and that R65 often exaggerates her pain to new people. RN M states that R65 takes her scheduled medication routinely, she goes to the Rheumatologist routinely, and that her dose of [MEDICATION NAME] was increased on 1/14/2020. Doctor's notes from office visit on 1/14/2020 indicates in part that her hand joints are much improved with the addition of [MEDICATION NAME] .will increase dose of [MEDICATION NAME] to see if it can be more helpful in her toes. R65 is receiving pain medication however the facility failed to create an indivdualized care plan for R65's pain.

Based on observation, interview, and record review the facility did not ensure that the resident environment has remained as free of accident hazards as is possible 5 of 21 resident rooms reviewed for hot water, affecting 2 sampled residents plus 3 supplemental residents (Resident 25, 26, 3, 21 and 27) out of a facility census of 118. The deficient practice also affected 2 of 2 Spa rooms reviewed, which are used independently by 5 residents (Residents 16, 17, 32, 33, and 34). Water temperatures in resident care areas reached dangerously high temperatures: Resident 25 room 136 and 135.5 degrees Fahrenheit Resident 26 room 133.4 and 136.2 degrees Fahrenheit Resident 27 room 120.1 degrees Fahrenheit Resident 3 room 117.5 degrees Fahrenheit Resident 21 room 115.7 degrees Fahrenheit FSP1 (Spa) 134.9 degrees Fahrenheit CSP2 (Spa) 117.3 degrees Fahrenheit The failure to ensure safe water temperatures to prevent accidents created a finding of immediate jeopardy. The immediate jeopardy began on 9/19/16 when the facility was made aware of dangerously high water temperatures in Resident 26's bathroom. Nursing Home Administrator A was notified of the immediate jeopardy on 9/28/16 at 2:05 pm. The facility removed the immediate jeopardy on 9/28/16 but the deficient practice continues at a scope/severity level E (potential for more than minimal harm that is not immediate jeopardy/pattern) as all of the facility corrective actions have not been fully implemented and as evidenced by: In 1 of 1 residents reviewed who utilizes an electric wheel chair (Resident 21), the facility did not ensure the wheel chair battery was charged in a safe area. This is evidenced by the following: On 9/28/16 at 9:10 am Surveyor spoke with DFS (Director of Facility Services) E regarding the facility's hot water temperature monitoring. DFS E stated a year ago all faucets were checked and recalibrated as it had been about 5 years since they moved to this new building. DFS E stated that if there is a complaint about water temps then action is taken. Otherwise, no routine water temperature checks are done. At a temperature of 133 degrees, scalding (third-degree burns) can occur in 15 seconds, and at 140 o scalding can occur in 5 seconds. At 136 o, the maximum temperature found, scalding could occur in approximately 10 seconds. Scalding may occur even faster in elderly residents because their skin tends to be thinner. Third-degree burns (full-thickness burns) damage the outer layer of the skin, the subcutaneous skin layer, and the muscle underneath. A full thickness burn not only destroys all three layers of skin, resulting in the loss of not only the skin but also the hair follicles, sweat glands, and the region where new skin cells are formed. For these reasons, full thickness burns may require skin grafts. Water Temp Time Required for a 3rd Degree Burn to Occur 155°F 68°C 1 sec 148°F 64°C 2 sec 140°F 60°C 5 sec 133°F 56°C 15 sec 127°F 52°C 1 min 124°F 52°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing. Burns create a potential for infection, which could have been particularly serious for Residents 21, 3, and 26 who have Diabetes Mellitus. Example 1 Resident 25's most recent MDS (Minimum Data Set) with an observation end date of 8/24/16 documents that Resident 25 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15 (cognitively intact) and is independent with his personal hygiene needs. On 9/28/16 at 9:55 am Surveyor spoke with CNA (Certified Nursing Assistant) H regarding Resident 25. CNA H stated Resident 25 is independent and is able to adjust the water temperature in his room. On 9/27/16 at 1:45 pm Surveyor obtained a hot water temperature of 136 degrees Fahrenheit at Resident 25's bathroom sink, a temperature at which hot-water scalding could occur in ten seconds. On 9/27/16 at 3:00 pm Surveyor spoke with MT (Maintenance Technician) C regarding the facility's hot water temperature monitoring. MT C told Surveyor that he likes to see hot water temperatures between 110 - 113 degrees Fahrenheit. MT C stated he is unaware of any scheduled or random water temp (temperature) checks, and unless there is a complaint about the hot water, no checks are done. MT C stated that about a year ago all the sinks were checked for water temps just because it had been awhile. Surveyor informed MC T of the hot water temperatures obtained by the State Survey team this afternoon including those in Residents 25 and 26's rooms. Surveyor was told Resident 25 and Resident 26's rooms share a mixing valve. On 9/27/16 at 3:00 PM Surveyor interviewed RN (Registered Nurse) R asking if she was aware of any issues with water temperatures being too hot prior to this date. RN R stated that she recalled that about a week before, on 9/18/16, she was working the PM shift when the day shift reported that they had called maintenance staff to report that the water in Resident 26's room was hot and placed a note on his faucet to alert staff. RN R stated that sometime on the PM shift on 9/18/16, a female maintenance staff (ADFS F) came in and turned off the hot water to Resident 26's bathroom, telling RN R that notification had been made and it would be taken care of the next day (Monday 9/19/16). RN R stated that the woman from maintenance asked if there were issues anywhere else. RN R stated she was not sure if there were other water temperature concerns, but was not aware of any. On 9/28/16 at 9:19 am Surveyor spoke with ADFS F regarding the hot water temps on the weekend of 9/18/16. ADFS F stated she received a call that Sunday (9/18/16) that a water temp was too high. ADFS F stated she checked the water temp of this resident room by hand and noted it to be hot so the water was turned off to this room. ADFS F stated the nursing staff had told her no other rooms were affected so she did not check any other rooms. ADFS F stated she left a voice message for MT C for Monday that he would need to adjust the water temp for that room. On 9/28/16 at 9:16 am Surveyor spoke again with MT C regarding the incident 2 weeks ago when the water temp in Resident 26's room was high. MT C stated he received a voice message on Monday 9/19/16 from ADFS (Assistant Director of Facility Services) F who came to the facility the day before (9/18/16) due to high water temps in Resident 26's room. MT C stated ADFS F turned the water off to this room until he (MT C) could adjust the temp. MT C stated when he checked the temp of the water on Monday (9/19/16) to this room he believes it was about 132 degrees Fahrenheit. He stated he adjusted the valve to provide water at 113 degrees Fahrenheit. MT C stated he noted the valve to stick and not really wanting to adjust, but he was able to eventually get it set. MT C stated he then reported to Lead Mechanic (LM) D that the valve was sticking, but was told that since it was working to leave it for now. MT C stated he does not have a work order for this job and does not have any documentation regarding it. MT C stated he did not do any rechecks of the water temp to this room. On 9/28/16 at 9:00 am Surveyor spoke with LM D regarding the facility's hot water temperature monitoring. LM D stated the facility has no system in place for routinely checking water temps. LM D stated if there is a problem then a work order is generated and the specific concern is addressed. LM D stated that about 2 weeks ago there was a problem with a high hot water temp in a resident room. LM D stated the on call maintenance staff came in and shut the water off to that room. LM D stated no work order was completed, but that MT C worked on the issue the next day. Surveyor requested to review any documentation regarding this incident. No documentation was provided. On 9/28/16 at 9:26 am Surveyor spoke with RN (Registered Nurse) G regarding the weekend of 9/18/16 and the hot water temps. RN G is the Clinical Care Coordinator. RN G stated she had been told by a staff nurse that the water in Resident 26's room was hot. RN G instructed staff to put up a sign instructing staff not to use the water in this room. RN G stated the water temps were checked by hand and that no other rooms seemed to be having this issue. RN G stated she is unaware of any burns related to hot water in the facility. After being informed of the high hot water temperature on 9/27/16 at 1:45 pm of 136 degrees Fahrenheit at Resident 25's bathroom sink, the facility began repairs. However, on 9/28/16 at 9:45 am Surveyor obtained a hot water temperature of 135.5 degrees Fahrenheit at Resident 25's bathroom sink. Surveyor observed steam coming up from the water. On 9/28/16 at 10:01 am Surveyor , together with NHA (Nursing Home Administrator) A obtained a hot water temperature of 135.5 degrees Fahrenheit at Resident 25's bathroom sink. NHA A immediately instructed staff to again halt any use of the water in this room. Example 2 On 9/27/16 at 2:40 pm Surveyor obtained a hot water temperature of 134.9 degrees Fahrenheit in the Spa sink in room FSP1. This room is locked and can be unlocked by staff. Example 3 On 9/27/16 at 2:30 PM Surveyor observed the water temperature in Resident 26's bathroom sink to register at 133.4 degrees. Surveyor asked Resident 26 if he had ever noticed the water in the bathroom sink being too hot. Resident 26 shrugged his shoulders. On 9/28/16 at 9:50 am Surveyor obtained a hot water temperature of 136.2 degrees Fahrenheit at Resident 26's bathroom sink. It is important to note the facility had been informed of the unsafe water temperatures to this room on 9/27/16 and had begun taking corrective action at that time. On 9/28/16 at 10:00 am Surveyor spoke with CNA (Certified Nursing Assistant) H regarding Resident 26 while in Resident 26's bathroom. CNA H told Surveyor that Resident 26 may need assistance in the bathroom, but could be independent at times. CNA H stated that he (CNA H) would be concerned if Resident 26 used the water in his room independently. CNA H touched the water coming from the faucet sink in Resident 26's room, confirmed that it was hot, and stated it was hotter than what he would want in his home. On 9/28/16 at 10:01 am NHA A was notified of the hot water temperature in Resident 26's bathroom and immediately instructed staff to again halt any use of the water in this room. Resident 26's most current MDS (Minimum Data Set) with an observation end date of 6/28/16 documents that Resident 26 has a [DIAGNOSES REDACTED]. Example 4 On 9/27/16 at 1:48 PM Surveyor took the temperature at Resident 27's sink in his personal bathroom. The temperature was 120.1 degrees Fahrenheit. Resident 27 is independent in all cares, including taking showers by himself. His Minimum Data Set completed 7/7/16 indicates he has severe cognitive impairment. Example 5 On 9/27/16 at 2:05 PM, Surveyor took the temperature of the sink in Picnic Point CSP2 Spa . The temperature was 117.2 degrees Fahrenheit. On 9/28/16 at 12:20 PM, Surveyor spoke with Certified Nursing Assistant (CNA) U. Surveyor asked CNA U which residents use the spa independently. CNA U stated that Resident 32, Resident 17, and Resident 33 all use the spa independently. CNA U stated that staff provide set up and check on the residents every 15 minutes when they are in the spa. On 9/28/16 at 12:30 PM, Surveyor spoke with Certified Nursing Assistant (CNA) V. Surveyor asked CNA V which residents use the spa independently. CNA V stated that Resident 17, Resident 34, Resident 33, and Resident 16 all use the spa independently. Example 6 On 9/27/16 at 1:03 pm Surveyor obtained a hot water temperature in Resident 3's bathroom of 117.5 degrees Fahrenheit. Resident 3's most current MDS (Minimum Data Set) with an observation end date of 8/4/16 documents that Resident 3 has short and long term memory problems and needs total assistance with personal hygiene. Resident 3 has a [DIAGNOSES REDACTED]. Example 7 On 9/27/16 at 1:49 pm Surveyor obtained a hot water temperature in Resident 21's bathroom of 115.7 degrees Fahrenheit. Resident 21's MDS (Minimum Data Set) with an observation end date of 7/1/16 documents that Resident 21 scored a 15 out of 15 on the BIMS (Brief Interview for Mental Status), does not ambulate, and needs extensive assistance with personal hygiene. Resident 21 has a [DIAGNOSES REDACTED]. Although the facility acted upon the high water temperature identified on 9/18/16 by shutting off the water and adjusting the valve in Resident 26's room on 9/19/16, the facility failed to monitor water temperatures in Resident 25 and 26's rooms after a problem was identified on 9/18/16, and failed to put into place measures to routinely and randomly ensure water temperatures throughout the facility are monitored on a routine basis. Consequently, surveyors continued to find water temperatures that were too hot on 9/27/16 and 9/28/16. This created a finding of immediate jeopardy. The facility removed the jeopardy on 9/28/16 at which time it had begun implementing the following: *Institute a water temperature watch in which all sinks and showers will have temperature taken every 2 hours. The results will be on a data collection form. *All employees will receive inservice education on checking, monitoring, and reporting any issues with water temperatures in the facility, beginning with the next shift each employee works. This education will also include what steps to take in the event they discover a high temperature. *The facility will gather data from the water temperature watch to determine exactly what mechanical repairs need to be made in order to assure consistently safe temperatures throughout the facility. The deficient practice continues at severity level 2 (potential for more than minimal harm that is not immediate jeopardy) as the facility continues to implement its corrective action plan and as evidenced by the following: Example 8 Resident 21's [DIAGNOSES REDACTED]. On 9/29/16 at 8:55 am Surveyor spoke with Resident 21 regarding her life experiences at the facility. At the time of this resident interview Resident 21 was in her bed. To the right of the bed was Resident 21's electric wheel chair. The wheel chair was plugged in and the battery was charging. On 9/29/16 at 9:05 am Surveyor asked RN (Registered Nurse) O where wheel chair batteries are to be charged. RN O stated I think they take them somewhere. Surveyor asked RN O if wheel chair batteries could be charged in resident rooms. RN O stated he was not sure. On 9/29/16 at 9:08 am Surveyor asked CNA (Certified Nursing Assistant) N where wheel chair batteries are charged. CNA N stated they are charged in their (residents) room. Surveyor then had CNA N accompany her to Resident 21's room. CNA N confirmed that Resident 21's wheel chair battery was being charged in her room. CNA N unplugged the charger.

Based on interview and record review, the facility did not ensure 1 resident (Resident 1) was free from verbal and physical abuse. Certified Nursing Assistant (CNA) E witnessed Resident 1 hit Licensed Practical Nurse (LPN) F in the arm. LPN F then pushed Resident 1's chair with her hip after Resident 1 had hit LPN F. LPN F then verbally argued with Resident 1 over the incident. CNA E did not intervene to stop the incident from occurring and did not immediately report the incident to the NHA or designee. The failure to report this incident prohibited the facility from immediately investigating the incident after the occurrence to prevent further potential abuse and allowed a second incident of abuse to occur between Resident 1 and LPN F 5 days later. CNA E was not provided with additional abuse training after the incident to include definition of abuse, how to recognize abuse or abuse reporting. CNA G witnessed a verbal and physical altercation between Resident 1 and LPN F, which resulted in Resident 1 trying to strike LPN F; LPN F grabbed Resident 1's wrist during the altercation. CNA G did not intervene to stop the incident from occurring, did not immediately report the incident to the NHA or designee. CNA G was not provided with additional abuse training after the incident to include definition of abuse, how to recognize abuse or abuse reporting. This is evidenced by: The facility's policy entitled Abuse, Neglect, Mistreatment, Misappropriation of Property or Injuries of Unknown Origin, Resident Rights Complaint Process and Mandatory Reporting of Crime dated [DATE] states in part; the facility will do everything in its control to prevent occurrences of abuse, mistreatment, neglect and misappropriation of property and will not retain staff who have been adjudicated as guilty of these unlawful activities. All alleged violations will be reported to the administrator or designee immediately, thoroughly investigated, and measures implemented to prevent further incidents. Incidents that meet state and federal criteria will be reported to Division of Quality Assurance (DQA) immediately and a written report filed within 5 working days of the incident. If the alleged violation is verified, the facility will take appropriate corrective action. Procedure: B. 1. Anyone who witnesses or becomes aware of any event that might meet any of the definition of abuse, neglect .shall take immediate action to ensure that the resident is safe and report the incident/situation to the Neighborhood Nurse immediately. Incidents that may constitute any form of mistreatment in the judgment of the witness should also be reported and immediate action taken to protect the resident. Resident 1 has [DIAGNOSES REDACTED]. Resident 1 was [AGE] years old and had a guardian, with protective placement at the facility. Of note, Resident 1 was discharged to the hospital on [DATE] and expired on [DATE]. A Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident 1 had moderate cognitive impairment. Section E, Behavior, notes that Resident 1 displayed no signs of Physical, Verbal or other behaviors directed toward others. Resident 1 has a care plan entitled Alteration in mental status related to dementia, history of hoarding dated [DATE]. An intervention to this care planned problem states in part; staff to do weekly checks of bedroom including drawers, closet and bathroom for hoarded items. Remove any food, dirty glasses, dirty placemats, old newspaper, silverware, food packets, condiment packets per MD order and consent of guardian. Of note, facility staff witnessed two incidents between Resident 1 and LPN F. Facility staff failed to immediately report the incidents to facility NHA or designee. The facility management staff became aware of the incidents between Resident 1 and LPN F after Registered Nurse Manager (RNM) D reviewed Resident 1's nursing notes on [DATE]. The facility immediately suspended LPN F on [DATE]. Nursing notes dated [DATE] at 1:03 PM state in part; Resident 1 dropped a knife; LPN F bent down to pick it up and Resident 1 hit LPN F on the left arm. LPN F pushed Resident 1's chair with her hip and Resident 1 stated don't hit me. LPN F stated to Resident 1 I did not hit you I pushed your chair; I did not hit you. Staff present at time of incident CNA E. On [DATE] at 2:05 PM Surveyor interviewed LPN F regarding the incident that occurred on [DATE] with Resident 1. LPN F stated the incident occurred as written in the nursing notes. LPN F stated Resident 1 was a hoarder and that she had a knife wrapped in a napkin and dropped it on the floor. LPN F stated she walked over to Resident 1 bent over and picked the knife up off the floor. LPN F stated as I was standing back up Resident 1 hit me hard on the arm. LPN F stated I hit Resident 1's chair with my hip after Resident 1 hit me on the arm. Surveyor asked LPN F if she hit the chair in retaliation to Resident 1 hitting her LPN F stated No. Surveyor asked LPN F if she would demonstrate how she hit Resident 1's chair. LPN F stood up and with her hip aggressively hit the chair with her hip. Surveyor asked LPN F what Resident 1 did after LPN F hit Resident 1's chair with her hip. LPN F stated Resident 1 stated don't hit me LPN F stated she told Resident 1 she did not hit her she pushed her chair. Surveyor read the nursing note dated [DATE] at 1:03 PM and asked LPN F if she should have handled the situation differently. LPN F replied my first intention was to hit Resident 1 but I knew I could not do that. Surveyor asked LPN F if the incident may have frightened Resident 1 or caused Resident 1 psychosocial distress or harm. LPN F stated management stated that I was intimidating but I do not feel I was intimidating. Surveyor asked LPN F if she should have handled the situation differently and LPN F stated I don't think so. Surveyor asked LPN F if she has received training on working with residents with dementia and how to handle residents with catastrophic reactions. LPN F stated No, and if I did it had to be over 5 years ago. LPN F stated the facility is going to have me take some dementia training in the next 6 months. On [DATE] at 1:00 PM Surveyor interviewed CNA E regarding the incident on [DATE]. Surveyor asked CNA E if he witnessed the incident. CNA E stated he did witness the incident. Surveyor asked CNA E if he intervened to stop the incident between Resident 1 and LPN F. CNA E stated he did not intervene. Surveyor asked CNA E if he reported the incident to a supervisor. CNA E stated he did not report the incident as he did not think what he witnessed was abusive or intimidating. CNA E stated he saw Resident 1 hit LPN F and LPN F pushed Resident 1's chair after Resident 1 hit LPN F. Surveyor asked CNA E to describe how LPN F pushed Resident 1's chair. CNA E said it was not like someone pushing a person up to the table. Surveyor asked CNA E if it was a more aggressive push. CNA E stated I would not use the word aggressive but it was not like sliding someone up to the table. Surveyor asked CNA E if there was a verbal altercation between Resident 1 and LPN F. CNA E stated what he recalled was once LPN F pushed Resident 1's chair Resident 1 stated don't hit me and LPN F stated in a bad tone don't lie about me, I did not hit you. Surveyor asked CNA E if he thought LPN F's tone was an appropriate way to address Resident 1. CNA E stated LPN F's tone Could have been better. Surveyor asked CNA E if he felt that LPN F's action was retaliation for Resident 1 hitting LPN F. CNA E stated I don't think LPN F intended to push Resident 1's chair in retaliation. Surveyor asked CNA E how Resident 1 appeared after the incident CNA E stated he did not recall Resident 1 acting any differently. Surveyor asked CNA E why he did not report the observation to the NHA or a designee CNA E stated I did not think I needed to report the incident as I do not think it met the definition of abuse. Surveyor asked CNA E if he witnessed LPN F in an altercation with other residents. CNA E stated No, I love working with LPN F she is my favorite nurse to work with. Surveyor asked CNA E if he has received training on abuse. CNA E stated the facility just provided training in the last couple of months. Per facility records CNA E received abuse and resident rights training on [DATE]. Surveyor asked CNA E if the facility has provided any additional training regarding types of abuse, recognition of abuse or abuse reporting since the incident on [DATE]. CNA E stated he has not received any further abuse training. Of note, due to the facility's failure to immediately report the incident to the NHA or a designee LPN F continued to work with vulnerable residents from [DATE] to [DATE], when the facility became aware of the incident. LPN F worked the following day shifts: [DATE] - date of incident 1 [DATE] [DATE] [DATE] [DATE] - date of incident 2 Nursing notes dated [DATE] at 1:28 PM state in part; LPN F removed an empty box of Kleenex from Resident 1's walker. Resident 1 yelled at LPN F give me back the box of Kleenex LPN F stated to Resident 1 you can't have it back. LPN F walked to the kitchen and when LPN F turned around Resident 1 had her fist up in LPN F's face, LPN F grabbed Resident 1's wrist and stated to Resident 1 do not hit me. Resident 1 stated, You're not the boss around here! LPN F told her I am when I am here. Resident 1 stated to LPN F I hate you! LPN F stated to Resident 1 I don't care; you need to go sit down. On [DATE] at 2:05 PM Surveyor interviewed LPN F regarding the incident that occurred on [DATE] with Resident 1. LPN F stated the incident occurred as written in the nursing notes. LPN F stated Resident 1 was a hoarder and that she had an empty box of Kleenex sitting on her walker and she always needed Kleenex. LPN F stated she walked over to Resident 1's walker removed the empty box of Kleenex and gave Resident 1 a new box of Kleenex. LPN F stated when she picked up the empty box of Kleenex she noticed spoons inside the empty box. LPN F stated Resident 1 stated to her give me back my box of Kleenex and I told her she could not have it back. LPN F stated she was walking to the kitchen, on the neighborhood, and when she turned around Resident 1 was behind LPN F with her fist held up in LPN F's face. LPN F stated she grabbed Resident 1's fist so she would not hit her and told Resident 1 do not hit me. Surveyor asked LPN F if she grabbed Resident 1's wrist in retaliation to Resident 1 trying to hit her; LPN F stated No. Surveyor asked LPN F to demonstrate how she grabbed Resident 1's wrist. Surveyor held her hand up in a striking motion and LPN F placed her fingers/hand loosely, like the letter C, around Surveyor 's wrist. LPN F stated I was trying to block Resident 1 from hitting me I did not grab Resident 1's arm tightly. Surveyor asked LPN F if there was a verbal altercation during the incident. LPN F stated she told Resident 1 not to hit her and Resident 1 yelled You're not the boss around here. LPN F stated I told her I was when I was here. LPN F stated Resident 1 stated she hated me and I told Resident 1 I did not care and she needed to go sit back down in her chair because she was not using her walker. Surveyor read the nursing note dated [DATE] at 1:28 PM and asked LPN F if she should have handled the situation differently LPN F replied No. Surveyor asked LPN F if the incident may have frightened Resident 1 or caused Resident 1 psychosocial distress or harm. LPN F stated management stated that I was intimidating but I do not feel I was intimidating some people may perceive things differently but what I said was not intimidating. Surveyor asked LPN F how Resident 1 reacted when she told Resident 1 she was the boss and to go sit down. LPN F stated Resident 1 stated she hated me then went and sat down. On [DATE] at 1:40 PM Surveyor interviewed CNA G regarding the incident on [DATE]. Surveyor asked CNA G if she witnessed the incident CNA G stated she did witness the incident. Surveyor asked CNA G if she intervened to stop the incident between Resident 1 and LPN F. CNA G stated she did not intervene. Surveyor asked CNA G if she reported the incident to a supervisor. CNA G stated she did not report the incident as she did not think what she witnessed was abusive. CNA G stated LPN F took the empty box of Kleenex from Resident 1 and that triggered the entire incident LPN F should have just left the empty box of Kleenex on Resident 1's walker. Surveyor asked CNA G about LPN F grabbing Resident 1's wrist. CNA G stated Resident 1 was going to hit LPN F and LPN F put her had up to block Resident 1 from hitting her. CNA G did not think LPN F intended to harm Resident 1. Surveyor asked CNA G if there was a verbal altercation between LPN F and Resident 1. CNA G stated Resident 1 stated You are not the boss of me. CNA G stated LPN F told Resident 1 she was the boss when she was here. CNA G stated I think LPN F was just trying to let Resident 1 know she was in charge of the unit and I think she was just trying to protect Resident 1. Surveyor asked CNA G how Resident 1 appeared after the altercation CNA G stated Resident 1 sat in her chair I think it was just a misunderstanding. Surveyor asked CNA G why she did not report the observation to the supervisor CNA G stated I did not think I needed to report the incident; LPN F was not aggressive. CNA G stated I think a lot of people interpret things wrong then it gets blown out of proportion. Surveyor asked CNA G if she has ever witnessed LPN F in an altercation with other residents. CNA G stated No, she is a good nurse; I do not think LPN F did anything inappropriate. Surveyor asked CNA G if she has received training on abuse. CNA G stated the facility just provided training on abuse and resident rights. Per facility records CNA G received abuse and resident rights training on [DATE]. Surveyor asked CNA G if the facility has provided any additional training regarding types of abuse, recognition of abuse or abuse reporting since the incident on [DATE]. CNA G stated she has not received any further abuse training. Of note, due to the facility's failure to immediately report the incident to the NHA or designee LPN F continued to work with vulnerable residents from [DATE] to [DATE], when the facility became aware of the incident. LPN F worked the following day shifts: [DATE] - date of incident 2 [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] On [DATE] Resident 1's nursing notes were reviewed by RNM D and LPN F was placed on administrative leave. RNM D reported the discovery of the nursing notes immediately to NHA A. On [DATE] at approximately 12:00 PM Surveyor asked NHA A when he was made aware of the incident regarding LPN F and Resident 1. NHA A stated he was made aware by either Director of Nursing (DON) B or RNM D on [DATE]. NHA A stated he was on vacation at the time of the incident but was notified via phone. On [DATE] at 11:20 AM Surveyor interviewed RNM D regarding the discovery of the incidents between LPN F and Resident 1. RNM D stated on [DATE] she was reviewing Resident 1's nursing notes relating to an earlier fall with injury. During the review of Resident 1's nursing notes RNM D discovered the nursing notes written by LPN F on [DATE] and [DATE]. RNM D stated once she read the nursing notes she discussed the documentation with another nurse manager and they immediately decided to place LPN F on administrative leave pending an investigation. Surveyor asked RNM D if she reported the incident to the NHA A on [DATE]. RNM D stated she did discuss the documentation with NHA A and NHA A was in agreement with the administrative leave. RNM D stated she interviewed LPN F on [DATE] and when she interviewed LPN F, LPN F stated what she documented in Resident 1's nursing notes was what happened. RNM D stated the facility then placed LPN F on further administrative leave pending investigation and submitted the Alleged Nursing Home Resident Mistreatment Report on [DATE]. Surveyor asked RNM D why the facility reported the incidents. RNM D stated after interviewing LPN F the facility felt that the incidents met the definition of abuse. The facility completed an Alleged Nursing Home Mistreatment Report on [DATE]. This report states, Date occurred: [DATE] of note, the incidents occurred on [DATE] and [DATE]. During an interview with LPN F on [DATE] regarding a charting entry, LPN F made statements that are concerning. The charting entries were concerning and LPN F was removed from the schedule until we could speak to her to clarify the charting (she was ill.) When she was interviewed yesterday afternoon, we had additional concerns and have now launched an investigation. She remains on administrative leave pending investigation. The investigation concluded the following: Misconduct Incident Report . date occurred [DATE] and [DATE]; date discovered [DATE] of note, the incident was discovered [DATE]. LPN F's charting entries of concern were noted. Initial review of charting justified placing LPN F on paid leave until she could be interviewed. (She was ill at the time as well.) Upon interview it was determined enough cause was present to do a report. LPN F was placed on paid administrative leave she has not worked since [DATE]. See attached documentation: A type written summary of the interview with LPN F states in part; Monday [DATE] at 1:30 PM interview with LPN F. LPN F was provided a record of her charting entries for Resident 1 from [DATE] through [DATE]. - RNM D asked LPN F to read the note dated [DATE] at 1:03 PM. Nursing notes dated [DATE] at 1:03 PM states in part; Resident 1 dropped a knife; LPN F bent down to pick it up and Resident 1 hit LPN F on the left arm. LPN F pushed Resident 1's chair with her hip and Resident 1 stated don't hit me. LPN F stated to Resident 1 I did not hit you I pushed your chair; I did not hit you. Staff present at time of incident CNA E. - LPN F read the note. RNM D asked LPN F if she could explain what was going on in that note or expound on the note. LPN F stated, What happened in the note is exactly what happened. RNM D explained the concern that it appears LPN F pushed Resident 1's chair in response to Resident 1 hitting LPN F on the arm. LPN F stated, Well my first response was I wanted to hit her, but I knew I could not do that. She hit me very hard on the arm, so I gave her chair a push with my hip. Resident 1 said do not hit me and I told her I did not hit you, I pushed your chair. RNM D stated to LPN F you wanted to hit Resident 1? LPN F said well that was my instinctive reaction at the time, but I did not hit her. RNM D asked LPN F to read the charting note from [DATE] at 1:28 PM. - Nursing notes dated [DATE] at 1:28 PM state in part; LPN F removed an empty box of Kleenex from Resident 1's walker. Resident 1 yelled at LPN F give me back the box of Kleenex LPN F stated to Resident 1 you can't have it back. LPN F walked to the kitchen and when LPN F turned around Resident 1 had her fist up in LPN F's face, LPN F grabbed Resident 1's wrist and stated to Resident 1 do not hit me. Resident 1 stated, You're not the boss around here! LPN F told her I am when I am here. Resident 1 stated to LPN F I hate you! LPN F stated to Resident 1 I don't care; you need to go sit down. - LPN F was asked to explain the events in that entry. LPN F said again, What I charted is what happened. RNM D asked LPN F if she could see anything in the charting that could be concerning. LPN F stated Resident 1 had asked for a new box of Kleenex, that hers was empty. LPN F stated I brought her a new box Kleenex and placed it on her walker seat. I went to pick up the empty one because she is not supposed to have so much stuff on her walker seat. She started yelling at me and put her first up in my face, so I grabbed her arm so she wouldn't hit me. LPN F stated Resident 1 hoards everything she can and she had spoons in the Kleenex box. RNM D explained that Resident 1's care plan indicates the facility will clean out Resident 1's room one time a week. It does not address taking things away from Resident 1 in between the weekly cleaning. RNM D explained to LPN F it difficult to understand why LPN F would argue and grab the arm of a [AGE] year old woman. RNM D stated LPN F's actions seem disproportionate to the threat Resident 1 was to LPN F. RNM D explained that to an elderly, frail and demented resident LPN F's actions could easily be interpreted as threatening or trying to assert power and control over the resident. To say things like I am the boss when I am here, I don't care that you hate me and go sit down and to have a physical interaction and argument with a resident over a Kleenex box with some plastic spoons in it is difficult to understand. RNM D asked LPN F why she did not disengage and walk away rather than enter a power struggle with her. LPN F shrugged her shoulders LPN F stated that CNA E was there when this happened. LPN F stated she told CNA E that this was going to bite her in the butt that was why she charted it. RNM D told LPN F if she felt that way and said that to a co-worker, that should have told her right then and then it was wrong and she should have called one of us. RNM D asked LPN F if she was under physical health stress or mental stress that was affecting her work as the two incidents were within a week. LPN F stated No. CNA E was called and interviewed by RNM D. CNA E recalled the incident and was reluctant to say anything. CNA E stated the incident was over a knife on the floor and Resident 1 hit LPN F pretty good on the arm. CNA E stated LPN F pushed Resident 1's chair. When asked how that looked CNA E stated LPN F went over and pushed Resident 1's chair up to the table. RNM D asked CNA E if he felt LPN F's actions were wrong in his gut CNA E stated No. CNA E stated LPN F could have handled it better. RNM D asked if it was abusive CNA E stated not to me, LPN F is a good nurse. On [DATE] at 11:20 AM Surveyor interviewed RNM D on how the facility proceeded after the interview with LPN F. RNM D stated LPN F was placed on administrative leave from [DATE] - [DATE], LPN F was required to review the facility abuse policy and resident rights policy prior to returning to work. RNM D stated LPN F will receive further training on dementia care within the next 6 months. Surveyor asked RNM D when LPN F last received abuse/resident rights training, prior to the incident on [DATE]. RNM D stated the facility just completed their annual training on resident rights and abuse and LPN F had attended that training on [DATE]. Surveyor asked RNM D if CNA E or CNA G were provided with additional abuse training after the incident as neither CNA intervened or reported the incident. RNM D was unable to provide further abuse education after the incidents on [DATE] and [DATE]. On [DATE] at approximately 12:00 PM Surveyor reviewed LPN F's personnel file. LPN F has been an employee of the facility since 2003. LPN F had no other disciplinary reports regarding abuse in her personnel file. LPN F was however provided with a letter of discipline dated [DATE] which states in part; this letter serves as notice that you are being issued a 15-day suspension for work rule violations connected with incidents occurring on [DATE] and [DATE] regarding care provided by you to a resident. (Resident 1) . In addition to violating the expected standards of care, your actions also exposed the resident (Resident 1) to emotional and psychological harm via feeling intimidated, powerless and/or abused. Your actions were more egregious give that the resident (Resident 1) was especially vulnerable because of her advanced age of [AGE] years and [DIAGNOSES REDACTED]. LPN F was allowed to return to employment on [DATE]. On [DATE] at 11:20 AM Surveyor interviewed RNM D on what measures the facility has in place to monitor LPN F's interactions with residents since she has returned to work on [DATE] to ensure abuse is not occurring in the facility and residents feel safe. RNM D stated the facility management staff completes walking rounds on the neighborhood, monitor resident behaviors and interactions between LPN F and residents on a daily basis. There have been no further concerns noted since LPN F's return to the facility. Despite CNA E having knowledge of the incident on [DATE] CNA E did not report the incident to the NHA or designee which allowed LPN F to continue to work with vulnerable residents. On [DATE] LPN F had a physical and verbal altercation, which considering the reasonable person meets the definition of abuse, with Resident 1. CNA E was not provided with further education on abuse after the incident on [DATE]. Despite CNA G having knowledge of the incident on [DATE] CNA G did not report the incident to the NHA or the designee which allowed LPN F to continue to work with vulnerable residents and the potential for abuse to continue. CNA G was not provided with further education on abuse after the incident on [DATE]. The facility failed to intervene to prevent verbal and physical abuse and failed to immediately report the abuse to the NHA or designee. This failure allowed abuse to re-occur in the facility and lead to the potential for continued abuse to occur. In addition, the facility failed to provide additional abuse education to the staff after the incidents occurred to ensure staff is able to recognize abuse, intervene when abuse occurs to ensure resident safety and immediately report abuse to ensure continued abuse does not occur. Using the reasonable person concept, a reasonable person would have been frightened, intimidated and felt verbally threatened by LPN F's actions. LPN F appeared to be retaliating against Resident 1 for striking her. LPN F's actions of aggressively pushing Resident 1's chair would frighten the reasonable person. In addition, LPN F's verbal altercation with Resident 1 stating I am the boss. would make the reasonable person feel intimidated and threatened potentially causing undo psychosocial harm.

Based on interview and record review, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) for 1 of 1 incidents reviewed. Certified Nursing Assistant (CNA) E witnessed Resident 1 hit Licensed Practical Nurse (LPN) F in the arm. LPN F then pushed Resident 1's chair with her hip after Resident 1 hit LPN F. LPN F then verbally argued with Resident 1 over the incident. CNA E did not intervene to stop the incident from occurring and did not immediately report the incident to the NHA or designee. The failure to report this incident prohibited the facility from immediately investigating the incident after the occurrence to prevent further potential abuse and allowed a second incident of abuse to occur between Resident 1 and LPN F 5 days later. In addition, once the facility became aware of the incident the facility failed to immediately report the incident to the State Agency. CNA G witnessed a verbal and physical altercation between Resident 1 and LPN F which resulted in Resident 1 trying to strike LPN F; LPN F grabbed Resident 1's wrist during the altercation. CNA G did not intervene to stop the incident from occurring, did not immediately report the incident to the NHA or designee. The failure to report this incident prohibited the facility from immediately investigating the incident after the occurrence to prevent further potential abuse. In addition, once the facility became aware of the incident the facility failed to immediately report the incident to the State Agency. This is evidenced by: The facility's policy entitled Abuse, Neglect, Mistreatment, Misappropriation of Property or Injuries of Unknown Origin, Resident Rights Complaint Process and Mandatory Reporting of Crime dated [DATE] states in part; the facility will do everything in its control to prevent occurrences of abuse, mistreatment, neglect and misappropriation of property and will not retain staff who have been adjudicated as guilty of these unlawful activities. All alleged violations will be reported to the administrator or designee immediately, thoroughly investigated, and measures implemented to prevent further incidents. Incidents that meet state and federal criteria will be reported to Division of Quality Assurance (DQA) immediately and a written report filed within 5 working days of the incident. If the alleged violation is verified, the facility will take appropriate corrective action. Procedure: B. 1. Anyone who witnesses or becomes aware of any event that might meet any of the definition of abuse, neglect .shall take immediate action to ensure that the resident is safe and report the incident/situation to the Neighborhood Nurse immediately. Incidents that may constitute any form of mistreatment in the judgment of the witness should also be reported and immediate action taken to protect the resident. Resident 1 has [DIAGNOSES REDACTED]. Resident 1 was [AGE] years old had a guardian; with protective placement at the facility. Of note, Resident 1 was discharged to the hospital on [DATE] and expired on [DATE]. A Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident 1 had moderate cognitive impairment. Section E, Behavior, notes that Resident 1 displayed no signs of Physical, Verbal or other behaviors directed toward others. Resident 1 has a care plan entitled Alteration in mental status related to dementia, history of hoarding dated [DATE] an intervention to this care planned problem states in part; staff to do weekly checks of bedroom including drawers, closet and bathroom for hoarded items. Remove any food, dirty glasses, dirty placemats, old newspaper, silverware, food packets, condiment packets per MD order and consent of guardian. Of note, facility staff witnessed two incidents between Resident 1 and LPN F. Facility staff failed to immediately report the incidents to facility NHA or designee. The facility management staff became aware of the incidents between Resident 1 and LPN F after Registered Nurse Manager (RNM) D reviewed Resident 1's nursing notes on [DATE]. The facility immediately suspended LPN F on [DATE] however, the facility failed to immediately report the incidents to the State Agency (SA). The facility did not report the incident to the SA until [DATE] after RNM D interviewed LPN F about the incidents and determined a self-report should be submitted to the SA. Nursing notes dated [DATE] at 1:03 PM states in part; Resident 1 dropped a knife; LPN F bent down to pick it up and Resident 1 hit LPN F on the left arm. LPN F pushed Resident 1's chair with her hip and Resident 1 stated don't hit me. LPN F stated to Resident 1 I did not hit you I pushed your chair; I did not hit you. Staff present at time of incident CNA E. On [DATE] at 2:05 PM Surveyor interviewed LPN F regarding the incident that occurred on [DATE] with Resident 1. LPN F stated the incident occurred as written in the nursing notes. LPN F stated Resident 1 was a hoarder and that she had a knife wrapped in a napkin and dropped it on the floor. LPN F stated she walked over to Resident 1 bent over and picked the knife up off the floor. LPN F stated as I was standing back up Resident 1 hit me hard on the arm. LPN F stated I hit Resident 1's chair with my hip after Resident 1 hit me on the arm. Surveyor asked LPN F if she hit the chair in retaliation to Resident 1 hitting her LPN F stated No. Surveyor asked LPN F if she would demonstrate how she hit Resident 1's chair. LPN F stood up and with her hip aggressively hit the chair with her hip. Surveyor asked LPN F what Resident 1 did after LPN F hit Resident 1's chair with her hip. LPN F stated Resident 1 stated don't hit me LPN F stated she told Resident 1 she did not hit her she pushed her chair. Surveyor read the nursing note dated [DATE] at 1:03 PM and asked LPN F if she should have handled the situation differently LPN F replied my first intention was to hit Resident 1 but I knew I could not do that. Surveyor asked LPN F if the incident may have frightened Resident 1 or caused Resident 1 psychosocial distress or harm. LPN F stated management stated that I was intimidating but I do not feel I was intimidating. Surveyor asked LPN F if she should have handled the situation differently and LPN F stated I don't think so. On [DATE] at 1:00 PM Surveyor interviewed CNA E regarding the incident on [DATE]. Surveyor asked CNA E if he witnessed the incident CNA E stated he did witness the incident. Surveyor asked CNA E if he intervened to stop the incident between Resident 1 and LPN F. CNA E stated he did not intervene. Surveyor asked CNA E if he reported the incident to a supervisor. CNA E stated he did not report the incident as he did not think what he witnessed was abusive or intimidating. CNA E stated he saw Resident 1 hit LPN F and LPN F pushed Resident 1's chair after Resident 1 hit LPN F. Surveyor asked CNA E to describe how LPN F pushed Resident 1's chair. CNA E said it was not like someone pushing a person up to the table. Surveyor asked CNA E if it was a more aggressive push. CNA E stated I would not use the word aggressive but it was not like sliding someone up to the table. Surveyor asked CNA E if there was a verbal altercation between Resident 1 and LPN F. CNA E stated what he recalled was once LPN F pushed Resident 1's chair Resident 1 stated don ' t hit me and LPN F stated in a bad tone don't lie about me, I did not hit you. Surveyor asked CNA E if he thought LPN F's tone was an appropriate way to address Resident 1. CNA E stated LPN F's tone Could have been better. Surveyor asked CNA E if he felt that LPN F's action was retaliation for Resident 1 hitting LPN F. CNA E stated I don't think LPN F intended to push Resident 1's chair in retaliation. Surveyor asked CNA E how Resident 1 appeared after the incident CNA E stated he did not recall Resident 1 acting any differently. Surveyor asked CNA E why he did not report the observation to the NHA or a designee CNA E stated I did not think I needed to report the incident as I do not think it met the definition of abuse. Surveyor asked CNA E if he witnessed LPN F in an altercation with other residents. CNA E stated No, I love working with LPN F she is my favorite nurse to work with. Of note, due to the facility's failure to immediately report the incident to the NHA or a designee LPN F continued to work with vulnerable residents from [DATE] to [DATE], when the facility became aware of the incident. LPN F worked the following day shifts: [DATE] - date of incident 1 [DATE] [DATE] [DATE] [DATE] - date of incident 2 Nursing notes dated [DATE] at 1:28 PM state in part; LPN F removed an empty box of Kleenex from Resident 1's walker. Resident 1 yelled at LPN F give me back the box of Kleenex LPN F stated to Resident 1 you can't have it back. LPN F walked to the kitchen and when LPN F turned around Resident 1 had her fist up in LPN F's face, LPN F grabbed Resident 1's wrist and stated to Resident 1 do not hit me. Resident 1 stated, You're not the boss around here! LPN F told her I am when I am here. Resident 1 stated to LPN F I hate you! LPN F stated to Resident 1 I don't care; you need to go sit down. On [DATE] at 2:05 PM Surveyor interviewed LPN F regarding the incident that occurred on [DATE] with Resident 1. LPN F stated the incident occurred as written in the nursing notes. LPN F stated Resident 1 was a hoarder and that she had an empty box of Kleenex sitting on her walker and she always needed Kleenex. LPN F stated she walked over to Resident 1's walker removed the empty box of Kleenex and gave Resident 1 a new box of Kleenex. LPN F stated when she picked up the empty box of Kleenex she noticed spoons inside the empty box. LPN F stated Resident 1 stated to her give me back my box of Kleenex and I told her she could not have it back. LPN F stated she was walking to the kitchen, on the neighborhood, and when she turned around Resident 1 was behind LPN F with her fist held up in LPN F's face. LPN F stated she grabbed Resident 1's fist so she would not hit her and told Resident 1 do not hit me. Surveyor asked LPN F if she grabbed Resident 1's wrist in retaliation to Resident 1 trying to hit her; LPN F stated No. Surveyor asked LPN F to demonstrate how she grabbed Resident 1's wrist. Surveyor held her hand up in a striking motion and LPN F placed her fingers/hand loosely, like the letter C, around Surveyor 's wrist. LPN F stated I was trying to block Resident 1 from hitting me I did not grab Resident 1's arm tightly. Surveyor asked LPN F if there was a verbal altercation during the incident. LPN F stated she told Resident 1 not to hit her and Resident 1 yelled You're not the boss around here. LPN F stated I told her I was when I was here. LPN F stated Resident 1 stated she hated me and I told Resident 1 I did not care and she needed to go sit back down in her chair because she was not using her walker. Surveyor read the nursing note dated [DATE] at 1:28 PM and asked LPN F if she should have handled the situation differently LPN F replied No. Surveyor asked LPN F if the incident may have frightened Resident 1 or caused Resident 1 psychosocial distress or harm. LPN F stated management stated that I was intimidating but I do not feel I was intimidating some people may perceive things differently but what I said was not intimidating. Surveyor asked LPN F how Resident 1 reacted when she told Resident 1 she was the boss and to go sit down. LPN F stated Resident 1 stated she hated me then went and sat down. On [DATE] at 1:40 PM Surveyor interviewed CNA G regarding the incident on [DATE]. Surveyor asked CNA G if she witnessed the incident CNA G stated she did witness the incident. Surveyor asked CNA G if she intervened to stop the incident between Resident 1 and LPN F. CNA G stated she did not intervene. Surveyor asked CNA G if she reported the incident to a supervisor. CNA G stated she did not report the incident as she did not think what she witnessed was abusive. CNA G stated LPN F took the empty box of Kleenex from Resident 1 and that triggered the entire incident LPN F should have just left the empty box of Kleenex on Resident 1's walker. Surveyor asked CNA G about LPN F grabbing Resident 1's wrist. CNA G stated Resident 1 was going to hit LPN F and LPN F put her had up to block Resident 1 from hitting her. CNA G did not think LPN F intended to harm Resident 1. Surveyor asked CNA G if there was a verbal altercation between LPN F and Resident 1. CNA G stated Resident 1 stated You are not the boss of me. CNA G stated LPN F told Resident 1 she was the boss when she was here. CNA G stated I think LPN F was just trying to let Resident 1 know she was in charge of the unit and I think she was just trying to protect Resident 1. Surveyor asked CNA G how Resident 1 appeared after the altercation CNA G stated Resident 1 sat in her chair I think it was just a misunderstanding. Surveyor asked CNA G why she did not report the observation to the supervisor CNA G stated I did not think I needed to report the incident; LPN F was not aggressive. CNA G stated I think a lot of people interpret things wrong then it gets blown out of proportion. Surveyor asked CNA G if she has ever witnessed LPN F in an altercation with other residents. CNA G stated No, she is a good nurse; I do not think LPN F did anything inappropriate. Of note, due to the facility's failure to immediately report the incident to the NHA or designee LPN F continued to work with vulnerable residents from [DATE] to [DATE], when the facility became aware of the incident. LPN F worked the following day shifts: [DATE] - date of incident 2 [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] On [DATE] Resident 1's nursing notes were reviewed by RNM D and LPN F was placed on administrative leave. RNM D reported the discovery of the nursing notes immediately to NHA A however the facility failed to report the incidents immediately upon discovery to the SA. On [DATE] at approximately 12:00 PM Surveyor asked NHA A when he was made aware of the incident regarding LPN F and Resident 1. NHA A stated he was made aware by either Director of Nursing (DON) B or RNM D on [DATE]. NHA A stated he was on vacation at the time of the incident but was notified via phone. On [DATE] at 11:20 AM Surveyor interviewed RNM D regarding the discovery of the incidents between LPN F and Resident 1. RNM D stated on [DATE] she was reviewing Resident 1's nursing notes relating to an earlier fall with injury. During the review of Resident 1's nursing notes RNM D discovered the nursing notes written by LPN F on [DATE] and [DATE]. RNM D stated once she read the nursing notes she discussed the documentation with another nurse manager and they immediately decided to place LPN F on administrative leave pending an investigation. Surveyor asked RNM D if she reported the incident to the NHA A on [DATE]. RNM D stated she did discuss the documentation with NHA A and NHA A was in agreement with the administrative leave. Surveyor asked RNM D when the facility notified the SA. RNM D stated the facility was unable to interview LPN F, due to illness, until [DATE] once the facility interviewed LPN F the facility had further concerns and completed the Alleged Nursing Home Resident Mistreatment Report on [DATE]. Surveyor asked RNM D why the report was not completed immediately upon discovery on [DATE]. RNM D stated LPN F struggles with her writing skills and RNM D initially thought LPN F's choice of words made the charting seem worse than it was. RNM D stated however, I knew that I did not want LPN F working in the building with other residents until I could interview her and sort this out; I thought this was in the best interest of the residents. RNM D stated on [DATE], LPN F was available for interview. RNM D stated she interviewed LPN F on [DATE] and when she interviewed LPN F, LPN F stated what she documented in Resident 1's nursing notes was what happened. RNM D stated the facility then placed LPN F on further administrative leave pending investigation and submitted the Alleged Nursing Home Resident Mistreatment Report on [DATE]. Surveyor asked RNM D why the facility reported the incidents. RNM D stated after interviewing LPN F the facility felt that the incidents met the definition of abuse. The facility completed an Alleged Nursing Home Mistreatment Report on [DATE]. This report states, Date occurred: [DATE] Of note, the incidents occurred on [DATE] and [DATE]. During an interview with LPN F on [DATE] regarding a charting entry, LPN F made statements that are concerning. The charting entries were concerning and LPN F was removed from the schedule until we could speak to her to clarify the charting (she was ill.) When she was interviewed yesterday afternoon, we had additional concerns and have now launched an investigation. She remains on administrative leave pending investigation. Of note, the facility discovered the documentation in Resident 1's medical record on [DATE] and interviewed LPN F on [DATE] but did not submit the initial Alleged Nursing Home Mistreatment Report until [DATE]. Despite the fact the facility became aware of the incident on [DATE] the facility did not begin its investigation until [DATE]. The investigation concluded the following: Misconduct Incident Report . date occurred [DATE] and [DATE]; date discovered [DATE] of note, the incident was discovered [DATE]. LPN F's charting entries of concern were noted. Initial review of charting justified placing LPN F on paid leave until she could be interviewed. (She was ill at the time as well.) Upon interview it was determined enough cause was present to do a report. LPN F was placed on paid administrative leave she has not worked since [DATE]. See attached documentation: A type written summary of the interview with LPN F states in part; Monday [DATE] at 1:30 PM interview with LPN F. LPN F was provided a record of her charting entries for Resident 1 from [DATE] through [DATE]. - RNM D asked LPN F to read the note dated [DATE] at 1:03 PM. Nursing notes dated [DATE] at 1:03 PM states in part; Resident 1 dropped a knife; LPN F bent down to pick it up and Resident 1 hit LPN F on the left arm. LPN F pushed Resident 1's chair with her hip and Resident 1 stated don't hit me. LPN F stated to Resident 1 I did not hit you I pushed your chair; I did not hit you. Staff present at time of incident CNA E. - LPN F read the note. RNM D asked LPN F if she could explain what was going on in that note or expound on the note. LPN F stated, What happened in the note is exactly what happened. RNM D explained the concern that it appears LPN F pushed Resident 1's chair in response to Resident 1 hitting LPN F on the arm. LPN F stated, Well my first response was I wanted to hit her, but I knew I could not do that. She hit me very hard on the arm, so I gave her chair a push with my hip. Resident 1 said do not hit me and I told her I did not hit you, I pushed your chair. RNM D stated to LPN F you wanted to hit Resident 1? LPN F said well that was my instinctive reaction at the time, but I did not hit her. RNM D asked LPN F to read the charting note from [DATE] at 1:28 PM. - Nursing notes dated [DATE] at 1:28 PM state in part; LPN F removed an empty box of Kleenex from Resident 1's walker. Resident 1 yelled at LPN F give me back the box of Kleenex LPN F stated to Resident 1 you can't have it back. LPN F walked to the kitchen and when LPN F turned around Resident 1 had her fist up in LPN F's face, LPN F grabbed Resident 1's wrist and stated to Resident 1 do not hit me. Resident 1 stated, You're not the boss around here! LPN F told her I am when I am here. Resident 1 stated to LPN F I hate you! LPN F stated to Resident 1 I don't care; you need to go sit down. - LPN F was asked to explain the events in that entry. LPN F said again, What I charted is what happened. RNM D asked LPN F if she could see anything in the charting that could be concerning. LPN F stated Resident 1 had asked for a new box of Kleenex, that hers was empty. LPN F stated I brought her a new box Kleenex and placed it on her walker seat. I went to pick up the empty one because she is not supposed to have so much stuff on her walker seat. She started yelling at me and put her first up in my face, so I grabbed her arm so she wouldn't hit me. LPN F stated Resident 1 hoards everything she can and she had spoons in the Kleenex box. RNM D explained that Resident 1's care plan indicates the facility will clean out Resident 1's room one time a week. It does not address taking things away from Resident 1 in between the weekly cleaning. RNM D explained to LPN F it difficult to understand why LPN F would argue and grab the arm of a [AGE] year old woman. RNM D stated LPN F's actions seem disproportionate to the threat Resident 1 was to LPN F. RNM D explained that to an elderly, frail and demented resident LPN F's actions could easily be interpreted as threatening or trying to assert power and control over the resident. To say things like I am the boss when I am here, I don't care that you hate me and go sit down and to have a physical interaction and argument with a resident over a Kleenex box with some plastic spoons in it is difficult to understand. RNM D asked LPN F why she did not disengage and walk away rather than enter a power struggle with her. LPN F shrugged her shoulders LPN F stated that CNA E was there when this happened. LPN F stated she told CNA E that this was going to bite her in the butt that was why she charted it. RNM D told LPN F if she felt that way and said that to a co-worker, that should have told her right then and then it was wrong and she should have called one of us. RNM D asked LPN F if she was under physical health stress or mental stress that was affecting her work as the two incidents were within a week. LPN F stated No. CNA E was called and interviewed by RNM D. CNA E recalled the incident and was reluctant to say anything. CNA E stated the incident was over a knife on the floor and Resident 1 hit LPN F pretty good on the arm. CNA E stated LPN F pushed Resident 1's chair. When asked how that looked CNA E stated LPN F went over and pushed Resident 1's chair up to the table. RNM D asked CNA E if he felt LPN F's actions were wrong in his gut CNA E stated No. CNA E stated LPN F could have handled it better. RNM D asked if it was abusive CNA E stated not to me, LPN F is a good nurse. On [DATE] at 11:20 AM Surveyor interviewed RNM D on how the facility proceeded after the interview with LPN F. RNM D stated LPN F was placed on administrative leave from [DATE] - [DATE], LPN F was required to review the facility abuse policy and resident rights policy prior to returning to work. RNM D stated LPN F will receive further training on dementia care within the next 6 months. Surveyor asked RNM D when LPN F last received abuse/resident rights training prior to the incident on [DATE]. RNM D stated the facility just completed their annual training on resident rights and abuse and LPN F had attended that training on [DATE]. On [DATE] at approxiamtely 9:00 AM Surveyor asked Registered Nurse Manager (RN) C how long LPN F had worked at the facility. RN C stated since June of 2003. RN C stated long enough to know better. On [DATE] at approximately 12:00 PM Surveyor reviewed LPN F's personnel file. LPN F has been an employee of the facility since 2003. LPN F had no other disciplinary reports regarding abuse in her personnel file. LPN F was however provided with a letter of discipline dated [DATE] which states in part; this letter serves as notice that you are being issued a 15 -day suspension for work rule violations connected with incidents occurring on [DATE] and [DATE] regarding care provided by you to a resident. (Resident 1) . In addition to violating the expected standards of care, your actions also exposed the resident (Resident 1) to emotional and psychological harm via feeling intimidated, powerless and/or abused. Your actions were more egregious give that the resident (Resident 1) was especially vulnerable because of her advanced age of [AGE] years and [DIAGNOSES REDACTED]. LPN F was allowed to return to employment on [DATE]. Despite CNA E having knowledge of the incident on [DATE] CNA E did not report the incident to the NHA or designee which allowed LPN F to continue to work with vulnerable residents. On [DATE] LPN F had a physical and verbal altercation, which considering the reasonable person meets the definition of abuse, with Resident 1. Despite CNA G having knowledge of the incident on [DATE] CNA G did not report the incident to the NHA or the designee which allowed LPN F to continue to work with vulnerable residents and the potential for abuse to continue. Despite the facility's knowledge of the incident on [DATE] the facility did not report the incident to the SA until [DATE]. The facility failed to immediately recognize 2 incidents of abuse, failed to immediately intervene to prevent the abuse, failed to immediately report the abuse to the NHA or designee and failed to immediately once aware of the incidents to report the incidents to the SA.