Every finding on record at Bailey Creek Health and Rehab

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to update the Care Plans for two (Resident #54 and Resident #99) of four residents reviewed.The findings include:Resident #54A review of Resident #54's admission Record revealed the facility initially admitted the resident on 06/04/2020, with diagnoses which included unsteadiness on feet, muscle weakness, malnutrition, muscle wasting and atrophy, and a fall from a non-moving wheelchair.A review of Resident #54's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/02/2026, revealed a Brief Interview of Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. Resident #54's MDS also revealed additional diagnoses, which included stroke, dementia, aphasia, bipolar disorder, and intellectual disabilities.A review of Resident #54's Progress Note entry on 03/13/2026 at 11:14 AM, revealed an unnamed Certified Nursing Assistant (CNA) delivered a breakfast tray to Resident #54. The unnamed CNA found Resident #54 on the floor, beside their bed, with blood coming from the bridge of their nose. The same Progress Note entry revealed Resident #54 was sent to the hospital for evaluation.A review of Resident #54's Progress Note entry on 03/13/2026 at 10:04 PM, described an observation of Resident #54 in bed with stitches to nose, discoloration to left eye, swelling to nose has decreased from earlier in the shift. A review of Resident #54's Progress Note entry (post-fall) on 03/16/2026, by the Director of Nursing (DON), revealed baffles [air-cushioned barrier device] to winged mattress and hand rail on left side of the bed. A review of Resident #54's Incident and Accident (I&A) report from 03/13/2026, revealed Resident has had a winged mattress in place and now changed to an enhanced height overlay with higher baffles X3 sides. This overlay further assists with defining the perimeter of the bed to minimize falls. Previously had one transfer/assist bar and now has two - to promote independence.A review of Resident #54's Care Plan revealed the resident was a high risk for falls, related to weakness, needed one staff member for transfers, and had previous falls that occurred on 04/30/2023 and 05/24/2024. Resident #54's Care Plan revealed interventions, prior to Resident #54's fall on 03/13/2026, which included:- Dropped the back of wheelchair to help prevent Resident #54 from leaning forward and falling. Date initiated 12/03/2024.- Begin restorative program. Date initiated 03/31/2025.- Monitor/document/report as needed for 72 hours to physician for signs and symptoms: pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation. Date initiated 09/17/2020. Revision on 06/08/2021.- Place transfer bars on bed to prevent resident's doll from falling out of bed. Date initiated 10/02/2025. Revision on 04/07/2026.- Replaced wheelchair with a new one. Tilted wheelchair back. Add antiroll back to wheelchair by 08/30/2024. Date initiated 08/26/2024.- Skid proof socks applied to aide in fall prevention, post fall 04/30/2023. Date initiated 05/01/2023.- Wheelchair armrest pouch. Post fall 05/24/2024. Date initiated 05/31/2024.- X-ray of left hip obtained. Date initiated 05/24/2024.Resident #54's Care Plan revealed additional interventions were listed for Resident #54 under high risk for falls related to weakness. Date initiated 06/04/2020 and revised on 06/08/2021:- Anticipate and meet Resident #54's needs. Date initiated 06/04/2020. Revision on 06/08/2021.- Ensure Resident #54's call light was within reach and encourage to use it for assistance as needed. Resident #54 needs prompt response to all requests for assistance. Date initiated 06/04/2020. Revised on 06/08/2021.- [Name Brand] winged mattress on bed. Date initiated 06/04/2020.- Encourage Resident #54 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date initiated 06/04/2020. Revised on 06/08/2021.- Follow facility fall protocol. Date initiated 06/04/2020. Revised on 06/08/2021.- Physical Therapy evaluate and treat as ordered or as needed. Date initiated 06/08/2020. Revised on 06/08/2021.Further review of Resident #54's Care Plan did not reveal clear interventions that were implemented after Resident #54's fall on 03/13/2026, as evidenced by actual fall 03/13/2026 with major injury and no related interventions for a date on or immediately after 03/13/2026.During a concurrent observation of Resident #54's room and interview on 04/09/2026 at 9:31 AM, CNA #1 indicated that Resident #54's bed had baffles at the foot of the bed and on both sides of the bed, as well as bilateral assist bars. In addition, CNA #1 indicated the baffles were not on Resident #54's bed prior to the fall but were placed on the bed after Resident #54 fell on [DATE].During an interview on 04/09/2026 at 10:48 AM, the MDS Coordinator revealed they were responsible for ensuring Care Plans had been completed. The MDS Coordinator indicated he would learn of a residents fall during morning meetings, which were department leader meetings that occurred on weekday mornings. The MDS Coordinator also indicated that Care Plans were to be updated after a resident had a fall, with the new interventions implemented after the date of the fall. In addition, the MDS Coordinator indicated if a Care Plan was not updated, as appropriate, interventions might not get done.During an interview on 04/09/2026 at 1:22 PM, the DON indicated the MDS Coordinator was primarily responsible for updating Care Plans, and Care Plans needed to be updated after a fall. The DON revealed that side rails, assist bars, and baffles needed to be included in a Care Plan if in use, and the interventions were expected to be included in the Care Plan within 24-48 hours after initiation. Additionally, the DON stated Care Plans would drive the closet Care Plans, which were the reference for the CNAs to use. The DON indicated that prior to Resident #54's fall on 03/13/2026, the resident had a winged mattress that was changed to a baffle overlay after the fall. In addition, Resident #54 had one assist rail, but it was only on the side where Resident #54 got up - but another one was placed on the left side, on the side where they fell the morning of 03/13/2026. The DON was not able to locate the interventions implemented after the fall on 03/13/2026, in Resident #54's Care Plan. The DON revealed a negative result of a Care Plan not being updated appropriately was that the nurse or CNA would not have the knowledge of what interventions were in place.During an interview on 04/09/2026 at 1:55 PM, the Administrator indicated the MDS Coordinator was the one responsible for updating Care Plans, and the purpose of updating Care Plans was so the nursing staff would know what care-related interventions needed to be done for residents. The Administrator indicated that it was expected for an intervention to be reflected on a Care Plan within 48-72 hours after the intervention(s) had been implemented.A review of the Fall Prevention Binder, with a date of 2022, revealed a specific, person-centered plan of care is a large component of successfully mitigating fall risk, and ensure fall risk is identified with appropriate interventions on the Closet Care Plans for communication to CNAs and other front-line staff.Resident #99A review of Resident #99's admission MDS, revealed Resident #99's functional abilities as dependent, or that resident required the assistance of two or more helpers to complete the activity of transferring from their chair, bed-to-chair, and walking 10 feet or more, including help with turns. A review of Resident #99's Nursing Morse Fall Scale and Care Plan, dated 06/24/2025, identified the resident to be at high-risk for falls. A review of Resident #99's I&A Report dated 06/26/2025 at 7:30 PM, revealed the resident sustained an unwitnessed fall. The report indicated an unnamed CNA found Resident #99 sitting on their bottom on the floor. The report revealed Resident #99 had stated they were trying to walk and slipped. The report revealed the resident was assessed and the nurse noted a bump on Resident #99's head. The I&A Report revealed the resident did state the bump hurt, along with their left shoulder. The on-call provider was notified, and the resident was sent to the hospital for evaluation. Resident #99 returned from the hospital with no new orders, and no fractures reported. The report indicated the resident's room was free of clutter and a new intervention for non-skid socks was implemented. A review of Resident #99's Nursing Progress Note dated 07/06/2025 at 7:42 PM, in reference to the residents unwitnessed fall on 06/26/2025, revealed the Long-Term Intervention was for the resident to always wear nonskid socks. Resident #99's Progress Note further revealed, added to the care plan: Yes.A review of Resident #99 Care Plan revealed the resident had actual fall and was at high risk for falls related to impaired mobility. Care Plan interventions included anti roll backs on the resident's wheelchair but did not include that the resident should wear non-skid socks.A review of Resident #99's MDS with an ARD of 07/10/2025, revealed Resident #99 had sustained falls since admission/entry; one fall with no injury and two falls with injury. A review of Resident #99's printed Kardex, provided by the Administrator, dated 04/08/2026, instructed staff to follow the facility fall protocol under the Safety section.During an interview on 04/08/2026 at 2:45 PM, the DON revealed that following a resident fall an intervention should be put into place. The DON then said those new interventions would go on to the Care Plan as soon as the MDS Coordinator knew about the new intervention. The DON stated the nurses would tell the staff about a new intervention and it was verbally passed along [to other staff]. The fall would then go on the 24-hour report. If there was a head injury, the nurses would start neuro[logical] checks, and we cannot close the follow-up investigation out until the neuro checks are completed, then a fall risk assessment is completed. Non-skid socks would be added to the closet Care Plan and the MDS Coordinator would then add it to the Care Plan with any new orders, a quarterly or with an MDS assessment. The DON confirmed it was important to ensure residents' care plans were up-to-date, and accurate, because they provided a picture for every one of the care needs of the resident. During an interview on 04/08/2026 at 3:00 PM, the Administrator confirmed Resident #99 sustained a fall on 06/26/2025, where a CNA found the resident sitting on their bottom on the floor, leaned against the wall. The Administrator stated the resident had reported they were trying to walk and slipped. The Administrator confirmed the intervention for non-skid socks was implemented. The Administrator then reviewed Resident #99's Care Plan and stated the non-skid socks intervention was not listed. The Administrator then verified that is was also not on the Kardex, that the CNAs used for resident care. The Administrator provided a copy of Resident #99's Kardex to this surveyor and stated the Kardex was where the CNAs documented. The Administrator revealed Resident #99's non-skid socks should have been added to their Care Plan, or at least their closet Care Plan. The Administrator stated they did not have a copy of Resident #99's closet Care Plan to know if it was there or not. The Administrator stated they used the Resident Assessment Instrument (RAI) manual as guidance in completing resident Care Plans. The Administrator revealed Resident #99 had sustained three falls since living at the facility, one prior to the fall on 06/26/2025, the actual fall on 06/26/2025, and one following [on 07/09/2025]. The Administrator stated the resident was wearing the non-skid socks when the fall on 07/09/2025 occurred.During an interview on 04/09/2026 at 10:48 AM, the MDS Coordinator stated Resident #99 sustained an unwitnessed fall on 06/26/2025, where a CNA found the resident sitting on their bottom near the door of their room. The MDS Coordinator stated that the use of non-skid socks was a new intervention that was implemented following that fall. The MDS Coordinator looked in their computer and stated the non-skid socks had not been added to Resident #99's Care Plan and should have been added no later than 07/06/2025. The MDS Coordinator stated the CNAs, nurses, and anyone who was providing care for the resident used the Care Plan and the closet Care Plan [as guidance in care of the resident]. The MDS Coordinator confirmed if an intervention was not added to the Care Plan, the staff could not utilize the new intervention. The MDS Coordinator stated the staff used the Fall Prevention Binder located at each nurses' station, then provided a copy of the Fall Prevention Binder to this surveyor. A review of the Fall Prevention Binder, provided by the MDS Coordinator indicated, Post Fall Assessment: A comprehensive post fall management plan should include, but is not limited to: Investigate the cause of the fall: What was the resident doing before he/she fell. Revise plan of care and/or facility practices to reduce likelihood of another fall. A review of a policy titled, Falls and Fall Risk, Managing, contained in the Fall Prevention Binder revealed, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors included: footwear that is unsafe or absent.A review of the facility Fall Protocol policy provided by the Administrator, indicated under Treatment/Management1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily indemnified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling.

Based on record review, observation, interview, facility document review, and facility policy review, it was determined that the facility failed to initiate and follow Enhanced Barrier Precautions (EBP) for one (Resident #75) of three residents observed for infection control. The finding include: A review of Resident #75's admission Record indicated the facility admitted the resident on 04/23/2025, with diagnosis which included chronic diastolic congestive heart failure, protein calorie malnutrition, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominate side, gastrostomy complications, dysphagia, and gastrostomy status with an onset date of 12/22/2022. A review of Resident #75's quarterly Minimum Data Set, with an Assessment Reference Date of 03/17/2026 revealed a Brief Interview for Mental Status score of 03, which indicated the resident had severely impaired cognition. Resident #75's MDS revealed the resident was dependent on staff in all areas of Activities of Daily Living, had an indwelling catheter and a feeding tube in place, and had a pressure reducing device for their chair and bed. A review of Residents #75's Order Summary Report revealed the resident was to receive nothing by mouth. Resident #75's Order Summary Report revealed additional orders which included: clean Gastrostomy Tube (G-tube) site every shift, enteral feed order for every shift, and the resident was on EBP related to their [name brand indwelling] catheter and G-tube. A review of Resident #75 Care Plan, with a revision date of 07/03/2025, revealed the resident required EBP, related to enteral feedings. Resident #75's Care Plan specified interventions for staff such as alcohol based handrub or wash with soap and water if visibly soiled before and after leaving the room; do not wear the same gown and gloves for the care of more than one resident; and wear gloves and gowns for high-contact resident care activities. During an observation of the morning medication pass on 04/08/2026 8:55 AM, this surveyor observed Licensed Vocational Nurse (LVN) #2 prepare medication for Resident #75, to be given via G-tube, at the medication cart. The following medications were administered: a generic medication used to lower blood pressure, a urinary system supplement, a generic stool softener, a brand name medication used to treat fluid retention, a generic medication used to prevent blood clots, a generic anti-depressant, a multi-vitamin with minerals, and a digestive supplement. LVN #2 crushed each individual pill and placed them into individual cups to be mixed with water. LVN #2 initially conducted proper handwashing and the application of gloves. LVN #2 then mixed small amounts of water to each individual cup to help with dissolving medication for ease in administration. LVN #2 removed their gloves, sanitized their hands, then applied new gloves, prior to disconnecting Resident #75's feeding tubing from their G-tube. LVN #2 failed to don a gown, which was ordered as part of Personal Protective Equipment (PPE), prior to disconnecting the resident's feeding tube from their G-tube and considered a high-contact resident care activity. LVN #2's sweater then touched Resident #75's bed as she leaned over to disconnect the resident's feeding tubing and applied a syringe to Resident #75's G-tube for a water flush. LVN #2's sweater again touched the resident's bed as their medication was added to a syringe for medication administration. After completing Resident #75's G-tube medication administration, LVN #2 removed their soiled gloves, washed their hands, and applied new gloves to then instill eye drops into the residents' eyes. During an interview on 04/08/2026 at 9:38 AM, LVN #2 confirmed that Resident #75 was on EBP. LVN #2 read the sign that was posted outside the resident's door, which indicated Enhanced Barrier Precautions. LVN #2 then informed this surveyor the required supplies to be included during direct care for Resident #75 were gloves and a gown. LVN #2 confirmed they did not use a gown when donning PPE but reported that it should have been worn during Resident #75's medication administration through their G-tube. During interview on 04/09/2026 at 12:56 PM, the Infection Preventionist (IP) revealed EBP should be used on residents with catheters, intravenous catheters (IVs), feeding tubes, and any type of indwelling devices, to decrease the spread of infections. The IP explained EBP should include wearing a barrier gown and gloves, if staff were performing direct patient care like bathing, dressing, incontinent care, or giving medication through a G-tube. The IP then added training with staff related to EBP and infection control included demonstration with returned demonstration by staff on donning and doffing PPE. During an interview on 04/09/2026 at 1:21 PM, the Director of Nursing (DON) explained the indication and purpose for EBP, was for it to be used with residents with wounds, catheters, IVs, and/or any draining fluids that may be source of infection, and its purpose was to decrease the spread of infection. The DON reported staff were in-serviced on EBP by using demonstration and return demonstration on donning and doffing PPE used for EBP and signs that were posted on appropriate resident's doors. The DON further included gown, and gloves should be worn during administration of medication through a G-tube. A review of a facility policy titled, Enhanced Barrier Precautions dated August 2022, revealed enhanced barrier precautions are utilized to prevent the spread of multi-drug-resistant organisms (MDROs). EBP employed targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities, which required the use of gown and gloves for EBP, included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) and wound care, any skin opening requiring a dressing, but this does not include protective coverings such as transparent covering, band aids, or steri-strips used to keep skin flaps in place. A review of facility provided policy titled, Enteral Feedings-Safety Precautions, dated November 2018, revealed all personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. The facility will remain current in and follow accepted best practices in enteral nutrition. A review of an In-service Education Report dated 02/08/2026, revealed topics of infection control: comprises evidence-based policies, procedures, and practices, designed to prevent the spread of infections in health care settings, protecting patients and staff.

Based on record review, interview, facility document review, observation, and facility policy review, the facility failed to ensure that physician orders were followed for two (Resident #1 and Resident #4) of two residents reviewed for dressing changes and to ensure one resident (Resident #1) received indwelling catheter care, as ordered. The findings include: Resident #1 A review of Resident #1's admission Record indicated the facility admitted the resident with diagnoses which included osteomyelitis (serious bone infection) of vertebra, sacral and sacrococcygeal region (base of the spine), type 2 diabetes mellitus, and pressure ulcer of unspecified site, unspecified stage. A review of Resident #1's Physician admission note, dated 05/13/2025, indicated the resident had been admitted with recent hospital discharge orders for antibiotics to be given until 06/13/2025, related to osteomyelitis. The Physician note also indicated that the resident did not have a Peripherally Inserted Central Catheter (PICC) in place, and the admitting physician was called. The resident's PICC line placement was scheduled for 05/13/2025. A review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/2025, revealed a Brief Interview Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. A review of Resident #1's Order Summary Report revealed an active order dated for 05/14/2025, for the resident to have a PICC line dressing change conducted every three days. A review of Resident #1's TAR for June of 2025, revealed no initials or check marks were documented to indicate the resident's order change PICC line dressing every day shift every 3 days had been completed on 06/01/2025, 06/04/2025, or 06/10/2025. A review of Resident #1's Skin and Wound Evaluation V7.0, dated 06/02/2025, indicated the resident had an unstageable pressure ulcer which covered an area of 5.6 centimeters, with orders for generic wound cleanser and primary dressing as [Name Brand Wound Dressing]/wet to dry, with a composite secondary dressing. Additional care included, but was not limited to, incontinence management and moisture barrier. A review of Resident #1's Order Summary Report contained an order dated 05/21/2025, to cleanse us [unstageable pressure ulcer] right heel with wound cleaner, paint with betadine, cover with [Name Brand Wound Dressing] foam then wrap with [Name Brand Gauze] every day shift. A review of Resident #1's TAR for June of 2025, revealed no check marks or initials were documented to indicate the dressing change to the resident's right heel had been completed on 06/01/2025 or 06/10/2025. A review of Resident #1's Physician's admission note dated 05/13/2025, contained an order to cleanse USPU [unstageable pressure ulcer] to coccyx with wound cleaner, apply wet to dry with [Name Brand Wound Dressing], cover with island dressing every day shift. A review of Resident #1's TAR for June of 2025, revealed no check mark or initials were documented to indicate the cleansing and dressing of the pressure ulcer on the resident's coccyx had been completed on 06/01/2025 and 06/04/2026. A review of Resident #1's Order Summary Report contained an order dated 06/04/2025, to cleanse USPU to coccyx with wound cleaner, apply wet to dry with [Name Brand Wound Dressing], cover with [Name Brand Wound Dressing] foam every day shift. A review of Resident #1's TAR for June of 2025, revealed no check mark or initials were documented to indicate the treatment for the resident's pressure ulcer to coccyx had been completed on 06/10/2025. A review of Resident #1's Order Summary Report contained an order dated 05/18/2025, for cath [catheter] care q [every] shift and PRN [as needed] with soap and water or wipes every shift for wound healing. A review of Resident #1's TAR for June of 2025, did not have a check mark or initials documented to indicate the catheter care had been completed as ordered (on day shift) on 06/02/2025, 06/03/2025, 06/04/2025, 06/06/2025, 06/07/2025, 06/08/2025, 06/09/2025, 06/10/2025, or 06/11/2025. During an interview on 03/20/2026 at 1:53 PM, the Director of Nursing (DON) reviewed Resident #1's TARs for May and June of 2025 and verified that the initials documented in a block indicated that the treatment or medication was given and that an X in the box indicated the treatment was not ordered for that day and an open block would indicate the treatment was not completed. The DON verified the absence of check marks and initials on the aforementioned dates would indicate the treatments had not been completed. Resident #4 A review of Resident #4's admission Record indicated the facility admitted the resident on 03/04/2026, with diagnoses which included infection and inflammatory reaction, due to internal left hip prosthesis, Methicillin-Resistant Staphylococcus Aureus (type of bacteria that has developed resistance to many antibiotics), and pain due to internal orthopedic prosthetic devices, implants and grafts. A review of Resident #4's Order Summary Report contained an order dated 03/05/2026, for dressing change PICC line to left upper arm every day shift every Wed. A review of Resident #4's TAR for March of 2026, reflected the resident had a PICC line to left arm, and an order for a dressing change to the PICC line every Wednesday. A check mark and initials were documented for 03/11/2026, and for 03/18/2026. The Chart Codes/Follow Up Codes, located at the bottom of each page of the TAR, revealed a check mark indicated the treatment had been administered. During a medication pass observation on 03/19/2026 at 8:25 AM, Licensed Practical Nurse (LPN) #4 looked at Resident #4's PICC line dressing and stated the handwritten date on the dressing looked like the date was either 11 or 14. LPN #4 stated she was unsure when the last PICC line dressing was changed, because the PICC line dressings could only be changed by a Registered Nurse (RN). LPN #4 revealed there were no initials visible on the dressing. During an observation on 03/19/2026 at 9:54 AM, the Treatment Nurse (TN) was in Resident #4's room standing by the resident's bedside, when this surveyor entered the room. The TN was wearing blue gloves, the resident's PICC line site was not covered, because the dressing had been removed. LPN #4, who was also present, administered oral medications and hung an antibiotic to infuse through Resident #4's PICC line, while the TN watched. Resident #4's PICC line site was uncovered for several minutes until after the antibiotic tubing was attached to the PICC line port. The TN stated that the dressing change was due yesterday [03/18/2026], but stated the dressing was not available at the time and had to be ordered from the pharmacy. The TN stated she signed the TAR, after she completed the dressing change. A review of a facility document located in Resident #4's Electronic Health Record titled, Nsg [Nursing] - I &A [Incident and Accident] note dated 03/19/2026 at 10:59 AM, completed by the DON, revealed the resident's PICC line dressing change was not completed on 03/18/2026, as ordered. The note also indicated the dressing was changed on 03/19/2026. During an interview on 03/19/2026 at 1:44 PM, LPN #4 reviewed Resident #4's TAR for 03/18/2026 and stated the initials in the box for the resident's PICC line dressing change were her initials and she revealed that she had entered them. She stated that she had not changed Resident #4's dressing but had checked with the TN and was told the dressing was within the 7-day time frame allowed for dressing changes to be performed, so LPN #4 had put her own initials in the block to indicate she had looked at the dressing. LPN #4 verified that an x in a box on the TAR indicated the treatment was not due on those days, and if the box was blank then that was where staff initials would be recorded. LPN #4 further indicated the block for 03/18/2026, where her initials were located, that if the treatment was completed the nurse who completed it would initial it, but she initialed it because she had looked at it. During an interview on 03/19/2026 at 2:13 PM, the TN stated she had changed Resident #4's PICC line dressing on 03/11/2026, however when she changed the dressing on 03/19/2026, the dressing had a written date of 03/14/2026. The TN reviewed Resident #4's TAR for March of 2026 and was unable to locate any documentation indicating the resident's PICC line dressing was changed on that date [03/14/2026]. The TN stated she did not know whose initials were on the dressing that she had removed on 03/19/2026. The TN then stated if she had changed the dressing, her initials would be on the TAR to indicate the dressing change had been completed, and verified her initials were documented on Resident #4's TAR for the 03/11/2026 dressing change. The TN read Resident #4's TAR order and verified that the order specified the resident's PICC line dressing was to be changed every Wednesday, and if the dressing was changed additionally between scheduled days, it would still need to be changed as ordered on Wednesday and physician orders should be followed. The TN stated that she was unsure which LPNs were allowed to change dressings and did not comment on why the LPN had placed her own initials in the block. During an interview on 03/19/2026 at 3:00 PM, the Advance Practice Nurse (APN) reviewed Resident #4's TAR and verbally confirmed the order for the residents dressing change to their PICC line site was for every Wednesday, and as needed. The APN stated that if the dressing was changed on a day other than Wednesday, it should still be changed on Wednesday, per order, to stay on schedule. The APN reviewed the TAR and stated the initials on 03/18/2026, indicated the dressing had been changed and she had not been notified that the dressing had not been changed. During an interview on 03/20/2026 at 1:53 PM, the DON reviewed Resident #4's TAR for March of 2026 and verified that staff initials in a block indicated the treatment or medication was given, and that an X indicated the treatment was not ordered for that day. The DON further revealed that an open block would indicate the treatment was not completed. A review of an in-service over the topic Infection Control while managing PICC lines dated 03/20/2026, specified in part, if PICC line dressings were changed PRN on an unscheduled day, then nursing administration was to be notified so that routine changes may be adjusted as necessary and the change was to be documented.

Based on record review, observations, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed between glove changes, a Peripherally Inserted Central Catheter (PICC) access was cleaned according to industry standards, and a PICC line dressing was intact prior to accessing the hub for one (Resident #4) of one resident reviewed for infection control practices during PICC access. The findings include: A review of Resident #4's admission Record indicated the facility admitted the resident with diagnoses which included infection and inflammatory reaction due to internal left hip prosthesis, Methicillin-Resistant Staphylococcus Aureus (MRSA) [a type of bacteria that has developed resistance to many antibiotics], and pain due to internal orthopedic prosthetic devices, implants and grafts. A review of Resident #4's entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/2026. The Point Click Care facility database indicated the admission MDS was incomplete and in progress. A review of Resident #4's Care Plan Report, initiated on 03/04/2026, revealed the resident had an MRSA colonization to their left hip. Interventions included contact isolation, antibiotic therapy as ordered, wear disposable gown and gloves during physical contact with resident, discard in appropriate receptacle and wash hands before leaving room; observe standard precautions for infection control; and keep open wounds covered rather than open to air. A review of Resident #4's Order Summary Report revealed the resident had a PICC line in their left arm. A dressing change for the resident's PICC line was ordered on 03/05/2026, to be changed every Wednesday, and an antibiotic was ordered on 03/04/2026, to be administered intravenously (IV) once daily, for infection of the left hip. A review of Resident #4's Treatment Administration Record (TAR) revealed the resident had an order for a dressing change for their PICC line to their left arm for every Wednesday. A check mark and initials for the Treatment Nurse (TN) were documented for Wednesday, 03/11/2026 and a check mark and initials for Licensed Practical Nurse (LPN) #4 were documented for Wednesday, 03/18/2026. The Chart Codes/Follow Up Codes located at the bottom of each page of the TAR revealed a check mark indicated the treatment was administered. A review of Resident #4's Medication Administration Record (MAR) revealed the resident had an IV antibiotic once daily for infection of the resident's left hip. A check mark and initials were documented for Wednesday, 03/18/2026. The Chart Codes/Follow Up Codes located at the bottom of each page of the MAR revealed a check mark indicated the mediation was administered. During an observation on 03/19/2026 at 8:25 AM, Licensed Practical Nurse (LPN) #4 confirmed that Resident #4 had a PICC line, was on contact precautions related to their PICC line, and had a wound with MRSA. LPN #4 prepared to enter Resident #4's room to obtain blood pressure and administer medications obtained from the medication cart located in the doorway of Resident #4's room. LPN #4 performed hand hygiene and donned two pair of gloves and PPE that included a facemask, gown and gloves. LPN #4 stated the reason for two pair of gloves was they needed to take Resident #4's blood pressure (BP), then they could remove one set of gloves, then obtain and administer Resident #4's medications. LPN #4 entered Resident #4's room a total of three times in order to obtain and administer medications from the medication cart, donning two sets of gloves each time. The third time, LPN #4 donned two pairs of gloves and stated they needed to pick up the used BP cuff from residents' and did not want to contaminate the donned gloves. LPN #4 picked up the BP cuff, reviewed reading, documented the resident's BP in the electronic health record (EHR), removed their outer gloves, opened the trash can with gloved hands, threw doffed outer gloves into trash can, then closed the trashcan lid with the second pair of gloves still in place on their hands. LPN #4 returned to the medication cart, opened the medication cart, removed medication cards and placed them on top of the medication cart. LPN #4 then removed their gloves, disposed of the gloves in the trashcan, and donned a clean pair of gloves without performing hand hygiene. LPN #4 began placing Resident #4's medication in a clear plastic medication cup, entered Resident #4's room and provided medications. LPN #4 removed their gloves and PPE, dropped the gloves and PPE into the trashcan, closed the trashcan lid with their bare hand, and then washed their hands. Next, LPN #4 donned Personal Protective Equipment (PPE) which included gloves, gown, and a mask. LPN #4 then gathered intravenous (IV) tubing, IV antibiotic, alcohol preps, and a 0.9% Sodium Chloride 10 cubic centimeter (cc) syringe. LPN #4 entered Resident #4's bathroom and obtained three paper towels, placed on Resident #4's overbed table and placed the 0.9% Sodium Chloride 10 cc syringe, the antibiotic fluid bag, and the IV tubing on the paper towels. LPN #4 removed the 0.9% Sodium Chloride 10 cc syringe from the outer packaging, removed the IV tubing from the outer packaging, removed the clear, non-disinfecting cap from the access port of the PICC line and used the alcohol prep pad to wipe twice across access port (< 3 seconds). The LPN then attached and infused 0.9% Sodium Chloride into port. The IV tubing that was in LPN #4's hand touched Resident #4's bedding, then LPN #4 released the PICC line access port, which fell back onto the resident's arm. LPN #4 disposed of the IV tubing, adjusted Resident #4's arm, walked back to medication cart, obtained an unopened package of IV tubing from the medication cart, returned to Resident #4's bedside, adjusted facemask, opened IV tubing, removed medication bag access cover and inserted spiked end of the IV tubing into the IV medication bag, then primed the IV tubing. LPN #4 wiped the access port of Resident #4's PICC line with an alcohol pad for < 3 seconds, attached the IV tubing to the PICC access port and started the medication flowing through the IV tubing, into Resident #4's arm. No hand hygiene or glove change was done during this process. LPN #4 stated they were unsure of when the last dressing change to Resident #4's PICC line site was done, a Registered Nurse (RN) changes the PICC dressings, LPNs cannot change them. LPN #4 stated the date on dressing is either 11 or 14. LPN #4 removed their PPE, washed their hands in Resident #4's bathroom sink, then exited Resident #4's room. During a concurrent observation and interview on 03/19/2026 at 9:54 AM, LPN #4 donned PPE and no hand hygiene was performed, prior to entering Resident #4's room. The Treatment Nurse (TN) was in Resident #4's room standing at the resident's bedside wearing blue gloves. Resident #4's PICC line site was not covered; the dressing had been removed. Resident #4 was not wearing a mask and was looking at their open site. LPN #4 administered Resident #4's oral medication, disconnected tubing from the resident's PICC line, wiped the access port of Resident #4's PICC line with an alcohol pad for three seconds, and flushed the access port with a 0.9% Sodium Chloride 10 cc syringe. The TN stated they were responsible for bandage changes, treatments, and PICC line dressing changes and believed Resident #4's PICC was changed Wednesday [03/11/2026] or Thursday [03/12/2026] of last week. The TN then reported the dressing removed from Resident #4's PICC line today, was marked as the 14th but did not have the dressing that was removed as it was in the trashcan. The TN reported Resident #4's dressing change was due yesterday [03/18/2026], but the dressing was not available and had to be ordered from the pharmacy and the dressing needed to be changed every seven (7) days. The TN stated the TAR was signed by the nurse completing the dressing change, after dressing changes were completed. A review of Resident #4's Nsg [Nursing] - I&A [Incident and Accident] Note, dated 03/19/2026 at 10:59 AM, signed by APN, indicated an incident description of A dressing change for a PICC line not performed on the day ordered 03/19/2026. Immediate intervention indicated the dressing was changed on 03/19/2026, with no signs or symptoms of infection observed. During an interview on 03/19/2026 at 1:44 PM, LPN #4 stated the process for providing medication to Resident #4 was to, knock on the door and I gown up and glove. I usually go in and do [pronoun] BP and give [pronoun] pill. LPN #4 stated, I have two pair [of gloves] on and I pull the top pair off, I clean the site, I flush it and wipe the tip [referring to the access port] off, start IV medication and when done, wipe it [access port] off again and flush. LPN #4 stated the purpose of double gloving was, So I don't have to keep changing it [gloves] and it was not the facility's policy to double glove. LPN #4 stated hand hygiene should have been performed after removing their gloves and donning new ones. LPN #4 could not respond to length of time the PICC line access should be scrubbed and stated they would obtain an answer. On 03/19/2026 at 2:02 PM, LPN #4 entered the conference room and stated, I should have cleaned [PICC line access port] hub with an alcohol pad for at least 15 seconds. During an interview on 03/19/2026 at 2:13 PM, the TN stated Resident #4's PICC dressing was removed prior to LPN #4 entering the resident room. The TNs dirty gloves and Resident #4's old PICC dressing, that had been removed by TN, were disposed of in the trash. The PICC dressing kit was opened and sterile gloves were donned. The TN pointed out the sterile gloves in an unopened PICC dressing kit and described the sterile gloves as blue in color. The TN revealed the PICC dressing kits were kept on hand in the past, and now the pharmacy would only send 2-3 kits at a time. No particular nurse or person was responsible for ordering the dressing kits, they were ordered by anyone that would be changing the dressing, and knowing this one was the last one, I ordered. The TN revealed she had changed Resident #4's PICC dressing 2-3 times, since the resident's admission on [DATE]. During an interview on 03/19/2026 at 3:00 PM, the Advanced Practice Nurse (APN) stated she expected the nurses to keep PICC sites and access ports sterile/clean during administration of medications and flush to prevent cross contamination, and for the nurses to change gloves and wash their hands. One set of gloves should be used, removed and hands washed, then put on a new pair of gloves. Staff should not double glove. A review of Resident #4's Progress Notes dated 03/19/2026 at 8:14 PM, revealed an APN note assessment of Resident #4's PICC line that was done, with no evidence of improper cleansing of the resident's medication administration ports. There were also no health-related concerns with Resident #4's PICC line dressing change on 03/14/2026 or 03/19/2026, and any errors related to the dressing appears documentation related. with instruction to monitor and notify of any changes in Resident #4's condition. During an interview on 03/20/2026 at 9:10 AM, the Administrator provided an unlabeled package that contained a cap used for PICC lines, and stated the cap eliminated the need to sanitize the PICC line access. The Administrator also provided a file folder that contained documentation on Proper Access of Central Venous Catheter, a policy and procedure on infection control, medication administration, medication and treatment orders, donning and doffing PPE, progress note, and an In-service Education Report dated 03/20/2026, with a topic of Infection Control while managing PICC lines. The folder had a handwritten note indicating a one-on-one with LPN #4 was conducted, observation rounds were to be done to ensure treatments were completed per orders, nurse practitioner assessed resident, lab comparison done. The Centers for Disease Controls (CDCs) recommendation of at least 5 second scrub, Curos product eliminates scrub, continued use of Curos and scrub for 15 seconds per recommendation. The Administrator stated the expectation of staff was to document care, medication administration, follow physician orders, and follow infection prevention practices to prevent infections. One on one in-service education on PICC line infection control was done with LPN #4 on 03/20/2026. During an interview on 03/20/2026 at 1:53 PM, the Director of Nursing (DON) stated staff should wear only one set of gloves, drop things in the trash bag, remove the bag from the trash can and put in a red bag and wash their hands. Cleaning the PICC port should be done for 15 seconds with alcohol swabs, even if they have the medicated caps. Medicated caps were in a drawer, and we are looking but cannot find the box. that contained the unlabeled caps. The IV tubing should not be opened while wiping the port access, and you would want to have the dressing in place before starting the medication to prevent risk of infection. A review of a facility provided document titled, Inservice Education Report, dated 03/20/2026, addressing Infection Control while managing PICC lines, indicated needless access device should be disinfected using a disinfecting wipe for at least 15 seconds, allowed to air dry. Use only the [NAME] caps. These are Curos Disinfecting Caps for Needleless Connectors that alleviate the need for vigorous scrubbing. Additional education included notification of nursing administration if PICC line dressings were changed PRN on an unscheduled day so schedule for routine changes may be adjusted as necessary, and document the change on the MAR and in the progress notes. Maintain hand hygiene to avoid potential contamination. always sanitize or wash hands after discarding items and before donning clean or sterile gloves. The in-service document was unsigned. A review of an undated CDC facility provided document titled, Sequence for Donning Personal Protective Equipment (PPE), instructed use of PPE varied with level of precautions required and donning PPE in order of gown, mask, goggles, gloves. To use safe work practices to protect self and limit the spread of contamination included, keep hands away from face, limit surfaces touched, change gloves when torn or heavily contaminated, preform hand hygiene. A review of a document titled, 3M Curos Disinfecting Port Protectors Implementation Guide, revealed, on page 40 of 112, Page 15: A. Sequential Scrub - . has been in place for more than 1 minute., there is no need to scrub upon removal of the cap. In addition, you should scrub if any of the following conditions are present: -Scrub between sequential accesses (i.e., Between multiple medications given in one sitting, such as Saline, Medication, Saline) . Scrub if you remove the cap and set down the port before accessing, if the port becomes contaminated, or if you leave an uncapped port unattended for any length of time. B. Sequential Aseptic. has been in place for more than 1 minute. there is no need to scrub upon removal of the cap. Maintain aseptic technique between sequential accesses (i.e. between multiple medications given in one sitting such as Saline, Medication, Saline). For a sequential access, you would remove the disinfecting cap, flush, maintain aseptic technique. give your medication, maintain aseptic technique. flush and then replace with a new Curos Disinfecting Cap. A review of a policy and procedure titled, Handwashing/Hand Hygiene, revised October 2023, included a policy statement, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The policy interpretation indicated all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections. Hand hygiene is indicated, a. immediately before touching a resident; b. before performing an aseptic task (for example. handling an invasive medical device), after touching a resident or their environment and immediately after glove removal. The policy revealed, 5. The use of gloves does not replace hand washing/hand hygiene, and hand hygiene should be performed prior to applying and after removing gloves.

Based on observation, interview, and facility policy review, the facility failed to ensure the ice scoop holder was maintained in clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the residents food, failed to ensure opened food items in the freezer were sealed to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing techniques to prevent potential cross contamination of food and clean dishes for residents who received meals from 1 of 1 kitchen. The findings are: 1. On 9/4/24 at 3:20 PM, the following observations were made on the spice rack above the food preparation counter: a. A plastic container of oregano with best by date of 5/24/2024. b. A plastic container of parsley flakes with best by date of 8/5/2024. 2. On 9/4/24 at 3:37 PM, the following observations were made on a shelf in the 3- door freezer in the storage room: a. Two opened boxes of beef patties, the box was not covered or sealed. 3. On 9/4/24 at 4:13 PM, the ice scoop holder on the wall by the ice machine in the dining room had a coral-colored wet residue at the bottom of it. The substance was easily removed when wiped with a clean paper by the Registered Dietitian (RD). She stated it was wet black residue. a. On 9/06/24 at 11:15 AM, the RD was asked who used the ice from the ice machine and how often they cleaned it. She stated, The maintenance man cleans it once a month. The kitchen uses it to fill beverages served to the residents at mealtimes. They clean it daily. 4. On 9/3/24 at 4:40 PM, Dietary Aide (DA) #3 washed and dried her hands and turned off the dirty faucet with her clean hands. DC#3 then picked up clean plates and placed them on the trays with fingers inside the plates. DA#3 lifted the trash can lid and threw tissue paper into the trash can. Without washing her hands, she picked plates to be used in portioning desserts and placed them on the tray with fingers inside the plates. 5. On 9/4/24 at 5:05 PM, DC #2 picked up the blender motor from a rack by the food preparation counter and placed it on the counter, contaminating his hands. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for supper. 6. On 9/3/24 at 5:09 PM, DA #3 washed and dried her hands and turned off the dirty faucet with her clean hands. DA #3 then picked up clean plates and placed them on the trays with her fingers inside the plates. DA #3 lifted the trash can lid and threw tissue paper into the trash can. Without washing her hands, she placed new gloves on her hands, contaminating the new gloves, she used her gloved hands to pick up clean utensils close the areas that would go into the month and wrapped them in individual napkins for the residents to use at their supper meal. 7. On 9/3/24 at 5:12 PM, DC #2 removed a recipe book on the counter out of the way. Without washing his hands, he placed new gloves on his hands contaminating the gloves, DC #2 used his gloved hand to remove ham log from the bag and placed it on the cutting board and then sliced it to be used in making ham and chesses sandwiches to be served to the resident who requested it. DC #2 was asked what he should have done after touching diet objects and before handling food items. DC #1 stated, I should have washed my hands. 8. On 9/04/24 at 5:14 PM, DA #3 pushed a cart containing a pan with glasses of ice in it from the dining room into the kitchen. Without washing her hands, DA #3 picked up glasses by the rims and poured water in them to serve to residents at their supper meal. 9. On 9/5/24 at 12:12 PM, DA #4 closed the door to the janitor's closet. Without washing his hands, he picked up a clean blade and attached it to the base to be used in pureeing food items to be served to the residents for lunch meal. a. On 9/6/24 at 8:27 AM, DA #4 was asked, what he should have done after touching diet objects and before handling food items. DA #4 stated, I should have washed my hands. 10. A review of a facility policy titled, Employee cleanliness and Handwashing Technique undated provided by the Business Manager on 9/5/2024, indicated, Dietary department employees are required to wash their hands on the occasions before beginning shift, after disposing or handling of trash or food and any other time deemed necessary.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure all cleaning cart doors locked to ensure residents could not access cleaning supplies and chemicals from the unlocked carts to prevent injuries. The facility failed to identify and ensure sharp, jagged plastic from a busted air conditioner frame was repaired to prevent accidents or injuries to 1 (Resident #17) sampled resident reviewed for accidents or injuries. Findings include: 1. a. On 09/03/2024 at 9:30 AM, while walking down 400 Hall in the closed unit the surveyor observed the cleaning cart door ajar revealing disinfectants and bathroom and bowl cleaners while Housekeeping #5's back was to the cleaning cart. b. During an interview with Housekeeping #5 on 09/05/2024 at 9:50 AM, the Surveyor was told there has not been a working lock on any of the cleaning carts in over a year. Housekeeper #5 stated if a resident opened the cleaning cart doors they could remove chemicals from the cart. c. On 09/05/2024 at 10:05 AM, while walking down 100 Hall, the surveyor observed Housekeeping #6's cleaning cart's door open and facing the hallway with a bottle of bathroom disinfectant visible. Housekeeper #6 confirmed the lock has not worked in at least a year and was concerned a resident could spray themselves in the face. d. During an interview with the Housekeeping Supervisor on 09/05/2024 at 10:13 AM, the Housekeeping Supervisor confirmed none of the cleaning carts have locked in the last four years. e. On 09/05/2024 at 10:50 AM, the Administrator confirmed she was not aware the cleaning carts could not be locked, and stated housekeepers are trained to leave nothing on top of the carts, keep chemicals in the closed compartment, and to always leave the door facing them so they can keep an eye on the cart and mop water to protect residents. 2. A review of Resident #17's Medical Diagnoses revealed kidney disease, chronic pressure ulcers, and anemia. a. On 09/03/2024 at 10:46 AM, the Surveyor observed sharp, jagged plastic shards sticking up from Resident #17's busted air conditioner frame, across from the right side of the resident's bed. b. During an interview with Registered Nurse (RN) #7 in Resident #17's room, on 09/04/2024 at 10:45 AM, RN #7 confirmed she did not know how or when Resident #17's air conditioner broke but confirmed if Resident #17 were to bump against the air conditioner or strike it he/she could scratch or cut him/herself on the broken plastic. Resident #17 revealed a fear of the air conditioner. c. On 09/05/2024 at 4:00 PM, Director of Nursing (DON) confirmed staff should fill out a communication sheet when broken equipment is found in a resident's room, because sharp edges on a broken air conditioner could cause harm to the resident. d. A review of a policy titled Hazardous Areas, Devices and Equipment, (Revised, July 2017) revealed hazardous areas, devices and equipment are identified by the safety committee and should be addressed appropriately to prevent accidents and protect residents. Equipment that is poorly maintained and sharp objects could affect vulnerable residents are considered hazardous. Anything in a resident's environment that could possibly cause injury is considered hazardous and should be addressed by the safety committee for recommendations and monitoring of implemented interventions.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were appropriately stored behind a lock on the treatment cart to prevent misappropriation of resident medications. The facility failed to ensure medication was stored behind a locked door, and medications were not left at the bedside for 2 (Resident #61, and Resident #375) sampled residents reviewed for medication stored at the bedside. Findings include: 1. a. A review of a policy titled Storage of Medications, revised April 2007, revealed that nursing is responsible for making sure medications are stored and locked up appropriately and not left unattended. b. On 09/03/2024 at 10:11 AM, an unlocked treatment cart was observed with the bottom drawer pulled open resting across from Nurses Station 2. The Surveyor observed betadine solution, hydrogen peroxide 3%, wound solution, Isopropyl rubbing alcohol 70%, foot peeling spray, and 2 dermal wound cleanser sprays from an open bottom drawer. Topical antifungal medication, and antifungal powder were in the second drawer from the bottom. c. On 09/03/2024 at 10:12 AM, Registered Nurse (RN) #8 returned from Unit Manager 2's office and stated she had stepped away to get something and confirmed the treatment cart should be locked when unattended, because one of the residents in the hallway could have taken medications from the cart inappropriately. 2. a. Review of a policy titled, Self-Administration of Medication, (Revised, December 2016) revealed residents have the right to self-administer medications after being assessed and found physically and mentally safe to do so if they wish. Self-administered medications must be stored in a safe place, and if staff finds medications in a resident room the medication should be turned over to the charge nurse. A resident room is not considered a safe place. b. On 09/03/2024 at 10:25 AM, the surveyor was walking down the hall and observed antimicrobial wound gel, wound solution, and ointment gel resting in Resident #61's bedroom window. c. On 09/04/2024 at 10:25 AM, Registered Nurse (RN) #7 accompanied Surveyor to Resident #61's room and identified ointment gel resting in the window. 3. a. On 09/03/2024 at 10:59 AM, Resident #375's bedside table was observed open with generic vapor rub, vitamin C 1000 milligram (mg), and two containers of menthol rub resting in the drawer. b. On 09/04/2024 at 10:30 AM, RN #7 identified a bottle of vitamin C, vapor rub, and two containers of menthol rub resting in Resident #375's bedside table. Resident #375 stated she has used the medication since a hip surgery in April. c. On 09/04/2024 at 10:54 AM, RN #7 confirmed medication should not have been left in resident rooms and was concerned that other residents or visitors could use the medications for wound care in an inappropriate manner, swallow pills, or use medication inappropriately causing harm. RN #7 stated she does not know of any residents with self-administration rights. d. During an interview with the Director of Nursing (DON) on 09/05/2024 at 04:35 PM, DON confirmed staff should remove medications from resident rooms or tell the nurse so they can be removed, and medications should be locked away, because there is a risk for residents to abuse medications, or other residents that wander around the building could take someone else's medication from their room.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. This failed practice had the potential to affect 5 residents on pureed diets, 20 residents who received mechanical soft diets and 47 residents on regular diets from the kitchen, according to the list provided by the Registered Dietitian on 9/5/2024 (total Census 74). The findings are: 1. On 9/4/24, the lunch meal menu indicated residents on pureed diets were to receive one #6 (5.3 ounces) scoop of pureed lasagna. 2. On 9/4/24 at 3:42 PM, Dietary [NAME] (DC) #2 placed 6 slices of bread into a blender, used a 3-ounce spoon to portion 4.5 cup of meat sauce into a blender, added thickener and pureed. 3. On 9/5/24, the noon meal menu indicated, for the residents on regular diet and residents on mechanical soft diets were to receive 4 by 4 square serving of lasagna which would typically weigh around 8 ounces, and for pureed diets were to receive a #6 scoop which was equivalent to 2/3 cup. a. On 9/5/24 at 12:34 PM, DC #3 used a #10 scoop equivalent to 3/8 cup to serve a single portion of pureed lasagna to a resident on pureed diets, instead of a #6 scoop which is 2/3 cup. b. On 9/5/24 at 12:39 PM, DC #3 used a 3-ounce ladle (3/8 cup) to serve a single portion of beef lasagna to the residents on regular diets and residents on mechanical soft diets, instead of 4 by 4 square or 8 ounces which is a cup. c. On 9/6/24 at 8:27 AM, DC #3 was asked what scoop size he had used to serve beef lasagna to the residents on regular diets and residents on mechanical soft diets. DC #3 stated he used 3-ounce ladle to serve it to all residents on regular and mechanical soft diets.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure dementia training was provided for nursing aide staff to meet the needs of the facilities population. This failed practice had the potential to affect 18 (Residents #3, #17, #19, #21, #30, #31, #33, #40, #47, #49, #55, #60, #61, #64, #65, #176, #177, #375) sampled residents. Findings include: 1. A review of a policy titled In-Service Training Program, dated 10/2017, revealed all staff are required to attend scheduled in-services, and Certified Nursing Assistance (CNA)s must complete a performance review every 12 months. 2. The Administrator confirmed only the closed unit had a dementia in-service and provided an in-service How to Care for Residents with Behavioral Issues and Dementia, (date, 06/14/2024) revealed staff should encourage residents to do things for themselves, being consistent with care during mealtime, and prompting during mealtime and bathing to encourage resident participation. 3. During an interview with CNA #12 and CNA #13 on 09/04/2024 at 1:47 PM in the closed unit, CNA #12 revealed they have not had dementia training. 4. During an interview with the Director of Nursing (DON) on 09/05/2024 at 11:56 AM, the DON confirmed that dementia training was not provided to all staff in the past year and revealed the last time dementia training was done for staff was 06/2023. The DON stated her concern for the residents is that they are being cared for by people that may not know how to care for them, and confirmed all CNAs should have received dementia training, because dementia is not just in the closed unit.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure the privacy and dignity of 1 (Resident #33) sampled resident. This failed practice had the potential to affect 2 (Resident #33, Resident #49) sampled residents reviewed for privacy. Findings include: Review of a policy titled Quality of Life-Dignity, revised 08/2009, revealed every resident should always be treated with respect and dignity including their body during assistance with personal hygiene. The facility does not promote any practice that would demean, and not promote dignity to the resident. A review of Resident #33's Care Plan, dated 06/04/2024, revealed Resident #33 has increasing frequency of refusals specifically with hygiene and has identified routines that increase compliance to promote hygiene including wanting the door closed for privacy, despite a fear of being alone. A review of the Facility Assessment, revised 08/22/2024, revealed that staff competencies include caring for residents with mental and psychosocial issues without pharmacological interventions. On 09/05/2024 at 9:40 AM, Resident #33 was observed being rolled down 300 Hall in a shower chair to his/her room with buttocks exposed on both sides of the chair. On 09/05/2024 9:45 AM, Certified Nursing Assistant (CNA) #9 was asked the process for returning a resident to their room from the shower. CNA #9 said residents are placed in the shower chair and rolled back to their room, but Resident #33 refused to be covered because he/she was hot. CNA #9 confirmed Resident #33 should have been covered. On 09/05/2024 at 12:50 PM, CNA #10 confirmed that staff should make sure residents are covered when returning from the shower room, and CNA #11 said a sheet should be around the residents back and across their lap to make sure nothing is exposed to protect their dignity. CNA #9 and CNA #10 confirmed that Resident #33 was not covered when asked to assist in returning Resident #33 to resident's room. During an interview with Resident #33 on 09/05/2024 at 11:25 PM, the resident reported feeling cold rolling down the hallway when wet after a shower. On 09/05/2024 at 4:50 PM, the Director of Nursing (DON) confirmed staff are expected to cover residents when they are transported to resident rooms from the shower to protect the resident's dignity.

Based on record review and interview, the facility failed to ensure written notification of the reason for transfer/discharge to the hospital was provided to the resident and/or resident's representative to protect the resident rights for 1 (Resident #31) of 2 sampled residents who were reviewed for hospitalization . The findings are: 1. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/2024 indicated Resident #31 had a diagnoses of heart failure, pneumonia, chronic obstructive pulmonary disease, and scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A nurses note dated 04/18/2024 at 8 AM indicated; the Certified Nurse's Aide came to the nurse reporting Resident #31 was acting abnormally. The nurse assessed the resident and contacted the Nurse Practitioner and reported the residents change in condition. It was decided the resident should be sent to the hospital, paramedics were called, and the resident was transferred to the hospital. b. A medical provider progress note dated 04/24/2024 indicated, Resident #31 was admitted to the hospital on 04/19/2024 to the intensive care unit for acute respiratory failure requiring the resident be placed on a mechanical respirator. c. On 09/05/2024 at 8:40 AM, the Administrator was asked for a copy of the notice of transfer given to Resident #31 and/or the resident's representative when she went to the hospital on 04/18/2024. d. On 09/05/2024 at 3:20 PM, the Administrator came to the Surveyor and stated when Resident #31 transferred to the hospital on 4/18/2024 a report for the notification of transfer should have been generated, but they could not find one. e. On 09/05/2024 at 4:10 PM, the Administrator was asked if they had a policy on transfer to the hospital. f. 09/05/2024 04:30 PM, the policy titled, Transfer or Discharge, Emergency did not address notification of the resident and/or the resident representative of the reason why the resident was transferred to the hospital.

Resident #31 hospitalization Based on record review and interview, the facility failed to ensure written notification of the bed hold policy to include the reserve bed payment was provided to the resident and/or resident's representative to protect the resident rights for 1 (Resident #31) of 2 (R#31 and R#74) sampled residents who were reviewed for hospitalization . The findings are: 1.The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/2024 indicated Resident #31 had a diagnoses of heart failure, pneumonia, chronic obstructive pulmonary disease, and scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A nurses note dated 4/18/2024 at 8 am indicated; the Certified Nurse's Aide came to the nurse reporting Resident #31 was acting abnormally. The nurse assessed the resident and contacted the Nurse Practitioner and reported the residents change in condition. It was decided that the resident should be sent to the hospital, paramedics were called, and the resident was transferred to the hospital. b. A medical provider progress note dated 04/24/2024 indicated, Resident #31 was admitted to the hospital on 04/19/2024 to the intensive care unit for acute respiratory failure requiring the resident be placed on a mechanical respirator. c. On 09/05/2024 at 08:40 AM, the Administrator was asked for a copy of the bed hold notification given to Resident #31 and/or her representative when she went to the hospital on 4/18/2024. d. On 09/05/2024 at 03:20 PM, the Administrator came to the Surveyor and stated when Resident #31 transferred to the hospital on 4/18/2024 a report for the bed hold notification should have been generated but they could not find one. e. On 09/05/2024 at 04:10 PM, the administrator was asked if they had a policy on transfer to the hospital. f. 09/05/2024 04:30 PM, the policy titled, Transfer or Discharge, Emergency did not address notification of the resident and/or resident representative of the bed hold policy to include the reserve bed payment when a resident is transferred to the hospital.

FACILITY Infection Control Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure staff applied appropriate personal protective equipment (PPE) such as isolation gowns when interacting with 1 (Resident #1) of 2 sampled residents reviewed for Enhanced Barrier Precautions. This deficient practice had the potential to affect all residents who are on Enhanced Barrier Precautions. 1. Quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 6/27/24 indicated Resident # 1 with diagnoses of Gastrostomy status, Hemiplegia and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Aphasia. MDS indicated resident has a Gastrostomy tube and a BIMS score of 3 (0-7 suggests severe cognitive impairment) a. A physicians order dated 4/18/24 indicated - Enhanced Barrier Precautions b. On 09/04/2024 at 11:12 AM, during Gastrostomy placement check, the surveyor observed Licensed Practical Nurse (LPN) # 1 prepared to check placement of Gastrostomy tube. The surveyor observed Enhanced precautions signs outside Resident # 1 door. The surveyor observed LPN #1, without Personal Protective Equipment (PPE). LPN#1 checked tube placement. Gloves were worn. No gown was worn. c. On 9/4/2024 at 11:15 During the interview with LPN # 1 regarding not wearing isolation gown during check of gastrostomy tube. LPN # 1 stated should have worn a gown due to resident on Enhanced Barrier Precautions to help prevent infections and prevent body fluids from contaminating staff. d. On 9/5/2024 at 8:30 AM surveyor asked the administrator for Enhanced Barrier Precautions Policy. At 9:48 surveyor was provided a policy titled Enhanced Barrier Precautions indicated Policy Interpretation and Implementation: 1. Enhanced Barrier Precautions (EBP)are used as an infection prevention and control intervention to reduce spread of multi-dose resistant organisms (MDROs) to residents. 2. EBP's employ targeted gown and glove use during high contact resident care activities 3. Examples of high contact resident care activities . g Device care or use: .feeding tube

Based on record review and interview, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated for 3 (Residents #2, #3, and #4) of 5 case mix residents. This failed practice placed all 62 residents at risk for verbal abuse. The findings are: On 2/26/24 at 11:05 AM, the Form 7734 - Summary of Incident that was submitted to the Office of Long Term Care documented that an allegation was reported by Resident #3 to the Administrator on 1/17/24 documenting that Certified Nursing Assistant (CNA) #1 threatened to beat Resident #4's butt while at smoke break and was holding on to the awning pole and shaking his/her butt in Resident #4's face. Resident #3 could not remember what day it happened; he/she stated it was a few days ago. On 2/6/24 at 11:07 AM, the Form 762 - Findings and Actions Taken documented: Upon completion of the investigation the facility determined the reported incident was unsubstantiated. Witness statements were obtained from 2 other residents who reported to be smoking at the same time. One resident is Resident #3's roommate and the other resident a female smoker who stated she did not see any event occur. Additional interview with Resident #4 with no negative effects noted. Interview with CNA #1 where he denied even being outside to smoke with residents due to, he/she has asthma. CNA #1 was suspended pending the outcome of the investigation and returned to work upon completion. CNA #1 will be assigned to an area where Resident #3 does not live due to a personality conflict between the resident and CNA #1. Both the resident and CNA #1 agreed and verbalized satisfaction with the decision. Signed by the Facility Administrator Date: 2/6/2024. On 2/26/24 at 11:45 AM, Resident #3 was asked how things are going and stated, well not so good. Resident #3 stated, [CNA #1] told me to shut up and he is mean to me and other residents. It all started when I told them about him. On 1/17/24, I reported what he said and did to [Resident #4]. We were out smoking, and [CNA #1] told [Resident #4] he would [physically assault the Resident]. I asked him what did you said? He didn't answer me, but he then jumps on a pole and placed his butt in [Resident #4's] face. [Resident #4] was upset and said [expletive] to [CNA #1]. I reported this and they investigated it. They did not do anything to him after I reported it. He is still working here. They covered it up. They made it look like I was lying. I am not lying, and I don't appreciate them making me out to be a liar. I am 61 and I know what is going on. Some of these people can't talk or protect them self. [CNA #1] works the evening shift. He was mad at me for telling on him. On 2/21/24, I went out to smoke, and [CNA #1] let another resident have two cigarettes and I could only have one. I asked him why? I told him that was racist, and he told me to shut up. I was only getting one cigarette. I reported that incident too. On 2/26/24 at 12:00 PM, the Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitively intact). On 2/26/24 at 3:10 PM, Resident #5 was asked about the incident in the smoking area, and he/she said, Saturday evening we went out to smoke and [CNA #1] started aggravating [Resident #4]. [CNA #1] took the cigarette from the resident and [threatened to assault the resident]. Resident #4 tried to get the cigarette back and [CNA #1] kept aggravating him/her. [CNA #1] would act like he/she was taking [the resident] back in the facility, then wouldn't. Resident #4 was mad and upset over the way he/she was being treated. Resident #4 cussed at the CNA. On 2/26/24 at 12:25 PM, the MDS dated [DATE] for Resident #5 documented a BIMS of 15. On 2/26/24 at 11:10 AM, the Administrator was asked why he/she had unsubstituted the abuse allegation and said, I must protect my employees. I felt both of the residents did not like [CNA #1] because of his/her lifestyle. The Administrator stated she had spoken to Resident #4 who did not remember the incident. Resident #4 had a BIMS of 3 (0-8 indicates severe cognitive impairment). On 2/26/24 at 1:45 PM, Resident #2 stated that on the evening shift of 1/5/24 he/she asked CNA #1 to receive a shower and CNA #1 said, I am the only CNA here and there won't be any showers. Resident #2 stated he/she called the Director of Nursing (DON) and told them what was going on. Resident #2 told the Administrator he/she did not want CNA #1 back in their room. Resident #2 stated that CNA #1 came back into his/her room and was using a threatening manner towards him/her. Resident #2 said that CNA #1 said, You are lying on me. I never said you could not get a shower. Resident #2 told him/her to get out of the room. The DON was on the phone and overheard the conversation and told Resident #2 he/she would take care of it Monday, and that was retaliation. The DON also said CNA #1 was told not to go back into the room. So, he knew he was not to go back into his room, and he did it anyway. Resident #2 stated when he/she was moved during Covid on 12/19/23 he/she was a roommate with Resident #6. He/she stated Resident #6 is unable to say anything, all they can do is point. CNA #1 came in and Resident #6 pointed to his brief. CNA #1 picked [Resident #6] up out of wheelchair and threw him/her in the bed. CNA #1 was angry that the resident needed to be changed. On 2/26/24 at 2:00 PM, the MDS dated [DATE] for Resident #2 documented a BIMS of 15. On 2/26/24 at 9:30 PM, the Annual MDS dated [DATE] for Resident #6 documented a BIMS of 3 (0-8 indicates severely cognitive impaired). On 2/26/24, the Administrator started an abuse allegation investigation for Residents #2, #3, and #6. Each one was a complaint against CNA #1. On 2/26/24 at 3:29 PM, the DON provided the facility policies on abuse prevention. It documented, Policy Interpretation and Implementation: 1. Our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers. staff of other agencies serving the resident, family members, Legal guardians, sponsors, other residents, friends, or other individuals.

Based on observation, record review, and interview, the facility failed to ensure residents were free from accidents during resident care by allowing staff to not follow residents care plan. This failed practice had the potential to affect 1 resident that had a fall in the month of November during resident care who resided on the 100 Hall as documented on a list provided by the Administrator on 1/3/2024 at 11:41 am. The findings are: 1. On 1/2/2024 at 10:00 pm, during a review Resident #1's health record for a fall documented on 11/17/2023 in the facility. Documentation showed a Progress Note dated 11/17/23 by Licensed Practical Nurse #1 (LPN) in a summary stating Resident #1 was sent out to the hospital at 4:30 pm due to fall, noted bleeding to the right side of the head. Unable to locate Nursing Incident and Accident Report note in Resident #1's health record. Resident #1was admitted to the hospital for care and returned to the facility on [DATE] with hospice care with a diagnosis of Acute Hypokalemia. Resident #1 passed away in the facility on 1/26/2024 in relation to an electrolyte imbalance. a. On 1/2/2024 at 10:15 am, review of Resident #1's health record, a nursing incident and accident follow up note created by the Director of Nursing (DON) on 11/24/23 documented in summary witnessed fall from bed 11/17/2023 and intervention provided. No other details of fall documented in note. b. On 1/2/2024 at 12:31 pm received a copy of Resident #1's Witnessed Fall report prepared by LPN #1 from Administrator, the report documented incident description per nurse .called to room by Certified Nursing Aide (CNA) noted resident lying on the floor beside bed. Noted bleeding and laceration noted on right side of head . And charted under other info (information) documented, .rolled out of bed . and as witness shows staff CNA #1. c. ON 1/2/2024 at 1:15 pm, review of Resident #1's Care Plan with completed dates of 10/19/23, 7/24/23 and 4/25/23, showed, 2 persons assistance for bed mobility (turning and repositioning), dressing and toileting. d. On 1/2/2024 at 2:55 pm, the Surveyor asked CNA #1, a witness to the fall, What occurred on 11/17/2023 with resident #1? CNA #1 replied, I was in with the resident getting her ready for bed, like I always do, getting her under the covers. I was turning her over by myself, she was a one person assist. I was turning her on her left side facing the window. I had pulled her boots off her to take her pants off and when I was turning her over and I had some wipes to clean her up for the night. She was a little stiff and kind of jerked and she just went on over and off the bed onto the floor. I had my hand on her and tried to catch her, but she just went off the bed onto the floor. She hit her head. I had always turned her over like that by myself, and I guess since she did not have the boots on or something, she just went on over off the bed. I went around to her and started hollering for help and the nurses came to help me. The Surveyor asked, What level was the bed in when this occurred? CNA #1 replied, It was up level for me to do the care. CNA #1 stated, She was a one person assist but after that we changed her to a two person assist. e. On 1/2/2024 at 3:30 pm, the Surveyor asked the Administrator when she had spoken with CNA #1 on the phone about the fall of Resident #1 on 11/27/2023, what did the aide report to her? The Administrator replied, She told me she was getting Resident #1 dressed for bed and when she turned her over the resident jerked and fell out of the bed. The Surveyor asked, Did the aide say she was in the room providing the care alone? The Administrator stated, Yes she did. f. On 1/2/2024 at 4:15 pm, the Surveyor asked the DON, Per Resident #1's care plan, what is the staff needed for Resident #1's Activities of Daily Living care for bed mobility, dressing and toileting? The DON replied, Shows two person assist with bed mobility, toileting and dressing, I don't know why that would say that. I always thought she was a one person, pretty sure that is what everyone has been doing on her since she was so tiny. The DON stated CNA staff does use the closet care plans. g. On 1/3/2024 at 8:00 am, the Administrator provided copy of Resident #1's closet care plan. The document showed resident as .Fall risk, Transfer skills Mechanical lift with purple trim lift pad x 2 staff, Bowel and Bladder dependent for 2 persons assist incontinent, Dressing is noted to be left blank on the closet care plan . h. On 1/4/2024 at 12:09 pm, the Administrator provided policy titled, Using the Care Plan with a revised date of August 2006. The policy stated in part, .the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, safe homelike environment for residents who reside in rooms 303, 304, 305, 310 and 316. The findings are: a. On 10/30/2023 at 8:50 AM in room [ROOM NUMBER] surveyor observed resident sitting in wheelchair close to air-conditioning/heating [AC/HT] unit. The screen inside of AC/HT unit was visibly dirty with dust and debris. The AC/HT unit continued to have a dirty screen and vent on 11/01/23 at 3:33 PM and 11/02/2023 at 8:10 AM. b. On 10/30/23 at 9:00 AM, upon surveyor going into room [ROOM NUMBER], the resident in bed A immediately got up and stated, Let me show you something. The resident then walked to the sink, turned on the water to let the sink fill, then turned the water off and stated, See how long it takes to drain? The sink drained slowly. The resident then stated look at all that, pointing at corrosion on the faucet. The resident stated, He had reported these problems 3 months ago and it has been that way ever since. The surveyor observed gray/rust colored build-up and corrosion around the faucet and handles on the sink c. On 10/02/2023 at 8:30 AM, while rounding the surveyor noted the following rooms to have AC/HT units with visible dust, dirt, and debris on screen under vents: room [ROOM NUMBER], 304, 305, 310, and 316. d. On 10/02/2023 at 9:30 AM, the surveyor observed the lavatory sink in room [ROOM NUMBER] continues to be corroded around the faucet and handles and slow to drain with water damage noted to wall under sink. e. On 11/02/23 01:57 PM, the Administrator was asked, Who does cleaning and maintenance on AC/HT units?' The Administrator stated, The maintenance director does, but he isn ' t here right now. The Administrator then walked with me down to room [ROOM NUMBER] and I showed her the AC/HT vent , she stated, Oh yeah, I'll get him on it as soon as he gets back. We then walked to room [ROOM NUMBER] and I showed her the lavatory sink and asked, What do you think about this faucet? The ADM stated, I ' ll have maintenance see about this when he gets back too. f. On 11/23/2023 at 3:00 PM, the maintenance director called the surveyor to room [ROOM NUMBER] pointed to the sink and stated, I have ordered a faucet to replace this one.

Based on observation, interview, and record review the facility failed to ensure fingernails were clean, groomed, and free from jagged edges to promote good personal hygiene and grooming for 2 (Resident #8 and #26) of 14 (Resident #4, #5, #8, #11, #17,#20, #21, #24, #26, #37, #39, #43, #54, and #57) sampled residents that were dependent on staff for fingernail care. The findings are: 1. Resident #26 had a diagnosis of Diabetes Mellitus, Heart Failure, and End Stage Renal Disease. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20//23 documented that the resident scored 7 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required substantial/maximal assistance with toileting, moderate/partial assistance with personal hygiene and was independent with eating. a. The care plan with an initiation date of 10/17/23 documented, .Focus: (Resident #26) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness .Goal: (Resident #26) will improve current level of function in (ADLs) .Interventions/Tasks: . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 10/30/23 at 02:27 PM, Resident #26 was sitting up in a wheelchair in his room. The resident's fingernails on both hands appeared to be ungroomed with 1/8-to-1/4-inch nail growth past the end of the nail bed. There was a black substance noted under the nails and some of the nail edges were jagged in appearance. c. On 11/01/23 at 11:30 AM, Resident #26 was sitting up in wheelchair in the dining room. His fingernails on both hands appeared to be ungroomed with 1/8 to 1/4 inch of nail growth past the end of the nail bed. There was a black substance noted under the nails and some of the nails edges were jagged in appearance. d. On 11/02/23 at 10:35 AM, Resident #26 was lying in bed with his eyes closed. His right hand was lying outside the covers. His fingernails appear ungroomed with 1/8 to 1/4/inch of nail growth past the nail bed. There was a black substance noted under the nails and some of the nails edges were jagged in appearance. e. On 11/02/23 at 10:40 AM, Licensed Practical Nurse (LPN) #1 was asked to accompany the surveyor to (Resident #26's) room. Once in the resident's room LPN #1 was asked, Can you describe (Resident #26's) nails for me? LPN #1 looked at Resident #26's nails and stated, The nails on both hands need to be trimmed and cleaned and his hands need to be washed. We will get this done. LPN #1 was asked, Who is responsible for doing nail care? LPN #1 stated, Anyone can do the care unless the resident is diabetic. (Resident #26) is a diabetic, so the nurse is supposed to do his nails. LPN #1 was asked, How often should nail care be done? LPN #1 stated, It should be done as needed because nails grow at different rates for different people. Nail care should be done during ADL (Activities of Daily Living) care, but since he is a diabetic and we do finger sticks on him we should see when his nails need to be done then. LPN #1 was asked, Do you know if (Resident #26) refuses care? LPN #1 stated, I am not sure, but I will ask him if he will let us cut his nails. LPN #1 turned to the resident and stated to the resident, Can I trim your nails? The resident stated, They are not long enough. LPN #1 stated to the resident, They are getting kind of long. The resident stated, You can cut them a little bit. LPN #1 stated, I am going to get some things together now and see if I can trim his nails. f. On 11/02/23 at 11:55 AM, LPN #1 stated to the surveyor, I just wanted to let you know (Resident #26) let me cut his nails and I cleaned his hands really well. g. On 11/2/23 at 2:35PM, The Director of Nursing (DON), was asked, Who is responsible for doing nail care on residents? The DON stated, Primarily the CNA (Certified Nurse's Aides). The wound care nurse also helps because she has the bigger clippers for the thicker more difficult to cut nails and the pediatrist also comes and cuts nails. The DON was asked, How often should nail care be done? The DON stated, It should be done at least with the residents showers and the wound care nurse is supposed to monitor the nails weekly. The DON was asked, Why is it important that a residents nails are kept clean and groomed? The DON stated, For infection prevention, cross contamination and to promote good hygiene. h. On 11/2/23 at 3:20PM, the policy titled Fingernails/Toenails, Care of (Revised date February 2018) provided by the administrator documented, .Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections . General Guidelines: 1. Nail Care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around nail bed . 4. Trimmed and smooth nails prevent the resident for accidently scratching and injuring his or her skin . 2.Resident # 8 had a diagnosis of Dementia. The MDS with an ARD of 09/29/2023 documented 10/30/23 requires extensive assistance of one person for personal hygiene and was total dependent on one person for bathing. a. The care plan with a revision date of 04/14, 2021 documented, .(Resident #8) has an ADL (activities of daily living) self-care performance deficit r/t (related to) DEMENTIA . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse .Keep fingernails short .If the resident refuses and/or becomes agitated try a different approach such as have another staff member attempt care, postpone care and try again later, etc. and notify the charge nurse of the situation . b. Review of MDS with an ARD of 9/29/23 documented the following question and response, .Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? With the following answer; 0. Behavior not exhibited . c. On 10/30/2023 at 11:35 AM, Resident #8 was sitting in a wheelchair at the dining room table. The fingernails on his left and right hand were long, 1/4 inch past the tips of his fingers, and had a dark brown substance under the nails. The surveyor asked Resident#8, Do you like your nails that long? Resident #8 stated, No. d. On 10/31/23 at 01:10 PM, Resident #8 was observed sitting in wheelchair in his room watching television. Resident #8's fingernails continue to be long with a dark brown substance noted under the nails. e. On 11/02/23 at 08:30 AM, Resident #8 was sitting in wheelchair in his room watching television, the surveyor observed nails on both hands continue to be long with a dark brown substance under the nail. The surveyor asked, Do your nails need to be cut? Resident #8 replied, Yes, they do, as he looked down at his hands. f. On 11/02/23 at 11:32 AM, certified nursing assistant [CNA] # 1 was asked if Resident #8 refused care and they replied, I don't think so, sometimes maybe. CNA #1 and #2 accompanied this surveyor to Resident #8's room and were asked to describe their nails. CNA #2 stated, Oh they need to be cut, cleaned, everything. The surveyor asked why this was important and CNA #1 replied so they don't scratch themselves and because they are dirty. 46724

Based on Observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for oxygen use for one (R#5) of 5 (R#1, #5, #21, #24 and #37) sampled residents who had physicians orders for oxygen. The findings are: 1. Resident #5 had a diagnosis of chronic obstructive pulmonary disease. The Minimum Data Set [MDS] with an assessment reference date [ARD] of 08/29/2023 documented the resident was receiving oxygen therapy. a. The physician's orders dated 09/07/2022 documented, Oxygen @ 2 LPM (liters per minute) Continuous every shift. b. On 11/02/2023 at 9:00 AM, the Surveyor reviewed Resident #5's plan of care. The care plan failed to address Resident #5's oxygen use. c. On 11/02/2023 at 2:36 PM, the MDS (Minimum Data Set) Coordinator was asked to look at Resident #5's care plan and tell the surveyor what information on oxygen is in their care plan. After reviewing the care plan, the MDS Coordinator stated, It's not on there. The MDS Coordinator was asked why it is important for the oxygen to be on the care plan? The response was, Because she needs it, so staff will know and because oxygen saturation could drop. D. On 11/3/23 at 9:24 AM, the policy titled Care Plan, Comprehensive Person-Centered provided by the Administrator documented, Policy Interpretation and Implementation .8. The comprehensive care plan will: . Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being .

Based on observations, interview, and record review the facility failed to post signage indicating oxygen in use for one (R#5) of five (R#1, #5, #21, #24 and #37) sampled residents who had physician order for oxygen. The findings are: 1.Resident #5 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Minimum Data Set with an assessment reference date [ARD] of 08/29/2023 documented the resident was receiving oxygen therapy. a. A physician's orders dated 09/07/2022 documented, Oxygen @ 2 LPM (liters per minute) Continuous every shift. b. On 10/30/23 at 09:45 AM, Resident#5 was sitting in a wheelchair in their room, an oxygen concentrator was beside the bed running at 3 liters with an attached nasal cannula lying on the bed. There was not an oxygen in use sign posted outside the room entrance. c. On 10/31/23 at 12:48 PM, Resident #5 was sitting on the side of their bed. The nasal cannula was absent, but concentrator was running at 3 liters. There continued to be no signage posted on or around the door. d. 11/01/23 at 03:36 PM There is no oxygen in use sign on doorway to room. The resident's nasal canula attached to oxygen concentrator was draped over bed railing. e. On 11/02/2023 at 1:45 PM, LPN#2 was asked, Does (R#5) use oxygen? LPN #2 replied, When they want to. LPN #2 was asked, Should there be an oxygen sign on the door indicating they used oxygen? LPN #2 replied, Probably for safety, in case there is a fire. But they use a concentrator not a tank, should they still have a sign? The surveyor then asked, Why is it important that this resident is identified as using oxygen? LPN #2 stated, Because they need to breathe, and due to fire risks. f. On 11/02/2023 at 2:00 PM, the surveyor asked the Director of Nursing [DON], Who is responsible for ensuring an oxygen in use sign is posted on resident's doors? The DON stated, It is a team effort. The surveyor then asked the DON, Does Resident #5 use oxygen? The DON confirmed the resident uses oxygen and further responded, Do they not have a sign on their door, they should have unless one of the residents removed it. g. On 11/2/23 at 3:30PM, the policy titled Oxygen Administration (Revised October 2010) documented, . Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Equipment and Supplies .No Smoking/Oxygen in Use signs .Steps in the Procedure: .3. Place an Oxygen in Use sign on the outside of the room entrance door .

Based on Observation, Interview, and Record Review the facility failed to maintain an effective pest control program for 1of 1 facility, to prevent the potential for illnesses. The findings are: a. On 10/17/22 at 11:30 AM, there were Gnats flying around in the conference room. b. On 10/17/22 at 12:23 PM, there were Gnats flying around in the kitchen. c. On 10/17/22 at 12:27 PM, there were Gnats flying around in the dining room. d. On 10/17/22 at 12:29 PM, Certified Nursing Assistant (CNA)#3 was feeding Resident #5. CNA #3 was waving her hands back and forth over Resident #5 tray trying to keep the Gnats off her food. The Surveyor asked CNA #3, How long has the facility had Gnats? She stated, We've had Gnats for about 2 or 3 months. e. On 10/17/22 at 1:10 PM The Surveyor asked the Maintenance Supervisor, What has the facility done to get rid of the Gnats? He stated, We started with the Gnats 2 months ago. I called (Pest Control Company) and asked them to come treat the Gnats. They thought it was a sanitation issue. They came and sprayed, and they still were bad. Another company called Pest Control #1 came out and treated the Gnats, then we started seeing a little less of the Gnats. They came back and treated the whole building. f. On 10/17/22 at 1:26 PM, the Maintenance Supervisor provided an invoice from Pest Control #1. It documented, .The Maintenance Supervisor was going on a run in the van, but I did speak with Administrator. She said the main problem they been having is with the Gnats. She knows that the nursing home will have to fix the problem inside or the [Gnats] will continue to come back; did fly service .Target pests: Roaches, Rodents, Spiders, Ants, Beetles, Crickets, and Wasps, Centipedes, Flies, Millipedes, Scorpions, Silverfish . g. On 10/17/22 at 1:44 PM, a staff from Pest Control #2 was called. The Surveyor asked the staff what her name was. She stated, I rather not give out my name. The Surveyor asked the staff, Have your company ever treated Facility #1 for Gnats? She stated, That is a sanitation issue, and that's not something we take care of. h. On 10/18/22 at 12:19 PM, Resident #4 was sitting at the dining room table eating lunch. There were gnats flying around his food. The Surveyor asked Resident #4, Do the Gnats ever get in your food. He stated, Oh yeah, they fly in my food. They could get rid of the Gnats, but I guess they don't want to pay for it. i. On 10/18/22 at 1:21 PM, The Surveyor asked CNA #1, How often do you see Gnats? She stated, I've seen them pretty often. She's had people come spray, but you still see them. The Surveyor asked CNA #1, Do you ever see Gnats on the resident's food? She stated, I have, I just go get them something to replace it. j. On 10/18/22 at 1:36 PM, The Surveyor asked CNA #2, How often do you see Gnats? She stated, Every second, they are bad. The Surveyor asked CNA #2, Do you ever see Gnats on the resident's food? She stated, Yes, and we have to fan it off. k. On 10/18/22 1:46 PM, The Surveyor asked LPN #1, How often do you see Gnats? She stated, Everyday, almost in my nose and in my eyes every day. I had to throw my lunch away several times because gnats landed in them. The Surveyor asked LPN #1, Do you ever see gnats on the resident's food? She stated, Yes I have, the lady I was sitting with at lunch does not see well. l. On 10/18/22 at 1:58 AM, The Surveyor asked LPN #2, How often do you see Gnats? She stated, Every day, all day long. The Surveyor asked LPN #2, Do you ever see gnats on the resident's food? She stated, Yes ma'am, in the dining room yes ma'am. m. On 10/18/22 at 3:24 PM, The Surveyor asked CNA #4, How often do you see Gnats? She stated, Every day pretty much. The Surveyor asked CNA #4, Do you ever see Gnats on the resident's food? She stated, If I see one, I fan them away. n. On 10/18/22 at 3:40 PM, The Surveyor asked the Dietary Manager, How often do you see gnats in the kitchen? She stated, They are everywhere in the facility. They've gotten better. The Surveyor asked the Dietary Manager, Do Gnats ever get in the food? She stated, I can't say they haven't. I've had to remake trays because of the Gnats. o. On 10/19/22 at 11:30 AM, The Surveyor asked the Director of Nursing (DON), How often do you see Gnats? She stated, Daily, it's not that many today. It was way worse that this when I first started. The Surveyor asked the DON, How do the facility ensure that the gnats don't get in the resident's food? She stated, We make rounds, and whatever they are not eating we cover up, so the Gnats won't get in. The Surveyor asked the Director of Nursing (DON), Do you ever see Gnats on the resident's food? She stated, Yes, they even fall in my food. It's not in our control. We have been doing everything to get rid of them. p. On 10/19/22 at 11:45 AM, The Surveyor asked the Administrator, How often do you see Gnats? She stated, We've identified we have a problem. We have gnats and I'm spraying daily. They are coming to spray today. The Surveyor asked the Administrator, How do the facility ensure that the Gnats don't get in the resident's food? She stated, I spray daily, and walk around during meals to help with that. We get them a new tray if it happens.

Based on observation, record review, and interview, the facility failed to ensure a planned fall prevention intervention was consistently implemented to prevent a fall with injury for 1 (Resident #30) of 6 (Residents #15, #17, #27, #30, #32, #62) case mix residents who had a history of falls in the past 90 days. This failed practice resulted in past noncompliance at actual harm for Resident #30, who fell and sustained a fractured proximal tibia and fibula, and had the potential to cause more than minimal harm for 12 residents who had falls in the past 90 days, according to a list provided by the Director of Nursing (DON) on 5/14/21 at 7:50 a.m. The findings are: Resident #30 had diagnoses of [CONDITION(S)], Cognitive Communication Deficit, Muscle Weakness and Lack of Coordination. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/8/21 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was dependent for transfers, locomotion, required extensive assistance with bed mobility and toileting, and had a fall with major injury. a. The Care Plan with an initiation date of 8/17/19 documented, . [Resident #30] has had an actual fall with (no injury) . Changed to Geri (Geriatric)-Chair Date Initiated: 11/07/2020 . b. A Nsg-I&A (Nursing Incident and Accident) Note effective date 2/14/21 at 12:40 documented, . Upon entering room resident sitting in front of wheelchair left leg bent at an awkward position. Resident said she slid out of chair . Immediate Intervention: Staff assisted resident to bed. Assessed for injury and found left leg near knee swollen. Left second toe with skin tear. Text NP (Nurse Practitioner), orders to send to the hospital . c. The emergency room Physicians' Orders dated 2/14/21 documented, . 1. D/C (Discharge) to Nursing Home 2. Knee Immobilizer 3. See CT (Computed Tomography Scan) report regarding fracture and notify family and PCP (Primary Care Physician) . d. A radiology report dated 02/14/21 documented, . CT left knee without intravenous contrast .1. Proximal tibia shaft minimally displaced fractures, extra-articular, without definite tibial plateau involvement. 2. Proximal fibula impaction fracture. 3. Possible but unlikely minimal displaced intra-articular fracture alone the anterior aspect of the distal femur . e. On 05/10/21 at 12:11 PM, Resident #30 was lying in bed with her eyes closed. There was a geriatric chair with a cushion in the seat at the bedside. f. On 05/13/21 at 11:00 AM, Unit Manager #1 was asked, Why did you document on the residents incident report for 2/14/21 that staff were re-in-serviced that the resident is to be up in geriatric chair when out of bed, and when was the resident first placed in a geriatric chair? Manager #1 stated, I cannot remember, can I look and see? Unit Manager #1 then looked in the electronic record and stated, According to the care plan, she was already supposed to be in a geriatric chair at the time of her fall. Unit Manager #1 was asked, When does the care plan say that she was first supposed to be in the geriatric chair? Unit Manager #1 stated, On November 7th, 2020. g. On 05/13/21 at 12:55 PM, Unit Manager#1 was asked, Do you know why Resident #30 was up in a wheelchair and not a geriatric chair at the time of her fall on 2/14/21? Unit Manager #1 stated, I honestly have no idea. Unit Manager #1 was asked, Do you know which staff were caring for the resident at the time of the incident? Unit Manager #1 stated, It happened on a Sunday, and I do not remember who was involved. Unit Manager was asked, How have you monitored to ensure that staff have been putting Resident #30 in a geriatric chair when she is out of bed since her fall on 2/14/21? Unit Manager #1 stated, We (Nurse Management) make daily rounds on the halls to ensure the interventions are in place. h. On 05/13/21 at 12:55 PM, Certified Nursing Assistant (CNA) #2 was asked, Have you ever worked with Resident #30? She stated, Yes. She was asked, Did you work with her when she fell in February? She stated, Yes. She was asked, Can you tell me what happened? She stated, The day she fell I was getting off my lunch break and the nurse paged for 3A CNA. We came down the hall and she was on the floor. The nurse checked her and everything. They did her vitals, she called, then they sent her out. She was asked, What type of wheelchair did she have at the time? She stated, She was in a regular wheelchair with footrest. She was asked, Did you receive any in-services after the incident? She stated, Yes. She was asked, What kind? She stated, Making sure we check on the residents every 2 hours and that they're on the right cushions when they're in the wheelchair. She was asked, Was she in the right wheelchair when she had the fall in February, and did she have the right cushion? She stated, Sometimes she thinks she's in her right mind. She was trying to go to the bathroom. She was asked, At the time she had the fall was she supposed to be in a Geri-chair? She stated, No. She was asked, Did anyone tell you that she was supposed to be in a Geri-chair? She stated, No, she has been in a regular wheelchair since she's been here. When you were in-serviced after she had the fall in February did anyone inform you that she needed a Geri-chair? She stated, Yes. She was asked, After the fall in February. when did she get the Geri-chair? She stated, Probably a couple days later when they started getting her back up. She was asked, Do they do any monitoring now to ensure the staff are putting her in the right chair? She stated, Yes. She was asked, When interventions are put into place after a fall how are you made aware of those interventions? She stated, The nurse. i. On 05/13/21 at 1:05 PM, the Director of Nursing (DON) was asked, Did the staff call you when Resident #30 fell on [DATE]? The DON stated, Yes they did call me. The DON was asked, What were you told happened when the resident fell ? The DON stated, I was told that the resident slid out of the wheelchair. The DON was asked, Was [Resident #30] supposed to be up in a wheelchair? The DON stated, She had a prior incident and at that time she was changed from a wheelchair to a geriatric chair. The DON was asked, Did you ask staff why she was not in the geriatric chair when they reported the fall to you? The DON stated, I don't recall that specifically. I just recall they said she fell from the chair and was sent to the emergency room . The DON was asked, What was the intervention that was put in place after the fall? The DON stated, Staff were re-in-serviced to ensure she was in a geriatric chair. The DON was asked, How did you monitor to ensure that the resident was in a geriatric chair when she was out of bed? The DON stated, Nurse Management staff and the Weekend Registered Nurse round on the halls in the morning and in the evening to ensure that she is in the geriatric chair. She usually gets up in the mornings, but night shift is aware if she gets up, she is to be in the geriatric chair. The DON was asked, Do you have a rounding sheet that this is documented on? The DON stated, We have rounding sheets for each hall that document interventions that the Management staff must monitor for when they make their rounds. The DON provided a Staff Development form dated 2/14/21 with staff signature sheet attached documented, . Resident (#30) is to be in a geri (geriatric) chair at all times . and a form titled 3A MASTER ROUNDS: that documented, (Resident #30) . winged mattress, nonskid pad under chair cushion, geri (geriatric)-chair, encourage to lay down for naps . j. On 05/13/21 at 1:09 PM, CNA #3 was asked, Do you work with Resident #30? She stated, Yes, sometimes. She was asked, Were you here the day she fell in February? She stated, No I wasn't working that hall or with her that day. She was asked, When interventions are put in place after a fall who informs you of those changes? She stated, The nurse, or the Unit Manager. She was asked, Do you know if Resident #30 had a Geri-chair before her fall in February? She stated, I think she was in a wheelchair, if I'm not mistaken. She was asked, Did you receive any in-services after the fall? She stated, Yes I do remember that. She was asked, What did they tell you? She stated, Just to make sure she's not trying to get up. To keep an eye on her and check on her, and that she needs to be in a Geri-chair. k. The Policy titled Fall Risk Assessment revised March 2018 provided by the Director of Nursing on 05/14/21 at 7:50 AM documented, .Policy Statement: The Nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information . Policy Interpretation and Implementation: . 9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try and minimize the consequences of risk factors that are not modifiable.

Complaint # (AR 226) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a resident was free from staff-to-resident verbal abuse and threatened neglect and all necessary measures were taken to prevent further potential abuse / neglect, as evidenced by failure of management staff to immediately report to the Administrator and remove Nursing Assistant (NA) #1 from all resident care after NA #1 was overheard heard cursing and threatening Resident #1. The failure to report the incident to Administration resulted in additional failures, including delays in providing appropriate protective measures, reporting the incident to the Office of Long Term Care and law enforcement and initiating an investigation for 1 (Resident #1) of 1 case mix resident who was the victim of witnessed verbal abuse by Nursing Assistant #1. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, and had the potential to affect 43 residents who resided on the 300 Hall (where NA #1 remained after the abuse incident occurred), as documented on a list provided by the Director of Nursing (DON) on 7/20/17. The facility removed the immediate jeopardy and corrected the failed practices 6/8/17 prior to the survey. The Administrator was informed of the past immediate jeopardy condition on 7/20/17. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/2/17 documented the resident scored 13 (13-15 indicates cognitively intact), was totally dependent on the assistance of two plus people for transfer and required limited assistance of two plus people for bed mobility. a. The Care Plan updated 7/4/17 documented, The resident is/has potential to be verbally aggressive (yelling, cursing, verbally threatening, etc. (et cetera)) related to resisting care . Interventions .Staff to de-escalate behavior by resident specific intervention of leaving resident alone and re-approach at later time . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away . Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 6/8/17 documented, Facility Staff Member Completing DMS-762 (Administrator name) .Date Incident Reported to OLTC (Office of Long Term Care): 6/8/2017 Time: 5:40 PM. Date of Incident: 6/7/2017 Time and Date of Discovery: 6/8/2017 Time 4:30 PM. Type of Incident . Abuse: Verbal (marked) . Name of Involved Resident: (Resident #1) . At approximately 4:30 pm on 6/8/17 it was reported to the administrator that (NA #1), had gotten into a verbal shouting match with resident (Resident #1) around 10:00 pm on 6/7/17. Upon being informed of this, I (Administrator name), began interviewing staff and (Resident #1) regarding the incident. I received (Nursing Assistant (NA) #1) statement and suspended her immediately pending the outcome of the investigation. After reviewing the witness statements; it appears that (Resident #1) became agitated that (NA #1) had not put him to bed immediately upon his request. He began cursing at her which caused her to respond in kind. Another staff member retrieved the charge nurse who removed (NA #1) from the room and issued a verbal reprimand regarding her conduct. (Resident #1) demanded everyone leave his room at that point. I interviewed (Resident #1) after being notified of the incident and he played it off as if it never happened . Based on interviews with staff and (Resident #1); it has been determined that (NA #1) used profanity during the verbal altercation instead of removing herself from the escalating encounter. Based on resident care standards and our employee handbook we have substantiated the verbal abuse allegation and have termed (NA #1) . Notification Status Administrator / Written Designee must be notified . (Administrator) Date 6/8/2017 Time 4:30 PM. Name of Family Member (Resident #1's Spouse) . Doctor Notified . Date 6/8/17 Time 4:45 PM .Date 6/8/17 Time 5:00 PM . Name of Law Enforcement Agency (Local Police Department) . c. An OLTC Witness Statement dated 6/8/17 by NA #1 documented, Last night around 2100 hrs (9:00 p.m.) I went into (Resident #1's) room to change his diaper (incontinent brief). But shortly after arriving he commented that I didn't care and told me to get the (expletive beginning with f) out his room because I didn't give a (expletive beginning with sh) about him. That's when (Licensed Practical Nurse (LPN) #1) enter and asked what was going on (and why had he) cussed me out. It took me off guard and I said 'Damn.' That was only inappropriate word I used. She even said I cussed him out, so waiting for her to stand with everybody and tell me what I (said) other than Damn. Because honestly that's all that was on my end. d. An OLTC Witness Statement dated 6/8/17 by LPN #1 documented, At approx. (approximately) 10 pm last night (Certified Nursing Assistant (CNA) #3) approached me (at) my nurses station and told me (NA #1) was cussing out (Resident #1). When I approached resident's room I heard (Resident #1) cussing (at) the CNA tell her she was worthless and to get out. When I asked what was going on (NA #1) told me she was trying to explain to (Resident #1) that she had lot of other residents she had to lay down and she didn't have time to lay him down when he wanted her to. Then (Resident #1) told both of us (NA #1 and I) to get out of his room and don't come back. I counseled (NA #1) on proper CNA/resident interaction and told her not to go back in there for the rest of the night. e. An OLTC Witness Statement dated 6/8/17 by CNA #1 documented, I was going to help (CNA #3) in (another resident's room) then I heard (NA #1) and (Resident #1) was arguing. (They were) cursing at each other. (NA #1) said she wasn't coming back in that damn room anymore. I told (LPN #2 and LPN #3) about it, they said long as the charge nurse know she will (handle) it. f. An OLTC Witness Statement dated 6/8/17 by CNA #2 documented, I was putting (another resident) to bed and I heard (Resident #1) use profanity towards aide, aide in return used profanity back to resident. I went and got the nurse (LPN #1), (nurse) listen for a minute then went in the room with resident and aide. This CNA was unavailable for interview during the survey. g. An employee time sheet for NA #1, provided by the Administrator on 7/19/17 at 3:00 p.m., documented, Termed and Inactive . In .Wed (Wednesday) 6/07 (6/7/17 - date of incident) 3:06 PM Out 11:10 PM . Thu (Thursday) 6/08 . In 3:08 PM . Out 4:23 PM . Fri (Friday) 6/09 . Suspension . Sat (Saturday) 6/10 Suspension . NA #1's employee file was reviewed at this time, and contained a form signed and dated 4/25/17 by NA #1 that was entitled, Working Together to Prevent Abuse Brochure Acknowledgment. The form documented, I hereby acknowledge that I have both received and read a copy of my facility's brochure on working together to Prevent Abuse. I further acknowledge that I understand that it is my responsibility to make sure that I fully comprehend it. I understand the definition of abuse, the definition of neglect, and my responsibilities to prevent and report as outlined in the brochure and training presentation. I understand that my Supervisor, or Administrative Personnel will answer any questions that I have about the content. I agree to abide by the guidelines as contained, and fully understand that failure to do so may result in termination of employment, possible revocation of any patient care licensure I may hold, and possible criminal and/or civil legal actions. This signed acknowledgement is in my file as a permanent record. I am signing the acknowledgment of my own free will. h. On 7/19/17 at 5:20 p.m., the Administrator was asked who informed him of the incident with the NA and Resident #1 and stated, 3 to 11 (3:00 p.m. to 11:00 p.m.) CNA. The Administrator was asked who the CNA was who had reported the incident to him and stated, (CNA #1). The Administrator was asked at approximately what time the incident was reported to him and stated, Approximately 4:30 p.m. The Administrator was asked if that was on 6/8/17 and stated, Yes. The Administrator was asked what was reported and stated, She said that she overheard (NA #1) and (Resident #1) loud words, she heard (NA #1) using profanity and (Resident #1) as well . she had a raised voice and he had a raised voice and profanity exchanged between them. The Administrator was asked what was done and stated, We suspended (NA #1) immediately, started the investigation and got statements from everyone that was on the shift that night. I interviewed (Resident #1) .advised her (NA #1) you have to rise above that and when I called her in to get her witness statement and counsel, advised her it wasn't right. The Administrator was asked what was not right and stated, If, in fact, she used profanity back towards one of the residents. (Resident #1) didn't deny it happened but he played it off like it didn't happen. We talked to the charge nurse and CNAs who worked that night, asking them what they had seen, heard and witnessed. The Administrator was asked when the suspension for NA #1 began and stated, Within minutes after getting the allegation. The Administrator was asked when the incident actually occurred and stated, Approximately 10 p.m. on 6/7. The Administrator was asked if he obtained witness statements from cognitive residents and stated, We did . The Administrator was asked if, during the investigation, it was determined why the alleged incident of verbal abuse was not reported to him when it occurred. The Administrator stated, Particularly, we had a new LPN at the time and we in-serviced everyone. The Administrator was asked who the nurse was who had not reported the allegation and stated, I think it was (LPN #1). The Administrator was asked if the LPN was in-serviced and stated, I talked to her after this was reported to me. The Administrator was asked if NA #1 should have been allowed to continue to work after an allegation of verbal abuse and stated, No. i. On 7/19/17 at 5:55 p.m., LPN #1 was asked how long had she been a nurse and stated, September 2015. The LPN was asked how long she had been employed at the facility and stated, The beginning of April (2017). The LPN was asked who the CNA was who had cursed at Resident #1 and stated, Her first name was (NA #1 first name). The LPN was asked who the resident was and stated, His name is (Resident #1's first name), not sure of his last name . Another CNA named (CNA #2) . said (CNA #1) was cussing out (Resident #1) . She just said she was cussing him out, so I headed that way. The LPN was asked who else heard or reported the cursing and stated, I'm not sure. The LPN was asked when the incident occurred and stated, Not sure, been about a month ago. The LPN was asked what was done when the incident was reported to her and stated, First, I approached the room, heard some aggravation tone of her (NA #1's) voice, so I went in an asked (Resident #1) what was the problem, and she (NA #1) said she needed to be in there at certain time to put him to bed and he had to wait and (NA #1) was trying to explain to him that she had a lot of people to put down that night and she couldn't be in there when he wanted her to, then I took (NA #1) in the hallway and I told her that we were there for residents and that he should be able to go to bed when ready, he had that right and if she needed help, ask me or another CNA, so I told her since they did have an altercation or whatever you want to call it, would be best for her to not go back in there for that night and I would get another CNA to pick him up. The LPN was asked if NA #1 had cared for other residents after that. LPN #1 stated, Yes. She remained on her assigned hall. She continued with all of her assigned residents except for (Resident #1). The LPN was asked if the NA had remained on the Resident #1's hall (300 Hall) and stated, Yes. The LPN was asked when the NA had left the building and stated, I didn't see, was after her shift. LPN #1 was asked if she had seen NA #1 go into other residents' rooms after the incident and stated, Yes, she didn't have an attitude with the other residents, and she was really polite with me. The LPN was asked where the incident was documented and stated, I didn't, I just told (Administrator) the next day. LPN #1 was asked if she had reported the incident of verbal abuse and stated, Not at the time; I didn't think there was anything to report. The LPN was asked if the incident should have been reported and stated, I did not hear any profanity. The CNA said she was cussing out (Resident #1). The LPN was asked if a CNA/staff member cursed at a resident, if that was verbal abuse, and the LPN stated, Yes. The LPN was asked what should have been done and stated, Call (Administrator) immediately and have the CNA or whoever is involved leave. LPN #1 was asked if she had called the Administrator immediately and stated, No. The LPN was asked if she had NA #1 leave the premises and stated, No. The LPN was asked if NA #1 continued to work in the building and stated, Yes. The LPN was asked if there had been in-servicing on the abuse protocol and stated, We did an orientation video; the next day (after the incident) (Administrator) told me even if someone reports it, I have to call him. At 6:20 p.m., the LPN was shown the abuse in service sheet dated 6/8/17 and the LPN pointed to her name on the sign-in list and stated, .me. The LPN was asked when she had started work, if she was in-serviced on abuse protocol and stated, Yes, on a video. LPN #1 was asked if the allegation of verbal abuse should have been reported to the Administrator immediately after it was reported to her and stated, Yes. j. On 7/19/17 at 6:26 p.m., the Director of Nursing (DON) was asked if the NA had received abuse training when hired and the DON stated, Yes. The DON was asked if any verbal abuse towards a resident was to be reported and the DON stated, Supposed to be reported to the Administrator immediately. The DON was asked what was to be done when there was an allegation of abuse and the DON stated, Protect the resident. The DON was asked after the allegation of verbal abuse incident had occurred if the NA had continued to work. The DON stated, Yes she did. The DON was asked if the residents were protected while the NA worked and the DON stated, No. k. On 7/19/17 at 7:20 p.m., CNA #1 was asked if she had ever reported any verbal abuse and stated, Yes. The CNA was asked who she had reported the alleged verbal abuse to and stated, The charge nurse. The CNA was asked which charge nurse and stated, (LPN #1) . The CNA was asked what was reported and stated, That (NA #1) was in the room with (Resident #1) and cussing out loud with (Resident #1) and back and forth with each other. The CNA was asked what NA #1 said and stated, She said, 'you keep your mother (expletive beginning with f) hands off me'; she said somebody else could take this room and she was not coming back in that dam room anymore. The CNA was asked what was done by LPN #1 after the NA was reported for cursing the resident and stated, (LPN #1) didn't do anything. She talked to (NA #1), called her out of the room and took her off by herself and somebody else took over the resident. CNA #1 was asked if (NA #1) kept working after the LPN talked with her and stated, Yes. The CNA was asked if the NA had provided care for residents for the rest of the shift and stated, Yes. The CNA was asked if there had been any in-service on abuse policy since the incident occurred. The CNA stated, Yes. The CNA was asked if NA #1 worked the next day after the incident and stated, .well, she came in; they sent her home. The CNA was asked if she had reported the abuse to anyone else and stated, Yes (Administrator), when I thought the nurse had not done anything. The CNA was asked when it was reported to the Administrator. The CNA stated, The next day when I saw (NA #1) at work. I know we are supposed to report as soon as we witness or hear about abuse. l. The facility removed the immediate jeopardy and corrected the failed practices on 6/8/17, when NA #1 was removed from the building and the necessary reporting, investigation, staff re-training, and ongoing monitoring were initiated, as evidenced by the following: 1.) An Employee Memorandum form dated 6/8/17 documented, Employee Name: (NA #1) . Date of occurrence: 6/7/17. Date of Memorandum: 6/8/17 . Suspension for (blank) days or until pending outcome of verbal abuse allegation . Comment / Explanation: Employee was overheard cussing back (and) forth with resident (Resident #1) . The form was signed by NA #1 and the Administrator on 6/8/17. 2.) A Termination of Employment form dated 6/8/17 documented, Employee Name (NA #1) .Other Involuntary Termination . Abuse/Neglect . Last Day Worked: 6/8/2017 . 3.) A Staff Development form dated 6/8/17 documented staff were in-serviced on, Any suspicion of Abuse-neglect must be reported to the Administrator immediately. Verbal abuse-if you hear or hear by word of mouth from someone that verbal abuse has occurred to a resident you must report to the Administrator immediately! Physical abuse, mental abuse, sexual abuse, neglect. Any form has to be reported immediately! The attendance sheet was signed by all CNA and licensed nursing staff members. 4.) A staff memo dated 6/8/2017 and signed by the Administrator documented, Effective immediately, I expect to get 2 phone calls when there is potential abuse or neglect. 1. The House Supervisor (Charge Nurse after regular business hours)-call me immediately upon witnessing/hearing of potential abuse or neglect. 2. The employee who witnesses or hears about potential abuse or neglect needs to also call me. Your supervisor may forget. You own the problem until you call me too .update notification was provided during the previous documented in-service. 5.) A staff memo dated 6/8/17 and signed by the DON documented, Nurse Managers to include in daily morning rounds observations for s/s (signs and symptoms) of abuse or neglect. Ask residents if they have been abused or witnessed abuse to another resident. 1. Observe for non-verbal signs of abuse or neglect. 2. Observe for physical signs of abuse or neglect. 3. Observe for withdrawn behavior which can be a sign of verbal abuse. 6.) On 7/20/17 at 12:40 p.m., the Administrator submitted a copy of the facility's written Quality Assurance (QA) report dated 6/12/17 that documented, Problem - Charge Nurse did not remove accused party from resident contact immediately upon receipt of potential verbal abuse. 1. Resident (Resident #1) assessed and interviewed. No concerns identified with assessment and no indications of psychosocial concerns related to the alleged incident. (NA #1) immediately suspended upon receipt of allegation of verbal abuse involving resident (Resident #1). (LPN #1) was interviewed in conjunction with the facility abuse and neglect investigation; abuse and neglect retraining was completed with LPN by the facility administrator including recognizing potential abuse (and)/or neglect and all appropriate actions to take with alleged or suspected abuse (and)/or neglect including the required notifications within the facility to supervisor, administrator, md (medical doctor), family, police and OLTC. Facility investigation initiated by administrator on 6/8/17; 7734 (DMS form 7734 - OLTC Incident and Accident Report) submitted to OLTC same date, appropriate notifications completed. 2. Facility observation rounds and resident interviews were initiated to identify any observations of or any concerns verbalized by residents suspicious of abuse/neglect. No negative findings were identified. 3. In-services on recognizing and reporting abuse and neglect were initiated; in-service topics also included changes in facility practice that the administrator expects two phone calls with any suspected abuse/neglect. One phone call from house supervisor receiving the report from the witness and the second call received from the front-line staff who witnessed or heard of potential abuse/neglect. This will ensure that a potential abuser is removed from resident contact immediately. 4. Increased monitoring implemented to ensure all incidents of alleged or abuse/neglect are properly recognized and that notifications and resident protection were properly initiated and reported. Effective 6/8/17, increased monitoring specific to questioning residents during facility rounds regarding treatment staff, visitors and other residents was begun 5 (times) weekly ongoing, with any concerns identified to be addressed/corrected immediately and taken to the facility quality assurance process for further plan development. On 6/8/17, I assessed and interviewed (Resident #1). There are no physical or psychosocial concerns identified related to the alleged incident of potential verbal abuse that is under facility investigation. 7.) On 7/19/17 at 6:26 p.m., the Director of Nursing (DON) was asked if there had been any in-service on abuse policy and procedure after the 6/7/17 incident and stated, It was actually the next day, on 6/8. The DON was asked who had in-serviced LPN #1 on abuse and stated, It was me. The DON was asked if there had been any monitoring after the allegation of verbal abuse and stated, Yes we did. 8.) On 7/20/17 at 11:00 a.m., the DON submitted a signed statement that documented, On 6/8/17, I initiated resident rounds interviewing cognitive residents located on all halls regarding abuse and neglect. All residents interviewed verbalize that they have not been abused or neglected nor have they any knowledge of any suspected or alleged abuse. A Daily census sheet dated 6/8/17 documented residents on each hall were interviewed regarding abuse, including 7 residents on the 300 Hall where Resident #1 resided. The DON also provided monitoring sheets that were initiated on 6/8/17 and continued into the month of July 2017, which documented ongoing monitoring of residents for any signs / symptoms of abuse / neglect, and copies of continued interviews with cognitive residents beginning 6/8/17 and continued into the month of July 2017, with no further negative findings to date.

Complaint # (AR 226) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure an allegation of staff-to-resident verbal abuse and threatened neglect was immediately reported to the Administrator and that the alleged perpetrator, Nursing Assistant (NA) #1, was immediately removed from all resident care after NA #1 was overheard heard cursing and threatening Resident #1. The failure to report the incident to Administration resulted in additional failures, including delays in providing appropriate protective measures, reporting the incident to the Office of Long Term Care and law enforcement and initiating an investigation in accordance with State law, for 1 (Resident #1) of 1 case mix resident who was the victim of witnessed verbal abuse by Nursing Assistant #1. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, and had the potential to affect 43 residents who resided on the 300 Hall (where NA #1 remained after the abuse incident occurred), as documented on a list provided by the Director of Nursing (DON) on 7/20/17. The facility removed the immediate jeopardy and corrected the failed practices 6/8/17 prior to the survey. The Administrator was informed of the past immediate jeopardy condition on 7/20/17. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/2/17 documented the resident scored 13 (13-15 indicates cognitively intact) was totally dependent on the assistance of two plus people for transfer and required limited assistance of two plus people for bed mobility. a. The Care Plan updated 7/4/17 documented, The resident is/has potential to be verbally aggressive (yelling, cursing, verbally threatening, etc. (et cetera)) related to resisting care . Interventions .Staff to de-escalate behavior by resident specific intervention of leaving resident alone and re-approach at later time . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away . Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 6/8/17 documented, Facility Staff Member Completing DMS-762 (Administrator name) .Date Incident Reported to OLTC (Office of Long Term Care): 6/8/2017 Time: 5:40 PM. Date of Incident: 6/7/2017 Time and Date of Discovery: 6/8/2017 Time 4:30 PM. Type of Incident . Abuse: Verbal (marked) . Name of Involved Resident: (Resident #1) . At approximately 4:30 pm on 6/8/17 it was reported to the administrator that (NA #1), had gotten into a verbal shouting match with resident (Resident #1) around 10:00 pm on 6/7/17. Upon being informed of this, I (Administrator name), began interviewing staff and (Resident #1) regarding the incident. I received (Nursing Assistant (NA) #1) statement and suspended her immediately pending the outcome of the investigation. After reviewing the witness statements; it appears that (Resident #1) became agitated that (NA #1) had not put him to bed immediately upon his request. He began cursing at her which caused her to respond in kind. Another staff member retrieved the charge nurse who removed (NA #1) from the room and issued a verbal reprimand regarding her conduct. (Resident #1) demanded everyone leave his room at that point. I interviewed (Resident #1) after being notified of the incident and he played it off as if it never happened . Based on interviews with staff and (Resident #1); it has been determined that (NA #1) used profanity during the verbal altercation instead of removing herself from the escalating encounter. Based on resident care standards and our employee handbook we have substantiated the verbal abuse allegation and have termed (NA #1) . Notification Status Administrator / Written Designee must be notified . (Administrator) Date 6/8/2017 Time 4:30 PM. Name of Family Member (Resident #1's Spouse) . Doctor Notified . Date 6/8/17 Time 4:45 PM .Date 6/8/17 Time 5:00 PM . Name of Law Enforcement Agency (Local Police Department) . c. An OLTC Witness Statement dated 6/8/17 by NA #1 documented, Last night around 2100 hrs (9:00 p.m.) I went into (Resident #1's) room to change his diaper (incontinent brief). But shortly after arriving he commented that I didn't care and told me to get the (expletive beginning with f) out his room because I didn't give a (expletive beginning with sh) about him. That's when (Licensed Practical Nurse (LPN) #1) enter and asked what was going on (and why had he) cussed me out. It took me off guard and I said 'Damn.' That was only inappropriate word I used. She even said I cussed him out, so waiting for her to stand with everybody and tell me what I said other than damn. Because honestly that's all that was on my end. d. An OLTC Witness Statement dated 6/8/17 by LPN #1 documented, At approx. (approximately) 10 pm last night (Certified Nursing Assistant (CNA) #3) approached me (at) my nurses station and told me (NA #1) was cussing out (Resident #1). When I approached resident's room I heard (Resident #1) cussing (at) the CNA tell her she was worthless and to get out. When I asked what was going on (NA #1) told me she was trying to explain to (Resident #1) that she had lot of other residents she had to lay down and she didn't have time to lay him down when he wanted her to. Then (Resident #1) told both of us (NA #1 and I) to get out of his room and don't come back. I counseled (NA #1) on proper CNA/resident interaction and told her not to go back in there for the rest of the night. e. An OLTC Witness Statement dated 6/8/17 by CNA #1 documented, I was going to help (CNA #3) in (another resident's room) then I heard (NA #1) and (Resident #1) was arguing. (They were) cursing at each other. (NA #1) said she wasn't coming back in that damn room anymore. I told (LPN #2 and LPN #3) about it, they said long as the charge nurse know she will (handle) it. f. An OLTC Witness Statement dated 6/8/17 by CNA #2 documented, I was putting (another resident) to bed and I heard (Resident #1) use profanity towards aide, aide in return used profanity back to resident. I went and got the nurse (LPN #1) (nurse) listen for a minute then went in the room with resident and aide. This CNA was unavailable for interview during the survey. g. An employee time sheet for NA #1, provided by the Administrator on 7/19/17 at 3:00 p.m., documented, Termed and Inactive . In .Wed (Wednesday) 6/07 (6/7/17 - date of incident) 3:06 PM Out 11:10 PM . Thu (Thursday) 6/08 . In 3:08 PM . Out 4:23 PM . Fri (Friday) 6/09 . Suspension . Sat (Saturday) 6/10 Suspension . NA #1's employee file was reviewed at this time, and contained a form signed and dated 4/25/17 by NA #1 that was entitled, Working Together to Prevent Abuse Brochure Acknowledgment. The form documented, I hereby acknowledge that I have both received and read a copy of my facility's brochure on working together to Prevent Abuse. I further acknowledge that I understand that it is my responsibility to make sure that I fully comprehend it. I understand the definition of abuse, the definition of neglect, and my responsibilities to prevent and report as outlined in the brochure and training presentation. I understand that my Supervisor, or Administrative Personnel will answer any questions that I have about the content. I agree to abide by the guidelines as contained, and fully understand that failure to do so may result in termination of employment, possible revocation of any patient care licensure I may hold, and possible criminal and/or civil legal actions. This signed acknowledgement is in my file as a permanent record. I am signing the acknowledgment of my own free will. h. On 7/19/17 at 5:20 p.m., the Administrator was asked who informed him of the incident with the NA and Resident #1 and stated, 3 to 11 (3:00 p.m. to 11:00 p.m.) CNA. The Administrator was asked who the CNA was who had reported the incident to him and stated, (CNA #1). The Administrator was asked at approximately what time the incident was reported to him and stated, Approximately 4:30 p.m. The Administrator was asked if that was on 6/8/17 and stated, Yes. The Administrator was asked what was reported and stated, She said that she overheard (NA #1) and (Resident #1) loud words, she heard (NA #1) using profanity and (Resident #1) as well . she had a raised voice and he had a raised voice and profanity exchanged between them. The Administrator was asked what was done and stated, We suspended (NA #1) immediately, started the investigation and got statements from everyone that was on the shift that night. I interviewed (Resident #1) .advised her (NA #1) you have to rise above that and when I called her in to get her witness statement and counsel, advised her it wasn't right. The Administrator was asked what was not right and stated, If, in fact, she used profanity back towards one of the residents. (Resident #1) didn't deny it happened but he played it off like it didn't happen. We talked to the charge nurse and CNAs who worked that night, asking them what they had seen, heard and witnessed. The Administrator was asked when the suspension for NA #1 began and stated, Within minutes after getting the allegation. The Administrator was asked when the incident actually occurred and stated, Approximately 10 p.m. on 6/7. The Administrator was asked if he obtained witness statements from cognitive residents and stated, We did . The Administrator was asked if, during the investigation, it was determined why the alleged incident of verbal abuse was not reported to him when it occurred. The Administrator stated, Particularly, we had a new LPN at the time and we in-serviced everyone. The Administrator was asked who the nurse was who had not reported the allegation and stated, I think it was (LPN #1). The Administrator was asked if the LPN was in-serviced and stated, I talked to her after this was reported to me. The Administrator was asked if NA #1 should have been allowed to continue to work after an allegation of verbal abuse and stated, No. i. On 7/19/17 at 5:55 p.m., LPN #1 was asked how long had she been a nurse and stated, September 2015. The LPN was asked how long she had been employed at the facility and stated, The beginning of April (2017). The LPN was asked who the CNA was who had cursed at Resident #1 and stated, Her first name was (NA #1 first name). The LPN was asked who the resident was and stated, His name is (Resident #1's first name), not sure of his last name . Another CNA named (CNA #2) . said (CNA #1) was cussing out (Resident #1) . She just said she was cussing him out, so I headed that way. The LPN was asked who else heard or reported the cursing and stated, I'm not sure. The LPN was asked when the incident occurred and stated, Not sure, been about a month ago. The LPN was asked what was done when the incident was reported to her and stated, First, I approached the room, heard some aggravation tone of her (NA #1's) voice, so I went in an asked (Resident #1) what was the problem, and she (NA #1) said she needed to be in there at certain time to put him to bed and he had to wait and (NA #1) was trying to explain to him that she had a lot of people to put down that night and she couldn't be in there when he wanted her to, then I took (NA #1) in the hallway and I told her that we were there for residents and that he should be able to go to bed when ready, he had that right and if she needed help, ask me or another CNA, so I told her since they did have an altercation or whatever you want to call it, would be best for her to not go back in there for that night and I would get another CNA to pick him up. The LPN was asked if NA #1 had cared for other residents after that. LPN #1 stated, Yes. She remained on her assigned hall. She continued with all of her assigned residents except for (Resident #1). The LPN was asked if the NA had remained on the Resident #1's hall (300 Hall) and stated, Yes. The LPN was asked when the NA had left the building and stated, I didn't see, was after her shift. LPN #1 was asked if she had seen NA #1 go into other residents' rooms after the incident and stated, Yes, she didn't have an attitude with the other residents, and she was really polite with me. The LPN was asked where the incident was documented and stated, I didn't, I just told (Administrator) the next day. LPN #1 was asked if she had reported the incident of verbal abuse and stated, Not at the time; I didn't think there was anything to report. The LPN was asked if the incident should have been reported and stated, I did not hear any profanity. The CNA said she was cussing out (Resident #1). The LPN was asked if a CNA/staff member cursed at a resident, if that was verbal abuse, and the LPN stated, Yes. The LPN was asked what should have been done and stated, Call (Administrator) immediately and have the CNA or whoever is involved leave. LPN #1 was asked if she had called the Administrator immediately and stated, No. The LPN was asked if she had NA #1 leave the premises and stated, No. The LPN was asked if NA #1 continued to work in the building and stated, Yes. The LPN was asked if there had been in-servicing on the abuse protocol and stated, We did an orientation video; the next day (after the incident) (Administrator) told me even if someone reports it, I have to call him. At 6:20 p.m., the LPN was shown the abuse in service sheet dated 6/8/17 and the LPN pointed to her name on the sign-in list and stated, .me. The LPN was asked when she had started work, if she was in-serviced on abuse protocol and stated, Yes, on a video. LPN #1 was asked if the allegation of verbal abuse should have been reported to the Administrator immediately after it was reported to her and stated, Yes. j. On 7/19/17 at 6:26 p.m., the Director of Nursing (DON) was asked if the NA had received abuse training when hired and the DON stated, Yes. The DON was asked if any verbal abuse towards a resident was to be reported and the DON stated, Supposed to be reported to the Administrator immediately. The DON was asked what was to be done when there was an allegation of abuse and the DON stated, Protect the resident. The DON was asked after the allegation of verbal abuse incident had occurred if the NA had continued to work. The DON stated, Yes she did. The DON was asked if the residents were protected while the NA worked and the DON stated, No. k. On 7/19/17 at 7:20 p.m., CNA #1 was asked if she had ever reported any verbal abuse and stated, Yes. The CNA was asked who she had reported the alleged verbal abuse to and stated, The charge nurse. The CNA was asked which charge nurse and stated, (LPN #1) . The CNA was asked what was reported and stated, That (NA #1) was in the room with (Resident #1) and cussing out loud with (Resident #1) and back and forth with each other. The CNA was asked what NA #1 said and stated, She said, 'you keep your mother (expletive beginning with f) hands off me'; she said somebody else could take this room and she was not taking care of him and she was not coming back in that dam room anymore. The CNA was asked what was done by LPN #1 after the NA was reported for cursing the resident and stated, (LPN #1) didn't do anything. She talked to (NA #1), called her out of the room and took her off by herself and somebody else took over the resident. CNA #1 was asked if (NA #1) kept working after the LPN talked with her and stated, Yes. The CNA was asked if the NA had provided care for residents for the rest of the shift and stated, Yes. The CNA was asked if there had been any in-service on abuse policy since the incident occurred. The CNA stated, Yes. The CNA was asked if NA #1 worked the next day after the incident and stated, .well, she came in; they sent her home. The CNA was asked if she had reported the abuse to anyone else and stated, Yes (Administrator), when I thought the nurse had not done anything. The CNA was asked when it was reported to the Administrator. The CNA stated, The next day when I saw (NA #1) at work. I know we are supposed to report as soon as we witness or hear about abuse. l. The facility removed the immediate jeopardy and corrected the failed practices on 6/8/17, when NA #1 was removed from the building and the necessary reporting, investigation, staff re-training, and ongoing monitoring were initiated, as evidenced by the following: 1.) An Employee Memorandum form dated 6/8/17 documented, Employee Name: (NA #1) . Date of occurrence: 6/7/17. Date of Memorandum: 6/8/17 . Suspension for (blank) days or until pending outcome of verbal abuse allegation . Comment / Explanation: Employee was overheard cussing back (and) forth with resident (Resident #1) . The form was signed by NA #1 and the Administrator on 6/8/17. 2.) A Termination of Employment form dated 6/8/17 documented, Employee Name (NA #1) .Other Involuntary Termination . Abuse/Neglect . Last Day Worked: 6/8/2017 . 3.) A Staff Development form dated 6/8/17 documented staff were in-serviced on, Any suspicion of Abuse-neglect must be reported to the Administrator immediately. Verbal abuse-if you hear or hear by word of mouth from someone that verbal abuse has occurred to a resident you must report to the Administrator immediately! Physical abuse, mental abuse, sexual abuse, neglect. Any form has to be reported immediately! The attendance sheet was signed by all CNA and licensed nursing staff members. 4.) A staff memo dated 6/8/2017 and signed by the Administrator documented, Effective immediately, I expect to get 2 phone calls when there is potential abuse or neglect. 1. The House Supervisor (Charge Nurse after regular business hours)-call me immediately upon witnessing/hearing of potential abuse or neglect. 2. The employee who witnesses or hears about potential abuse or neglect needs to also call me. Your supervisor may forget. You own the problem until you call me too .update notification was provided during the previous documented in-service. 5.) A staff memo dated 6/8/17 and signed by the DON documented, Nurse Managers to include in daily morning rounds observations for s/s (signs and symptoms) of abuse or neglect. Ask residents if they have been abused or witnessed abuse to another resident. 1. Observe for non-verbal signs of abuse or neglect. 2. Observe for physical signs of abuse or neglect. 3. Observe for withdrawn behavior which can be a sign of verbal abuse. 6.) On 7/20/17 at 12:40 p.m., the Administrator submitted a copy of the facility's written Quality Assurance (QA) report dated 6/12/17 that documented, Problem - Charge Nurse did not remove accused party from resident contact immediately upon receipt of potential verbal abuse. 1. Resident (Resident #1) assessed and interviewed. No concerns identified with assessment and no indications of psychosocial concerns related to the alleged incident. (NA #1) immediately suspended upon receipt of allegation of verbal abuse involving resident (Resident #1). (LPN #1) was interviewed in conjunction with the facility abuse and neglect investigation; abuse and neglect retraining was completed with LPN by the facility administrator including recognizing potential abuse (and)/or neglect and all appropriate actions to take with alleged or suspected abuse (and)/or neglect including the required notifications within the facility to supervisor, administrator, md (medical doctor), family, police and OLTC. Facility investigation initiated by administrator on 6/8/17; 7734 (DMS form 7734 - OLTC Incident and Accident Report) submitted to OLTC same date, appropriate notifications completed. 2. Facility observation rounds and resident interviews were initiated to identify any observations of or any concerns verbalized by residents suspicious of abuse/neglect. No negative findings were identified. 3. In-services on recognizing and reporting abuse and neglect were initiated; in-service topics also included changes in facility practice that the administrator expects two phone calls with any suspected abuse/neglect. One phone call from house supervisor receiving the report from the witness and the second call received from the front-line staff who witnessed or heard of potential abuse/neglect. This will ensure that a potential abuser is removed from resident contact immediately. 4. Increased monitoring implemented to ensure all incidents of alleged or abuse/neglect are properly recognized and that notifications and resident protection were properly initiated and reported. Effective 6/8/17, increased monitoring specific to questioning residents during facility rounds regarding treatment staff, visitors and other residents was begun 5 (times) weekly ongoing, with any concerns identified to be addressed/corrected immediately and taken to the facility quality assurance process for further plan development. On 6/8/17, I assessed and interviewed (Resident #1). There are no physical or psychosocial concerns identified related to the alleged incident of potential verbal abuse that is under facility investigation. 7.) On 7/19/17 at 6:26 p.m., the Director of Nursing (DON) was asked if there had been any in-service on abuse policy and procedure after the 6/7/17 incident and stated, It was actually the next day, on 6/8. The DON was asked who had in-serviced LPN #1 on abuse and stated, It was me. The DON was asked if there had been any monitoring after the allegation of verbal abuse and stated, Yes we did. 8.) On 7/20/17 at 11:00 a.m., the DON submitted a signed statement that documented, On 6/8/17, I initiated resident rounds interviewing cognitive residents located on all halls regarding abuse and neglect. All residents interviewed verbalize that they have not been abused or neglected nor have they any knowledge of any suspected or alleged abuse. A Daily census sheet dated 6/8/17 documented residents on each hall were interviewed regarding abuse, including 7 residents on the 300 Hall where Resident #1 resided. The DON also provided monitoring sheets that were initiated on 6/8/17 and continued into the month of July 2017, which documented ongoing monitoring of residents for any signs / symptoms of abuse / neglect, and copies of continued interviews with cognitive residents beginning 6/8/17 and continued into the month of July 2017, with no further negative findings to date.

Complaint # (AR 226) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure the facility's abuse prohibition policies and procedures were implemented, as evidenced by failure of staff to immediately report to the Administrator and failure to immediately suspend Nursing Assistant (NA) #1 from all resident care after NA #1 was overheard heard cursing and threatening Resident #1. The failure to report the incident to Administration resulted in additional failures, including delays in providing appropriate protective measures, reporting the incident to the Office of Long Term Care and law enforcement and initiating an investigation for 1 (Resident #1) of 1 case mix resident who was the victim of witnessed verbal abuse by Nursing Assistant #1. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, and had the potential to affect 43 residents who resided on the 300 Hall (where NA #1 remained after the abuse incident occurred), as documented on a list provided by the Director of Nursing (DON) on 7/20/17. The facility removed the immediate jeopardy and corrected the failed practices 6/8/17 prior to the survey. The Administrator was informed of the past immediate jeopardy condition on 7/20/17. The findings are: 1. The facility's abuse prevention policies and procedures, received on 7/18/17 from the Administrator, documented, Reporting Abuse Policy Statement It is the responsibility of our employees . to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source . to the administrator or his/her designee . All reports of abuse, neglect . will be immediately reported to the Administrator or designee and promptly investigated. If such incidents occur or are discovered after normal business office hours, the Administrator or designee must be notified . Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability . Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services .agitating a resident to solicit a response, derogatory statements directed to the resident .providing comments in a demeaning manner, directing a resident to use inappropriate language . Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to the administrator or his/her designee . Protection of Residents during Abuse Investigations Policy Statement . Our facility will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the administrator . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/2/17 documented the resident scored 13 (13-15 indicates cognitively intact) was totally dependent on the assistance of two plus people for transfer and required limited assistance of two plus people for bed mobility. a. The Care Plan updated 7/4/17 documented, The resident is/has potential to be verbally aggressive (yelling, cursing, verbally threatening, etc. (et cetera)) related to resisting care . Interventions .Staff to de-escalate behavior by resident specific intervention of leaving resident alone and re-approach at later time . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away . Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 6/8/17 documented, Facility Staff Member Completing DMS-762 (Administrator name) .Date Incident Reported to OLTC (Office of Long Term Care): 6/8/2017 Time: 5:40 PM. Date of Incident: 6/7/2017 Time and Date of Discovery: 6/8/2017 Time 4:30 PM. Type of Incident . Abuse: Verbal (marked) . Name of Involved Resident: (Resident #1) . At approximately 4:30 pm on 6/8/17 it was reported to the administrator that (NA #1), had gotten into a verbal shouting match with resident (Resident #1) around 10:00 pm on 6/7/17. Upon being informed of this, I (Administrator name), began interviewing staff and (Resident #1) regarding the incident. I received (Nursing Assistant (NA) #1) statement and suspended her immediately pending the outcome of the investigation. After reviewing the witness statements; it appears that (Resident #1) became agitated that (NA #1) had not put him to bed immediately upon his request. He began cursing at her which caused her to respond in kind. Another staff member retrieved the charge nurse who removed (NA #1) from the room and issued a verbal reprimand regarding her conduct. (Resident #1) demanded everyone leave his room at that point. I interviewed (Resident #1) after being notified of the incident and he played it off as if it never happened . Based on interviews with staff and (Resident #1); it has been determined that (NA #1) used profanity during the verbal altercation instead of removing herself from the escalating encounter. Based on resident care standards and our employee handbook we have substantiated the verbal abuse allegation and have termed (NA #1) . Notification Status Administrator / Written Designee must be notified . (Administrator) Date 6/8/2017 Time 4:30 PM. Name of Family Member (Resident #1's Spouse) . Doctor Notified . Date 6/8/17 Time 4:45 PM .Date 6/8/17 Time 5:00 PM . Name of Law Enforcement Agency (Local Police Department) . c. An OLTC Witness Statement dated 6/8/17 by NA #1 documented, Last night around 2100 hrs (9:00 p.m.) I went into (Resident #1's) room to change his diaper (incontinent brief). But shortly after arriving he commented that I didn't care and told me to get the (expletive beginning with f) out his room because I didn't give a (expletive beginning with sh) about him. That's when (Licensed Practical Nurse (LPN) #1) enter and asked what was going on (and why had he) cussed me out. It took me off guard and I said 'Damn.' That was only inappropriate word I used. She even said I cussed him out, so waiting for her to stand with everybody and tell me what I said other than damn. Because honestly that's all that was on my end. d. An OLTC Witness Statement dated 6/8/17 by LPN #1 documented, At approx. (approximately) 10 pm last night (Certified Nursing Assistant (CNA) #3) approached me (at) my nurses station and told me (NA #1) was cussing out (Resident #1). When I approached resident's room I heard (Resident #1) cussing (at) the CNA tell her she was worthless and to get out. When I asked what was going on (NA #1) told me she was trying to explain to (Resident #1) that she had lot of other residents she had to lay down and she didn't have time to lay him down when he wanted her to. Then (Resident #1) told both of us (NA #1 and I) to get out of his room and don't come back. I counseled (NA #1) on proper CNA/resident interaction and told her not to go back in there for the rest of the night. e. An OLTC Witness Statement dated 6/8/17 by CNA #1 documented, I was going to help (CNA #3) in (another resident's room) then I heard (NA #1) and (Resident #1) was arguing. (They were) cursing at each other. (NA #1) said she wasn't coming back in that damn room anymore. I told (LPN #2 and LPN #3) about it, they said long as the charge nurse know she will (handle) it. f. An OLTC Witness Statement dated 6/8/17 by CNA #2 documented, I was putting (another resident) to bed and I heard (Resident #1) use profanity towards aide, aide in return used profanity back to resident. I went and got the nurse (LPN #1) (nurse) listen for a minute then went in the room with resident and aide. This CNA was unavailable for interview during the survey. g. An employee time sheet for NA #1, provided by the Administrator on 7/19/17 at 3:00 p.m., documented, Termed and Inactive . In .Wed (Wednesday) 6/07 (6/7/17 - date of incident) 3:06 PM Out 11:10 PM . Thu (Thursday) 6/08 . In 3:08 PM . Out 4:23 PM . Fri (Friday) 6/09 . Suspension . Sat (Saturday) 6/10 Suspension . NA #1's employee file was reviewed at this time, and contained a form signed and dated 4/25/17 by NA #1 that was entitled, Working Together to Prevent Abuse Brochure Acknowledgment. The form documented, I hereby acknowledge that I have both received and read a copy of my facility's brochure on working together to Prevent Abuse. I further acknowledge that I understand that it is my responsibility to make sure that I fully comprehend it. I understand the definition of abuse, the definition of neglect, and my responsibilities to prevent and report as outlined in the brochure and training presentation. I understand that my Supervisor, or Administrative Personnel will answer any questions that I have about the content. I agree to abide by the guidelines as contained, and fully understand that failure to do so may result in termination of employment, possible revocation of any patient care licensure I may hold, and possible criminal and/or civil legal actions. This signed acknowledgement is in my file as a permanent record. I am signing the acknowledgment of my own free will. h. On 7/19/17 at 5:20 p.m., the Administrator was asked who informed him of the incident with the NA and Resident #1 and stated, 3 to 11 (3:00 p.m. to 11:00 p.m.) CNA. The Administrator was asked who the CNA was who had reported the incident to him and stated, (CNA #1). The Administrator was asked at approximately what time the incident was reported to him and stated, Approximately 4:30 p.m. The Administrator was asked if that was on 6/8/17 and stated, Yes. The Administrator was asked what was reported and stated, She said that she overheard (NA #1) and (Resident #1) loud words, she heard (NA #1) using profanity and (Resident #1) as well . she had a raised voice and he had a raised voice and profanity exchanged between them. The Administrator was asked what was done and stated, We suspended (NA #1) immediately, started the investigation and got statements from everyone that was on the shift that night. I interviewed (Resident #1) .advised her (NA #1) you have to rise above that and when I called her in to get her witness statement and counsel, advised her it wasn't right. The Administrator was asked what was not right and stated, If, in fact, she used profanity back towards one of the residents. (Resident #1) didn't deny it happened but he played it off like it didn't happen. We talked to the charge nurse and CNAs who worked that night, asking them what they had seen, heard and witnessed. The Administrator was asked when the suspension for NA #1 began and stated, Within minutes after getting the allegation. The Administrator was asked when the incident actually occurred and stated, Approximately 10 p.m. on 6/7. The Administrator was asked if he obtained witness statements from cognitive residents and stated, We did . The Administrator was asked if, during the investigation, it was determined why the alleged incident of verbal abuse was not reported to him when it occurred. The Administrator stated, Particularly, we had a new LPN at the time and we in-serviced everyone. The Administrator was asked who the nurse was who had not reported the allegation and stated, I think it was (LPN #1). The Administrator was asked if the LPN was in-serviced and stated, I talked to her after this was reported to me. The Administrator was asked if NA #1 should have been allowed to continue to work after an allegation of verbal abuse and stated, No. i. On 7/19/17 at 5:55 p.m., LPN #1 was asked how long had she been a nurse and stated, September 2015. The LPN was asked how long she had been employed at the facility and stated, The beginning of April (2017). The LPN was asked who the CNA was who had cursed at Resident #1 and stated, Her first name was (NA #1 first name). The LPN was asked who the resident was and stated, His name is (Resident #1's first name), not sure of his last name . Another CNA named (CNA #2) . said (CNA #1) was cussing out (Resident #1) . She just said she was cussing him out, so I headed that way. The LPN was asked who else heard or reported the cursing and stated, I'm not sure. The LPN was asked when the incident occurred and stated, Not sure, been about a month ago. The LPN was asked what was done when the incident was reported to her and stated, First, I approached the room, heard some aggravation tone of her (NA #1's) voice, so I went in an asked (Resident #1) what was the problem, and she (NA #1) said she needed to be in there at certain time to put him to bed and he had to wait and (NA #1) was trying to explain to him that she had a lot of people to put down that night and she couldn't be in there when he wanted her to, then I took (NA #1) in the hallway and I told her that we were there for residents and that he should be able to go to bed when ready, he had that right and if she needed help, ask me or another CNA, so I told her since they did have an altercation or whatever you want to call it, would be best for her to not go back in there for that night and I would get another CNA to pick him up. The LPN was asked if NA #1 had cared for other residents after that. LPN #1 stated, Yes. She remained on her assigned hall. She continued with all of her assigned residents except for (Resident #1). The LPN was asked if the NA had remained on the Resident #1's hall (300 Hall) and stated, Yes. The LPN was asked when the NA had left the building and stated, I didn't see, was after her shift. LPN #1 was asked if she had seen NA #1 go into other residents' rooms after the incident and stated, Yes, she didn't have an attitude with the other residents, and she was really polite with me. The LPN was asked where the incident was documented and stated, I didn't, I just told (Administrator) the next day. LPN #1 was asked if she had reported the incident of verbal abuse and stated, Not at the time; I didn't think there was anything to report. The LPN was asked if the incident should have been reported and stated, I did not hear any profanity. The CNA said she was cussing out (Resident #1). The LPN was asked if a CNA/staff member cursed at a resident, if that was verbal abuse, and the LPN stated, Yes. The LPN was asked what should have been done and stated, Call (Administrator) immediately and have the CNA or whoever is involved leave. LPN #1 was asked if she had called the Administrator immediately and stated, No. The LPN was asked if she had NA #1 leave the premises and stated, No. The LPN was asked if NA #1 continued to work in the building and stated, Yes. The LPN was asked if there had been in-servicing on the abuse protocol and stated, We did an orientation video; the next day (after the incident) (Administrator) told me even if someone reports it, I have to call him. At 6:20 p.m., the LPN was shown the abuse in service sheet dated 6/8/17 and the LPN pointed to her name on the sign-in list and stated, .me. The LPN was asked when she had started work, if she was in-serviced on abuse protocol and stated, Yes, on a video. LPN #1 was asked if the allegation of verbal abuse should have been reported to the Administrator immediately after it was reported to her and stated, Yes. j. On 7/19/17 at 6:26 p.m., the Director of Nursing (DON) was asked if the NA had received abuse training when hired and the DON stated, Yes. The DON was asked if any verbal abuse towards a resident was to be reported and the DON stated, Supposed to be reported to the Administrator immediately. The DON was asked what was to be done when there was an allegation of abuse and the DON stated, Protect the resident. The DON was asked after the allegation of verbal abuse incident had occurred if the NA had continued to work. The DON stated, Yes she did. The DON was asked if the residents were protected while the NA worked and the DON stated, No. k. On 7/19/17 at 7:20 p.m., CNA #1 was asked if she had ever reported any verbal abuse and stated, Yes. The CNA was asked who she had reported the alleged verbal abuse to and stated, The charge nurse. The CNA was asked which charge nurse and stated, (LPN #1) . The CNA was asked what was reported and stated, That (NA #1) was in the room with (Resident #1) and cussing out loud with (Resident #1) and back and forth with each other. The CNA was asked what NA #1 said and stated, She said, 'you keep your mother (expletive beginning with f) hands off me'; she said somebody else could take this room and she was not taking care of him and she was not coming back in that dam room anymore. The CNA was asked what was done by LPN #1 after the NA was reported for cursing the resident and stated, (LPN #1) didn't do anything. She talked to (NA #1), called her out of the room and took her off by herself and somebody else took over the resident. CNA #1 was asked if (NA #1) kept working after the LPN talked with her and stated, Yes. The CNA was asked if the NA had provided care for residents for the rest of the shift and stated, Yes. The CNA was asked if there had been any in-service on abuse policy since the incident occurred. The CNA stated, Yes. The CNA was asked if NA #1 worked the next day after the incident and stated, .well, she came in; they sent her home. The CNA was asked if she had reported the abuse to anyone else and stated, Yes (Administrator), when I thought the nurse had not done anything. The CNA was asked when it was reported to the Administrator. The CNA stated, The next day when I saw (NA #1) at work. I know we are supposed to report as soon as we witness or hear about abuse. l. The facility removed the immediate jeopardy and corrected the failed practices on 6/8/17, when NA #1 was removed from the building and the necessary reporting, investigation, staff re-training, and ongoing monitoring were initiated, as evidenced by the following: 1.) An Employee Memorandum form dated 6/8/17 documented, Employee Name: (NA #1) . Date of occurrence: 6/7/17. Date of Memorandum: 6/8/17 . Suspension for (blank) days or until pending outcome of verbal abuse allegation . Comment / Explanation: Employee was overheard cussing back (and) forth with resident (Resident #1) . The form was signed by NA #1 and the Administrator on 6/8/17. 2.) A Termination of Employment form dated 6/8/17 documented, Employee Name (NA #1) .Other Involuntary Termination . Abuse/Neglect . Last Day Worked: 6/8/2017 . 3.) A Staff Development form dated 6/8/17 documented staff were in-serviced on, Any suspicion of Abuse-neglect must be reported to the Administrator immediately. Verbal abuse-if you hear or hear by word of mouth from someone that verbal abuse has occurred to a resident you must report to the Administrator immediately! Physical abuse, mental abuse, sexual abuse, neglect. Any form has to be reported immediately! The attendance sheet was signed by all CNA and licensed nursing staff members. 4.) A staff memo dated 6/8/2017 and signed by the Administrator documented, Effective immediately, I expect to get 2 phone calls when there is potential abuse or neglect. 1. The House Supervisor (Charge Nurse after regular business hours)-call me immediately upon witnessing/hearing of potential abuse or neglect. 2. The employee who witnesses or hears about potential abuse or neglect needs to also call me. Your supervisor may forget. You own the problem until you call me too .update notification was provided during the previous documented in-service. 5.) A staff memo dated 6/8/17 and signed by the DON documented, Nurse Managers to include in daily morning rounds observations for s/s (signs and symptoms) of abuse or neglect. Ask residents if they have been abused or witnessed abuse to another resident. 1. Observe for non-verbal signs of abuse or neglect. 2. Observe for physical signs of abuse or neglect. 3. Observe for withdrawn behavior which can be a sign of verbal abuse. 6.) On 7/20/17 at 12:40 p.m., the Administrator submitted a copy of the facility's written Quality Assurance (QA) report dated 6/12/17 that documented, Problem - Charge Nurse did not remove accused party from resident contact immediately upon receipt of potential verbal abuse. 1. Resident (Resident #1) assessed and interviewed. No concerns identified with assessment and no indications of psychosocial concerns related to the alleged incident. (NA #1) immediately suspended upon receipt of allegation of verbal abuse involving resident (Resident #1). (LPN #1) was interviewed in conjunction with the facility abuse and neglect investigation; abuse and neglect retraining was completed with LPN by the facility administrator including recognizing potential abuse (and)/or neglect and all appropriate actions to take with alleged or suspected abuse (and)/or neglect including the required notifications within the facility to supervisor, administrator, md (medical doctor), family, police and OLTC. Facility investigation initiated by administrator on 6/8/17; 7734 (DMS form 7734 - OLTC Incident and Accident Report) submitted to OLTC same date, appropriate notifications completed. 2. Facility observation rounds and resident interviews were initiated to identify any observations of or any concerns verbalized by residents suspicious of abuse/neglect. No negative findings were identified. 3. In-services on recognizing and reporting abuse and neglect were initiated; in-service topics also included changes in facility practice that the administrator expects two phone calls with any suspected abuse/neglect. One phone call from house supervisor receiving the report from the witness and the second call received from the front-line staff who witnessed or heard of potential abuse/neglect. This will ensure that a potential abuser is removed from resident contact immediately. 4. Increased monitoring implemented to ensure all incidents of alleged or abuse/neglect are properly recognized and that notifications and resident protection were properly initiated and reported. Effective 6/8/17, increased monitoring specific to questioning residents during facility rounds regarding treatment staff, visitors and other residents was begun 5 (times) weekly ongoing, with any concerns identified to be addressed/corrected immediately and taken to the facility quality assurance process for further plan development. On 6/8/17, I assessed and interviewed (Resident #1). There are no physical or psychosocial concerns identified related to the alleged incident of potential verbal abuse that is under facility investigation. 7.) On 7/19/17 at 6:26 p.m., the Director of Nursing (DON) was asked if there had been any in-service on abuse policy and procedure after the 6/7/17 incident and stated, It was actually the next day, on 6/8. The DON was asked who had in-serviced LPN #1 on abuse and stated, It was me. The DON was asked if there had been any monitoring after the allegation of verbal abuse and stated, Yes we did. 8.) On 7/20/17 at 11:00 a.m., the DON submitted a signed statement that documented, On 6/8/17, I initiated resident rounds interviewing cognitive residents located on all halls regarding abuse and neglect. All residents interviewed verbalize that they have not been abused or neglected nor have they any knowledge of any suspected or alleged abuse. A Daily census sheet dated 6/8/17 documented residents on each hall were interviewed regarding abuse, including 7 residents on the 300 Hall where Resident #1 resided. The DON also provided monitoring sheets that were initiated on 6/8/17 and continued into the month of July 2017, which documented ongoing monitoring of residents for any signs / symptoms of abuse / neglect, and copies of continued interviews with cognitive residents beginning 6/8/17 and continued into the month of July 2017, with no further negative findings to date.