Every finding on record at Bennettsville Health And Rehabilitation Center

Based on review of the facility policy, record review, and interview, the facility failed to ensure the facility's surety bond covered the total amount of monies in the resident's personal fund account. As of 05/19/2026, there were 101 resident accounts with monies.Findings included:Review of the facility policy titled Resident Trust Fund revealed the following: 17. Financial Integrity/Surety Bonds: A. The Facility will provide a surety bond to protect resident funds from losses due to the facilities failure to hold, safeguard, manage and/or account for resident funds. D. The amount covered by the surety bond will be a least equal to the total amount of residents' funds, as of the most recent quarter. E. The BOM will review the surety bond amount quarterly for adequate coverage and notify the administrator of any necessary changes.Review of the facility's current surety bond revealed coverage was in the amount of $150,000. Further review of the monthly statements for resident funds from 11/30/2025 to 05/19/2026, revealed six of seven months were over the amount covered by the surety bond.During an interview on 05/19/26 at 1:15 PM, the Business Office Manager (BOM) confirmed the current surety bond did not cover the amount currently in the resident's personal fund account. The BOM stated the Regional Account Manager was aware. No documentation was provided during the survey process related to notification to the Regional Account Manager.

Based on review of the facility policy, observation, and interview, the facility failed to store and label medications and biologicals appropriately for 2 of 5 medication carts and in 1 of 2 medication rooms. Additionally, the facility failed to secure 1 of 2 medication storage rooms. Findings included: Review of the facility policy titled Medication Storage revealed the following, Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. 2. The medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members.Further review of the facility policy listed the following under the procedure section, . 6. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. 7. Once any multi-dose packaged medication or biological is opened, nursing will mark [NAME]-dose products (e.g. inhalers, insulin, ophthalmic, .) with the date opened and follow manufacturer/supplier guidelines with respect to expiration dates. During observation of the 100 Unit Medication Cart on 05/20/2026 at 12:06 PM, revealed the following:-Vitamin B12 500 micrograms (mcgs) (100 tabs), Lot#886Y08 with an expiration date of 4/26;-(2) Trelegy Ellipta 100 mcgs, Lot#UT8B with an expiration date of 9/27 with no open date;-Insulin Lispro 100 units(u)/milliliter (ml), Lot#08667380 with an expiration date of 5/23/28, with no open date;-(2) Lantus SoloStar 100u/ml, Lot#6F065664 with an expiration date of 10/31/28 with no open date;-Humalog Kwik Pen 100u/ml, Lot#D879710D with an expiration date of 6/21/28 with no open date. During an interview on 05/20/2026 at 12:34 PM, Registered Nurse (RN)1 confirmed the above findings and stated when a medication is opened it should be dated. During an observation on 05/20/2026 at 1:31 PM, review of the 500 Unit Medication Cart revealed, Ventolin HFA Inhaler 90 micrograms, Lot#JS7T, expiration date June 2027 with no open date. During an interview on 05/20/2026 at 1:31 PM, Licensed Practical Nurse (LPN)2 confirmed the above finding. During an observation of the 400/500 Medication Room on 05/20/2026 at 2:09 PM, revealed the following:-Tubersol 5 Tuberculin Units (TU)/.1ml, Lot#4C4RCI, expiration date 2/2028 with open date of 4/7/2026;-Tubersol 5 TU/.1 ml, Lot#4CA12CI, expiration date 2/2028 with no open date. During an interview on 05/20/2026 at 2:09 PM, LPN 3 confirmed the above findings. During an observation on 05/20/2026 at 2:38 PM, the 100 Medication Room was observed unsecured. At the time of the observation, RN1 confirmed the door to the 100 Medication Room was unsecured.

Based on review of facility policy, record review, and interview, the facility failed to afford Resident (R)86 the opportunity to participate in the care plan process, for 1 of 1 resident reviewed for care plan participation.Findings included: Review of the facility policy titled Care Plan Process, Person Centered Care states under the Procedure section the following: . 8. The IDT will invite participation from the resident and the resident's legal representative (if applicable). The IDT will document an explanation in the resident's medical record of the invitation, participation, or lack of participation of the resident and their resident representative if determined not practicable for the development of the resident's person-centered care plan. Review of R86's Face Sheet revealed R86 was admitted to the facility on [DATE], with diagnoses, which included, but was not limited to, cerebral infarction and cognitive communication deficit. Review of R86's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/24/26, revealed R86 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognitive function with minimal to no impairment. Review of R86's Electronic Medical Record revealed no documentation that R86 had been invited to participate in the care plan process. During an interview on 05/18/26 at 1:53 PM, R86 stated they had not been invited to participate in the care plan process. During an interview with the Care Plan Coordinator on 05/20/26 at 10:48 AM, the Care Plan Coordinator stated the normal procedure was to send out care plan invitations two weeks in advance. Once the care plan is completed and signed, it is then uploaded into the system. The Care Plan Coordinator continued by stating it was an oversight that R86 had not been invited to participate in the care plan process. The Care Plan Coordinator further stated a phone conference had been conducted with the resident's representative, and a bedside review had been done with the resident on 5/20/26.

Based on review of the facility policy, observation, record review, and interview, the facility failed to promote dignity for Resident (R)28. Specifically, R28 was given an insulin injection in her abdomen, while in the therapy department with other residents, staff and visitors present, for 1 of 2 residents reviewed for dignity. Findings included: Review of the facility policy titled, Patient/Resident Rights, states as the policy, The facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. Resident Rights: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Right to Dignity, Respect, and Freedom To be treated with consideration, respect, and dignity. Right to Participate in One's Own Care: Receive adequate and appropriate care. Review of R28's Face Sheet revealed the facility admitted R28 with diagnoses including but not limited to, DM type 2, hyperglycemia, dementia and seizures. During an observation on 05/19/2026 at 7:30 AM, during medication administration, R28 was to receive 30 units of Glargin Insulin subcutaneous 2 times daily. Licensed Practical Nurse (LPN)1 walked over to the resident, who was in the physical therapy area, where she was receiving physical therapy, and LPN1 stated, I need to give you your medications. LPN1 pulled up the resident's shirt and gave her the insulin injection, in the physical therapy area, with other residents and visitors present. LPN1 then walked away from the resident and back to the medication cart. During an interview on 05/19/2026 at approximately 7:35 AM, LPN1 agreed that she should have asked the resident if she wanted the injection in her abdomen or her arm, and then provide privacy.

Based on review of the facility policy, record review, and interview, the facility failed to notify the resident and/or the resident's representative of resident funds which were at or above the limit for Medicaid, for 1 of 4 residents reviewed for personal funds.Findings included:Review of the facility policy titled Resident Trust Fund revealed the following under section 15. Notification of Certain Balances: A. Residents or their legal representatives are notified in writing when their trust fund balance is within $200.00 of the Medicaid eligibility limits. B. A copy of this notification is filed in the resident's financial file.Review of Resident (R)27's Personal Funds revealed that as of 05/18/26, R27's Personal Funds had a balance in excess of $2,000.00. During an interview on 05/19/2026 at 1:15 PM, the Business Office Manager (BOM) stated the family was aware the personal funds account was above the limit and were trying to come to an agreement related to the resident's personal funds. No documentation was provided related to the conversation with the resident's family at the time of the survey.

Based on review of the facility policy, facility schedule for floor cleaning, facility schedule for buffing of floors, observations, and interview, the facility failed to provide a safe, clean, comfortable homelike environment for 1 of 3 buildings. Specifically, damaged furniture, water stained ceiling tiles, scarred doors, and build-up of dark substance was observed in Building 2.Findings included:Review of the facility policy titled Wheelchair safety: Use and Maintenance revealed the following: 4. Wheelchair Maintenance and Servicing. A. Wheelchairs will be inspected and receive preventive maintenance as needed. B. Resident, patients and staff remove equipment from service that is defective or requires maintenance or repair. C. Common replacement items include but are not limited to: 1) Arm, leg and footrests 2) Cushions 3) Seats 4) Back support 5) Front and rear wheel assemblies 6) Brakes. Review of the Wheelchair Cleaning Log revealed wheelchairs in rooms [ROOM NUMBERS] were observed and cleaned on 05/01/2026, 05/06/2026, and 05/13/2026. Review of the Hall Floors cleaning schedule revealed the 200 Hall had been cleaned on 04/22/2026. There was no documentation for Hall 200 for May 2026.Review of the facility Buffing Schedule revealed on Wednesdays Hall 200 receives buffing.During initial rounds on 05/18/2026 at 10:30 AM, the following was observed:room [ROOM NUMBER]D-Scraped paint behind head of bed; stained ceiling tiles, a build-up of dark substance at bathroom threshold.room [ROOM NUMBER]W-Bedside table with damaged and rough edges, scarred closet door.room [ROOM NUMBER]D-Over the bed table with rough edges, scarred closet door.Geri chair outside of rom 203 with torn/tattered armrests.room [ROOM NUMBER]-Damage to bathroom door, toilet plunger not covered.During environmental rounds with the Director of Nursing (DON) on 5/20/2026 at 11:00 AM, the above items were shown along with room [ROOM NUMBER]'s bathroom vanity loose from wall and room [ROOM NUMBER] wheelchair with torn/tattered armrests. During the environmental rounds, the DON stated the closet doors were being repaired and repainted and pointed out one that had been repaired. The DON wrote down the concerns when viewed during the round.

Based on review of facility policy, record review and interview, the facility failed to follow the recommendations from a Level 1 PASARR (Preadmission Screening and Resident Review), for 1 of 1 resident reviewed.Findings included: Review of the facility policy titled PASARR Documentation Policy states under the section General Guidelines for PASARR, 5. If the PASARR Level I screen indicates the individual may have an ID, DD, or MI diagnosis, follow the state-specific process for completion of the Level II evaluation. Review of Resident (R)17's Face Sheet revealed R17 was admitted to the facility on [DATE], with diagnoses which included, but was not limited to, anxiety disorder, depression, and paranoid schizophrenia. Review of R17's PASARR Level I dated 01/16/20, revealed a recommendation for a Level II PASARR for MI indicators. Further review of R17's Electronic Medical Record (EMR) revealed there was no PASARR Level II results from R17's PASARR Level 1 recommendation. A PASSAR Level II dated 12/28/11, was provided by the facility and reviewed with recommendations listed as medication management, assistance with ADL's, crisis intervention services, and support networks. However, this PASARR Level II was dated prior to the PASARR Level 1. During an interview with the Nurse Consultant on 05/20/2026 at 3:15 PM, the Nurse Consultant stated they did not know why another Level II had been recommended on 01/16/2020 and Social Services was looking into the matter. No further documentation was provided during the survey process.

Based on review of facility observation, interview, and record review, the facility failed to store food and utensils properly, and to ensure residents ate their meals in a clean and sanitary manner. Specifically, the facility failed to maintain clean storage containers for ready-to-use serving utensils; failed to remove dented cans from food service for 1 of 1 kitchen; and failed to offer hand hygiene to residents during meal service for 1 of 2 dining rooms. Findings include: 1. Failure to maintain clean storage containers for ready-to-use serving utensils; and failure to remove dented cans from food service. Review of the facility's policy titled, NUTRITION POLICIES AND PROCEDURES revised 6/20/23, documented under the SAFE FOOD HANDLING and Food/Beverages Prepared and Served by Facility Staff for Patients or resident portion of the policy: .6. Food is served with clean, sanitized utensils. 7. The food preparation area and utensils used to prepare food are cleaned and sanitized prior to each use, using approved washing and sanitizing techniques. Review of the facility's policy titled, NUTRITION POLICIES AND PROCEDURES' revised 6/20/23, documented under the FOOD SAFETY IN RECEIVING AND STORAGE and Receiving Guidelinesportion of the policy: .5. Inspect food when it is delivered to the facility and prior to storage for signs of contamination. Food packages shall be in good condition to protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Examples of signs of contamination include: A. Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks. On 04/08/25 at 6:50 AM, during an initial tour of the facility kitchen, ready-to-use serving spoons in various sizes were observed stored in translucent bowls, placed directly on a shelf, under a metal countertop next to the ice machine. The bowls were not in contact with the floor. The ready-to-use serving spoons were stored such that a combination of serving spoons of the same size were stored together. Specifically, several ready-to-use serving spoons of different measurements including two (2), three (3), four (4), six (6), and eight (8) ounce serving spoons were stored in separate translucent bowls as described above. The bowls were greasy to the touch, consistent with a buildup of oil, and had visible multi-colored (blackish, greenish, brownish, and yellowish) debris in sizes smaller than breadcrumbs stuck on the edges, surrounding areas, as well as the base of the storage bowls. In addition, an observation conducted in the dry storage room within the kitchen, revealed dented cans, including a can of Sysco Classic Chili Con Carne with Beans and Allens Baked Beans Seasoned with Bacon and [NAME] Sugar stored on the shelf ready to use. During an interview, on 04/08/25 at 6:59 AM, [NAME] 1 stated the serving spoons observed in the bowls were washed and ready to use. He/She observed the bowls and stated they were dirty and needed to be cleaned. [NAME] 1 added that the serving spoons stored in the bowls were possibly contaminated as well due to their direct contact with surfaces within the bowl and needed to be re-washed prior to use. However, [NAME] 1 was observed as he/she selected serving spoons of various sizes from the identified bowls, and without re-washing them, placed them into different breakfast menu items on the steam table. During an interview, on 04/08/25 at 7:15 AM, the Dietary Manager stated that all utensils should be stored in clean containers and that any utensil storage that appeared soiled, should be immediately addressed. The Dietary Manager stated the serving spoons should have been re-washed before use since the containers were visibly soiled. The Dietary Manager further stated dietary staff were trained in proper sanitation procedures, however, he/she clarified that the observed practice with [NAME] 1 warranted a need to provide better oversight and retraining. Regarding the dented cans, the Dietary Manager stated the facility's policy required that all dented cans be separated and returned to the vendor or discarded. The Dietary Manager stated that dented cans posed a food safety risk as the seal may be compromised, potentially allowing bacterial contamination. The Dietary Manager further stated that the identified dented cans should have been removed during inventory receipt and should not have been available for use on the basis that the practice represented a significant breakdown in the facility's kitchen sanitation protocols and food safety standards. During an interview, on 04/08/25 at 1:45 PM, the Director of Nursing stated, Food safety is essential to prevent foodborne illness, especially in our vulnerable population. The kitchen staff should follow proper sanitation procedures at all times, which includes proper utensil storage and removal of potentially unsafe food items, like dented cans. During an interview, on 04/08/25 at 2:31 PM, the Administrator stated the facility acknowledged the deficient practices and had started immediate re-education to dietary staff about the facility's expectations. 2. Failure to offer hand hygiene to residents during meal service. Review of the facility's policy titled INFECTION PREVENTION AND CONTROL POLICIES AND PROCEDURES, revised 05/15/23, documented under the SUBJECT portion of the policy, HAND HYGIENE/HANDWASHING: Hand Hygiene/Hand washing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff. During a dining observation on 04/09/25 at 12:39 PM, during the noon meal service. The observation focused on one annex of the facility's two (2) dining rooms. The observed dining room was accessible from a door directly across from the administrative staff's office. The observation revealed a group of nine (9) residents who sat at the dining table waiting to receive their meals. Eight (8) of the residents propelled themselves in wheelchairs, while one of the residents ambulated with a walker. The residents were settled at the dining table ready to be served their meals. At approximately 12:43 PM, facility staff started passing the residents' meal trays. The observation revealed that while the staff performed hand hygiene in between passing meal trays to the residents, none of the nine (9) residents was offered a hand hygiene opportunity. The residents had touched different surfaces, which included but not limited to, the wheels on the wheelchairs and other residents while waiting to be served. During an interview, on 04/09/25 at 1:03 PM, Licensed Practical Nurse (LPN)1 acknowledged that no residents were offered hand hygiene after having touched different surfaces, which failed to ensure the residents ate their meals with clean hands. LPN1 verified that there was no provision in the dining area for a hand hygiene opportunity for the residents. He/She stepped out of the dining room to retrieve an alcohol-based hand sanitizer, which was then used to sanitize the residents' hands after they had already started eating their meals. During an interview, on 04/09/25 at 1:11 PM, Nursing Assistant (NA)1 stated, We are supposed to offer residents hand hygiene before all meals. I didn't think about it this time because we were trying to get everyone served quickly. There should be hand sanitizer stations in each dining area, but ours was empty and nobody had replaced it. During an interview, on 04/09/25 at 1:17 PM, Certified Nursing Assistant (CNA)1 stated, I know we're supposed to help residents clean their hands before eating. It's something we discuss in our training, but sometimes during busy mealtimes it gets overlooked. CNA1 clarified that he/she did not offer hand hygiene to any of the residents that he/she served. During an interview, on 04/09/25 at 1:21 PM, CNA2 stated, Hand hygiene is important before meals, especially since many of our residents use their wheelchairs to get to the dining room and touch lots of surfaces. It's our responsibility to offer them a way to clean their hands before eating. Today, I had to assist a resident to the toilet and was not in the dining room when the tray service started initially hence the missed opportunity for hand hygiene with the residents. During an interview, on 04/09/25 at 2:38 PM, the Director of Nursing stated, Our policy requires that all residents be offered hand hygiene before meals. This is a basic infection control practice. Each dining area should have accessible hand hygiene supplies, and staff should be ensuring that every resident has an opportunity to clean their hands before eating. This represents a breakdown in our infection control practices that needs immediate correction.

Based on review of facility policy, interview, and record review, the facility failed to ensure Resident (R)1 and R2 were free from misappropriation of a narcotic medication, for 2 of 2 residents. Findings include: Review of the undated facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment documented, Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the facility policy titled, Controlled Substances with a revision date of 04/17/24, documented, All scheduled controlled medications removed from the storage for the purpose of administering doses to the resident will be entered onto the residents controlled drug receipt/record/disposition form. Additionally, the 8 rights for administering medication; #4. the right time, and Medications are administered no more than one hour before to one hour after the designated medication pass time. Review of R1's Facesheet revealed R1 was admitted to the facility on [DATE], with diagnoses that included but are not limited to: dementia, chronic pain, hypothyroid and atherosclerotic heart disease. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Review of R1's Physician Orders revealed an order for hydrocodone/acetaminophen (narcotic pain medication) 10 milligrams (mg)/325 mgs, give 1 tablet 4 times a day, with a start date on 06/20/23. Review of R1's Medication Administration Record (MAR) dated 11/01/24 - 11/13/24, recorded R1's hydrocodone/acetaminophen is ordered to give at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. Review of R1's Controlled Drug Receipt/Record/Disposition Form for hydrocodone/acetaminophen 10/325 (generic for Norco) revealed on 11/09/24 at 6:00 PM, Licensed Practical Nurse (LPN)1 signed the Norco medication from the narcotic box. There was an additional signature also dated 11/09/24 at 6:00 PM, by Registered Nurse (RN)1, that signed out the medication Norco for R1 from the narcotic box. Review of R2's Facesheet revealed R2 was admitted to the facility on [DATE], with diagnoses that include but are not limited to: unspecified dementia, pain unspecified, Type 2 diabetes mellitus, hypertention and anemia. Review of R2's MDS with an ARD of 09/07/24, revealed R2 had a BIMS score of 14 out of 15, indicating R2 was cognitively intact. Review of R2's Physician Orders revealed an order for hydrocodone/acetaminophen 5mg/325mg, take 1 tablet twice a day for pain with a start date of 02/24/24. Review of R2's MAR dated 11/01/24 - 11/13/24, revealed hydrocodone/acetaminophen is ordered to give at 8:00 AM and 8:00 PM. Review of R2's Controlled Drug Receipt/Record/Disposition Form for hydrocodone/acetaminophen 5/325 (generic for Norco) revealed LPN1 recorded an incorrect date for 11/09/24. LPN1 signed the norco on 11/08/24 at 8:00 AM and 8:00 PM, although the previous date was also 11/08/24, which is consistent with the dates previously recorded in sequence of the dates the norco was ordered for. On 11/09/24 at 9:00 PM the norco was again signed as removed from the narcotic box by LPN2. Review of Drug Enforcement Administration (DEA) form 106, Report of Theft or Loss of Controlled Substances signed on 11/15/24 by the Director of Nurses (DON), to report 2 narcotic medications. Further review of this record revealed it reported 2 hydrocodone/acetaminophen, one a 10/325 mg replaced with a white oblong tablet scored with imprint M367 was replaced with oblong white tablet unscored and imprinted E. Additionally, 5/325 mg tablet replaced with a white oblong tablet scored with imprint M365 was replaced with oblong white tablet unscored and imprinted E. Review of a statement written by Registered Nurse (RN)1 revealed he was the assigned nurse on 11/09/24, 400 hall, from 2:00 PM until 7:00 PM. RN1 reported the narcotic count was correct when he counted the narcotics with LPN1, before she left. RN1 further stated, discovered a basket with pre-pulled medications with residents name in the medication cart. I informed the DON that these medications were prepulled and they were locked up in the DON office as directed. I was unaware that these prepulled medications were narcotics. Review of a statement dated 11/09/24, signed by Licensed Practical Nurse (LPN)2, revealed, When counting the narcotics prior to [RN1] leaving, the count was correct. I pulled all my medications for all residents as ordered, including narcotics. I was unaware of any prepulled medication of any kind. I did notice that the narcotic medication I was scheduled to administer was signed out by [LPN1] with the correct medication times, even though she was not present in the facility at any time during my shift. During an observation and interview on 11/20/2024 at 11:36 AM, R1 was up in a wheelchair and had no complaints of pain and showed no physical signs of pain. During an observation and interview on 11/20/2024 at 11:45 AM , R2 was laying in bed and had no complaints of pain and showed no physical signs of pain. During an interview on 11/20/24 at 2:23 PM, LPN3 stated, I worked with [LPN1] on that date 11/09/24. Around 11 AM -12 PM, I noticed she was standing at the 400 cart. She was kind of swaying back and forth. Her eyes were closed. She appeared to be falling asleep. She looked wild eyed when she was awake with her eyes open. I notified my supervisor and DON. The on-call supervisor was [RN1]. He was on call that day. Somebody asked me, What's wrong with her? I can't remember who that was. Between 12-12:30 PM I notified them (supervisor and DON). It was about 20-30 minutes before they came in. They took [LPN1] privately off to speak to her. She left soon thereafter. She counted off with [RN1]. During an interview on 11/20/24 at 3:14 PM, LPN1 stated, I worked that Saturday 11/09/24 and was scheduled to work 16 hours that day. My DON came in around 2-3 PM. She said someone had reported I was inebriated or something. I clocked out around 3 PM. Pre-pouring meds is normal if you are working that kind of schedule. The DON called a few days later to say she found pre-pulled meds and she also said 2 Norco's were replaced with Excedrin. I don't know where the Excedrin came from. I did pre-pour narcotics that were ordered along with the evening medications. During an interview on 11/20/24 at 3:25 PM, the DON stated, I sent [LPN1] home because of a call I got earlier from the nurse who works on the 500 unit. She reported something was wrong with [LPN1]. [LPN1] was scheduled to work 16 hours and [RN1] took over until 7:00 PM and [LPN2] took the cart after [RN1] left. It was not until Tuesday that I looked at those meds. When he went to do med pass, there was a basket of medications he found in the cart. [RN1] called me between 3:30 PM - 4:00 PM. I left around 2-2:30 PM. When he called me, he only said their were pre-pulled meds, no mention of narcotics. I didn't know there were narcotics at that time. When [RN1] left that day at 7:00 PM, he only signed out [R1's] Norco. He didn't realize [LPN1] had signed out for the med earlier, for the same time. It was [LPN2] who came in afterward to relieve [RN1]. She called me about 8 PM or so to tell me the narcotics she was scheduled to give were already signed out by [LPN1]. When I reviewed the meds, the Nurse Practitioner was with me. She was able to use her drug identifier to identify the medication, that the Norco was not a Norco but an Excedrin. During an interview on 11/20/24 at 5:27 PM, the Administrator stated, The employee was terminated. She pulled pills and narcotics too early. With the Excedrin replacing the narcotic, she was the obvious person, the only one with the narcotic keys.

Based on review of facility policy, record review, and interview, the facility failed to develop a care plan for 2 of 3 residents, Resident (R)1, R2. Specifically, there were no care plan giving staff instructions on providing care to R1 and R2. R1 was sent to the local hospital concerning wounds and R2 developed maggots in a wound. On 3/12/24 at 4:35 PM, the Administrator and Director of Nursing (DON) were notified that the failure to develop a comprehensive care plan for R2 regarding wound care of the left foot constituted IJ at F656. On 03/13/24 at approximately 4:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/04/23. The IJ was related to 42 CFR 483.21 - Comprehensive Resident Centered Care Plan. On 3/13/24 at approximately 4:45 PM, the facility provided an acceptable IJ Removal Plan for F656. On 3/14/24 at 11:00 AM the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F656 at a lower scope and severity of D. Findings include: Review of the facility policy dated 05/05/23 titled Care Plan Process, Person Centered-Care revealed, Policy: The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident . Procedures: 3.develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs . 11. The person-centered care plan includes: A. Date B. Problem C. Resident goals for admission and desired outcomes . E. Interventions, discipline specific services, and frequency . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: second degree burn left foot, Stage 4 Chronic Kidney Disease, unstageable pressure ulcers on the left and right feet that developed into stage 4 pressure ulcers, and a stage 4 pressure ulcer on the left buttock/sacrum area. Further review of the Face Sheet reveled R1 was discharged to the hospital on 03/01/24. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23 revealed R2 had a Brief Interview of Mental Status score of 5 out of 15, indicating R1 was severely cognitively impaired. Further review of the MDS revealed under section M, 1 unstageable and a foot wound (burn), resident had 2 unstageable DTI's at the time the MDS assessment was completed. Review of R1's Physician Orders revealed the following active orders, Air mattress to bed for pressure reduction. Clean area to left buttock with dwc apply santyl cover with calcium alginate and secure with optifoam dressing once daily and prn until resolved. Geo mattress to bed for pressure reduction. Pressure reduction cushion to chair when out of bed. Elevate/Float Heels while in bed. Apply betadine to right heel pad with gauze and wrap with kerlix once daily. Apply skin prep to area to left inner ankle once daily. Apply skin prep to top of left foot once daily for protection. Elevate/Float Heels while in bed. Review of R1's Baseline Care Plan dated 12/06/23 and edited on 12/14/23, revealed the Baseline Care Plan wasn't complete and R1's wounds/ulcers were not addressed. Review of R1's Care Plan dated 12/28/23, revealed, Problem: Pressure Ulcer Risk for Injury r/t abnormalities of mobility. Further review of the care plan revealed, no care plan or interventions for providing care/treatment to any of R1's wounds/ulcers. Review of R1's Progress Note dated 03/01/24 at 5:29 PM, documented, Resident's family in house at bedside states resident's wound has a foul smelling odor, and request resident be sent to ER for further evaluation. Resident sent to [local hospital] per family request. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: amputation of great toe. Review of R2's Admission MDS with an ARD of 07/26/23 revealed R2's BIMS score of 15 out 15 indicating R2 was cognitively intact. Further review of the MDS under section M revealed, 2 unstagable DTI PU upon admission. Review of R2's Physician Orders dated 08/04/23, revealed the following order, Clean surgical site to left great toe with DWC apply non adherent dressing pad with gauze wrap loosely with kerlix and then apply ace wrap once daily and PRN. Clean surgical site to right great toe with DWC apply non adherent dressing cover with bordered gauze daily and PRN. Review of R2's Care Plan revealed no care plan to provide care/services, for R2's amputation. Review of R2's Progress Notes revealed R2 was discharged on [DATE] to the doctor's office and was directly admitted to the hospital. R2 did not return to the facility. Review of R2's Progress Notes dated 08/22/23 at 2:51 PM revealed, Resident return from [local orthorpedic] md states wound care nurse to address both l/r great toe amputation sites needs heels protectors l heel. wound care nurse made aware bilateral heels floated. copy of consultation given to wound nurse. Review of R2's Progress Notes dated 09/11/23 at 10:30 AM revealed, Nurse went in room to do drsg changes. started on left foot when i took the drsg off maggots was on resident wound bed. odor noted vs 97.9 57 128/60 r 18 spoke with [physician] states to get resident to [NAME] ortho asap drsg placed on left foot and bhrc transport took resident to [NAME] ortho . During an interview on 03/12/24 at 12:30 PM, the Minimum Data Set (MDS) Nurse stated, Our system turned over on 06/01/23 when we were bought by a new company. We had to manually input all of our care plans and they hired other nurses to help. They completed them remotely, but we got delayed. There were multiple residents that discharged before we had a change to get to the care plans. I never had a chance to see [R2]. I didn't go back to see who didn't have a care plan because I just haven't had the time. We hired another person here part time, but she quit. During an interview on 03/12/24 at 3:00 PM, the Administrator stated, I knew MDS was still catching up on the care plans. The computers changed last year on June 1, we were taken over by a new company. I didn't realize [R2] was affected by that turnover process and didn't have the care plans in place. During an interview on 03/13/24 at 11:45 AM, MDS Nurse revealed, [R1] had 3 stage 4 pressure ulcers when I completed his Discharge Minimum Data Set (MDS) on 03/01/24. I didn't know he had those wounds. He had a stage 4 on each heel and a stage 4 on his left buttock/sacrum. Two of those he acquired here. I reviewed his care plan and he does not have a care plan addressing any of those pressure ulcers. The MDS Nurse further stated, The wounds were not communicated to me. I went to the Administrator and told her I wasn't getting the information on the wounds. Since then, we now discuss all new wounds and healed wounds in the morning meeting. During an interview on 03/13/24 at 12:20 PM, the Wound Nurse stated, [R1] had 3 stage 4 pressure ulcers, to his sacral area and both heels. When he first admitted , he had a burn to his left foot and a dry area on the back of his left foot. Then when returned after the fall with fracture, he had an unstageable to his left foot. He then acquired new pressure ulcers on the right heel and left buttock that developed into stage 4 pressure ulcers. We had wound care see him and his family knew about the wounds. I do not complete the care plans for wounds, so I don't know why he didn't have care plans on those areas. During an interview on 03/13/24 at 12:32 PM, the Director of Nurses (DON) stated, [R1] should have care plans addressing each of his wounds. I do not see a care plan for them, only a risk for pressure ulcer care plan. We discuss them now every morning in the morning meeting after reviewing all the notes from the previous day or from the weekend, it was hit or miss before, but now it's daily. On 03/13/24 at approximately 4:45 PM, the facility presented a removal plan, which included the following: Resident 1 and Resident 2 identified no longer resides in the facility. A audit was completed to validate comprehensive care plans have been developed and implemented on residents with wounds by the Director of Nursing and Nurse Assessment Coordinator on 3/13/24. Care plans for the identified residents with wounds were updated on 3/13/24 by the Nurse Assessment Coordinator. The Administrator will reeducate the Interdisciplinary Team (IDT) on comprehensive care plan on 3/13/24 to include: Updating or developing comprehensive care plans when the resident the resident's clinical status or change in condition dictates the need. Development of comprehensive care plans no more than 21 days after admission. Any member of the Interdisciplinary Team not receiving this reeducation on 3/13/24 will receive prior to their next scheduled shift. The Director of Nursing will review comprehensive care plans for residents with wounds weekly to validate accuracy and completion. The Director of Nursing will review comprehensive care plans weekly following the Minimum Data Set quarterly assessments to validate completion and accuracy. The Medical Director was notified of the Immediate Jeopardy on 3/13/24. An Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 3/13/24.

Based on review of the facility policy, record review, and interview, the facility failed to ensure wound care was completed on days when Resident (R)2 went out to dialysis, subsequently R2 developed maggots in the wound of her left foot, for 1 of 2 residents reviewed for foot care. On 3/12/24 at 4:35 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to follow physicians orders to ensure wound care was completed on days when Resident (R)2 went out to dialysis, constituted Immediate Jeopardy (IJ) at F687. Furthermore, the Administrator and DON were notified that the failure to develop a comprehensive care plan for R2 regarding wound care of the left foot constituted IJ at F656. On 3/12/24 at approximately 4:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/04/23. The IJ was related to 42 CFR 483.25 - Quality of Care. On 3/13/24 at approximately 11:59 AM, the facility provided an acceptable IJ Removal Plan for F687. On 03/13/24 at 1:00 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F687 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F687 constituting substandard quality of care. Findings include: Review of the facility policy revised on 05/05/23, titled Physician Orders, states, Procedures: 3. Upon admission, the facility has physician orders for the resident's immediate care to include but not limited to: C. Routine Care orders to maintain or improve the resident's functional abilities . Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: amputation of great toe. Review of R2's Care Plan revealed no care plan related to care/treatment of R2's amputation. Review of R2's Wound Note dated 07/20/23, documented, Resident with surgical wound to right great toe from amputation. Resident stated amputation was performed approximately a month ago and she has not f/u with MD who performed operation. Facility will reach out to [physician] for f/u. Sutures are still intact with 10 visible sutures. There is an area that has some seropurulent drainage present with small open area measuring 0.8x0.2cm. Area cleaned with calcium alg. with silver applied to open area. MD and RR aware. Review of R2's Progress Notes dated 09/11/23, revealed, Maggots was on [R2] wound bed, odor noted. Review of R2's Progress Notes dated 09/11/23, revealed R2 was discharged to the doctor's office and was directly admitted to the hospital. R2 did not return to the facility. Review of R2's Physician Order dated 08/04/23, revealed an order to clean surgical site to left great toe with Dermal Wound Care (DWC) apply non adherent dressing pad with gauze, wrap loosely with kerlix and then apply ace wrap once daily and as needed (PRN). Review of R2's Treatment Administration Record (TAR) revealed missing signatures for the following days, 08/09/23, 08/18/23 and 08/30/23, indicating the treatment was not completed as R2 was at dialysis or not available. During an interview on 03/12/24 at 12:13 PM, the Director of Nurses (DON) stated, [signatures on the TAR] indicate that the nurse did not complete the dressing changes for [R2], but she has PRN orders so the nurses should have completed the dressing changes sometime later and would have given a report to the on-coming nurses that the dressings needed to be changed. [R2] received dialysis on Monday,Wednesday and Friday. The DON further stated, [R2] had maggots in her wound. We have never had maggots in a wound before, nor have we since seen maggots. She was sent to the doctor and then went to the hospital. She did not return. During an interview on 03/12/24 at 1:43 PM, Licensed Practical Nurse (LPN)1 stated, The odor was very foul, so I removed the dressing on [R2] left foot to look. I saw little white insects, I thought my eyes were deceiving me. They were falling out of her wound. I went and got my Administrator. She came immediately and said they were maggots, but they were tiny. It scared me, I had never seen them before. We cleaned the wound and called her doctor. [R2] was sent to her orthopedic physician and from there, he admitted her to the hospital. During an interview on 03/12/24 at 12:13 PM, the Administrator confirmed there were maggots in R2's left foot wound. The Administrator stated, [LPN1] came to me early that morning and told me to come see the wound. I saw the maggots in her wound. We cleaned it really well and applied the dressing. [LPN1] called her orthopedic doctor and she was sent out that day. He direct admitted her to the hospital. During an interview on 03/12/24 at 1:57 PM, the Wound Nurse stated, I have never seen maggots in a wound. I was not here that day they found them, I had requested that day off. On 03/12/24 at approximately 7:30 PM, the facility submitted a removal plan, which included the following: License Nurses that were working on 9/11/23 at the time maggots were found, were educated and on how maggots form, and that it takes 5-7 days for them to appear after a fly has lit on would and laid eggs. they were able to visualize what the maggots look like when they first hatch. This education was completed by the administrator. License Nurses staff completed ordered treatments for all other wounds in the facility on this date, September 11, 2023, and there were no other maggots present. Resident identified no longer resides in the facility, and has not since 09/11/23. Residents with wound care orders have the potential to be affected by the alleged deficit practice. An audit of residents with wound care orders will be completed by the Director of Nursing on 3/12/24 validating treatments are completed as ordered. There were no missing treatments identified. Licensed Nurses will be reeducated by the Director of Nursing on 3/12/24 on following physician orders including: - Wound care orders - When a resident is out of the facility and wound care is not completed as ordered, it should be completed upon the residents return - Documentation will reflect explanation to why wound care was not completed at time ordered and when it is completed upon residents return Any licensed nurse not receiving this education by this date will received prior to their next scheduled shift. This will be presented in New Hire orientation. Director of Nursing will validate daily in clinical morning meeting treatment for wound care is completed as ordered. Areas of concern will be addressed upon discovery. Medical Director was notified of this Immediate Jeopardy on 3/12/24. An Ad Hoc QAPI will be held on 3/12/24. AOC 3/12/24

Based on review of the facility policy, record review, and interview, the facility failed to ensure wound care was completed on days when Resident (R)2 went out to dialysis, subsequently R2 developed maggots in the wound of her left foot, for 1 of 2 residents reviewed for foot care. On 3/12/24 at 4:35 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to follow physicians orders to ensure wound care was completed on days when Resident (R)2 went out to dialysis, constituted Immediate Jeopardy (IJ) at F687. Furthermore, the Administrator and DON were notified that the failure to develop a comprehensive care plan for R2 regarding wound care of the left foot constituted IJ at F656. On 3/12/24 at approximately 4:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/04/23. The IJ was related to 42 CFR 483.25 - Quality of Care. On 3/13/24 at approximately 11:59 AM, the facility provided an acceptable IJ Removal Plan for F687. On 03/13/24 at 1:00 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F687 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F687 constituting substandard quality of care. Findings include: Review of the facility policy revised on 05/05/23, titled Physician Orders, states, Procedures: 3. Upon admission, the facility has physician orders for the resident's immediate care to include but not limited to: C. Routine Care orders to maintain or improve the resident's functional abilities . Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: amputation of great toe. Review of R2's Care Plan revealed no care plan related to care/treatment of R2's amputation. Review of R2's Wound Note dated 07/20/23, documented, Resident with surgical wound to right great toe from amputation. Resident stated amputation was performed approximately a month ago and she has not f/u with MD who performed operation. Facility will reach out to [physician] for f/u. Sutures are still intact with 10 visible sutures. There is an area that has some seropurulent drainage present with small open area measuring 0.8x0.2cm. Area cleaned with calcium alg. with silver applied to open area. MD and RR aware. Review of R2's Progress Notes dated 09/11/23, revealed, Maggots was on [R2] wound bed, odor noted. Review of R2's Progress Notes dated 09/11/23, revealed R2 was discharged to the doctor's office and was directly admitted to the hospital. R2 did not return to the facility. Review of R2's Physician Order dated 08/04/23, revealed an order to clean surgical site to left great toe with Dermal Wound Care (DWC) apply non adherent dressing pad with gauze, wrap loosely with kerlix and then apply ace wrap once daily and as needed (PRN). Review of R2's Treatment Administration Record (TAR) revealed missing signatures for the following days, 08/09/23, 08/18/23 and 08/30/23, indicating the treatment was not completed as R2 was at dialysis or not available. During an interview on 03/12/24 at 12:13 PM, the Director of Nurses (DON) stated, [signatures on the TAR] indicate that the nurse did not complete the dressing changes for [R2], but she has PRN orders so the nurses should have completed the dressing changes sometime later and would have given a report to the on-coming nurses that the dressings needed to be changed. [R2] received dialysis on Monday,Wednesday and Friday. The DON further stated, [R2] had maggots in her wound. We have never had maggots in a wound before, nor have we since seen maggots. She was sent to the doctor and then went to the hospital. She did not return. During an interview on 03/12/24 at 1:43 PM, Licensed Practical Nurse (LPN)1 stated, The odor was very foul, so I removed the dressing on [R2] left foot to look. I saw little white insects, I thought my eyes were deceiving me. They were falling out of her wound. I went and got my Administrator. She came immediately and said they were maggots, but they were tiny. It scared me, I had never seen them before. We cleaned the wound and called her doctor. [R2] was sent to her orthopedic physician and from there, he admitted her to the hospital. During an interview on 03/12/24 at 12:13 PM, the Administrator confirmed there were maggots in R2's left foot wound. The Administrator stated, [LPN1] came to me early that morning and told me to come see the wound. I saw the maggots in her wound. We cleaned it really well and applied the dressing. [LPN1] called her orthopedic doctor and she was sent out that day. He direct admitted her to the hospital. During an interview on 03/12/24 at 1:57 PM, the Wound Nurse stated, I have never seen maggots in a wound. I was not here that day they found them, I had requested that day off. On 03/12/24 at approximately 7:30 PM, the facility submitted a removal plan, which included the following: License Nurses that were working on 9/11/23 at the time maggots were found, were educated and on how maggots form, and that it takes 5-7 days for them to appear after a fly has lit on would and laid eggs. they were able to visualize what the maggots look like when they first hatch. This education was completed by the administrator. License Nurses staff completed ordered treatments for all other wounds in the facility on this date, September 11, 2023, and there were no other maggots present. Resident identified no longer resides in the facility, and has not since 09/11/23. Residents with wound care orders have the potential to be affected by the alleged deficit practice. An audit of residents with wound care orders will be completed by the Director of Nursing on 3/12/24 validating treatments are completed as ordered. There were no missing treatments identified. Licensed Nurses will be reeducated by the Director of Nursing on 3/12/24 on following physician orders including: - Wound care orders - When a resident is out of the facility and wound care is not completed as ordered, it should be completed upon the residents return - Documentation will reflect explanation to why wound care was not completed at time ordered and when it is completed upon residents return Any licensed nurse not receiving this education by this date will received prior to their next scheduled shift. This will be presented in New Hire orientation. Director of Nursing will validate daily in clinical morning meeting treatment for wound care is completed as ordered. Areas of concern will be addressed upon discovery. Medical Director was notified of this Immediate Jeopardy on 3/12/24. An Ad Hoc QAPI will be held on 3/12/24. AOC 3/12/24

Based on review of the facility policy, record review, and interviews, the facility failed to protect 1 Resident (R)1 out of 1 resident reviewed from verbal abuse by Certified Nursing Assistant (CNA)1. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Mistreatment undated indicated: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. R1 was admitted to the facility on [DATE] with diagnoses including but not limited to, dementia, depression, anxiety, heart failure and chronic obstructive pulmonary disease. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/23 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating R1 is cognitively intact. An observation of R1 on 01/25/23 at 1:52 PM revealed her sitting in her wheelchair, watching TV in her room. In an interview on 01/25/24 at 1:52 PM, R1 revealed she had asked CNA1 a question and she stated the CNA replied, What the F___you doing tending to her business and to stay the F___ out of her business. In an interview on 01/25/24 at 12:38 PM, Social Services Director revealed she was sitting in the office, and Human Resources came in. She stated she looked like she was upset and told her she heard CNA1 cursing at a resident. I told her to report it to the Unit Manager, and she left and made a report. After HR left, I went to check on R1 and R1 stated she was fine, but her feelings were hurt from what CNA1 said to her. In an interview on 01/25/24 at 12:46 PM, HR revealed she was coming from 200 hall to the time clock. She observed R1 at door and stated she needed help, and called out to CNA1. When CNA1 approached R1, CNA1 started cursing, and went to another room and didn't proceed to help R1. She stated she went to Social Services to report the incident. In an interview on 01/25/24 at 2:11 PM, CNA1 revealed she was working a 12-hour shift and had been switched from another hall. She stated she was in the middle of feeding another resident and she told R1 she would take her out to smoke when she had the time. She stated while she was sitting at the desk filling out notes, R1 was screaming at her. She stated, she only said to R1 Can you please mind your business? She stated she did not say what they said, she said. She stated she said something to the other staff member, but she didn't curse at R1. She stated she was terminated after her shift. In an interview on 01/25/24 at 2:31 PM, the Administrator revealed her expectations of staff when dealing with stressful situations is to walk away and ask for assistance. She stated HR reported accordingly and because of the profanity spoken by staff in the presence of other staff and R1, the CNA1 was terminated and the abuse was substantiated.

Based on review of facility policies and interviews, the facility failed to ensure a resident's medication was properly accounted for during each shift. Failure to provide accurate count of medication as it is properly stored in a narcotic box resulted in the medication to not be located in the facility. Specifically, not adhering to the company's policy increased the opportunity for medication diversion. Findings include: Review of the facility policy titled, Controlled Substances, Section 2.5 Receipt of Controlled Substances with a complete revision date of 04/01/22 states, The facility shall ensure the security of Controlled Substances and follow State and Federal record-keeping requirements for accountability of controlled substances. Section 2.6 Storage and Reconciliation of Controlled Substances states, The facility will systems in place to ensure the safe and secure storage of Controlled Substance Medications. 4. A scheduled reconciliation of controlled substance inventory should be completed at every nursing shift change and documented as required by state regulations. A. At the end of every shift the nurse/authorized staff member reporting on duty and the nurse/authorized staff member reporting off duty meet at the designated medication cart or storage area to count all Controlled Substance drugs. An interview on 08/29/23 at 12:20 PM with the Director of Nursing (DON) revealed that she received a call from the facility that a card of narcotics was missing, and the Administrator notified her that they were starting an investigation. The medication was revealed to have gone missing between the dates of 07/20/23 and 07/23/23. She revealed the resident was out of the facility for greater than ten days, at the hospital, and he was then discharged . His medications should have then been removed from the cart. When the resident returned, an electronic prescription was sent to be filled but the pharmacy stated they had already filled the prescription. She explains they attempted to determine who signed for the medication, but the medication sheet was missing from the narcotic book as well. The DON stated, The sheet was gone, and the pills were gone. They completed an investigation and narrowed it down to three nurses, but they were not able to determine who could have potentially misappropriated the medication. An interview on 08/29/23 at 1:04 PM with the Administrator revealed, that she doesn't like to see medication missing and that was the first time a whole sheet had been missing. She concluded that one of the staff members removed it as if they were taking it to turn in, but didn't. She stated she doesn't expect to have any medication diversion, there were three nurses and there was no way to narrow down from those three and there could have been no one else. The Administrator revealed that her expectations are to not tolerate drug diversion and as soon as a resident is discharged , all narcotics should be turned into the DON or the Administrator. During a followup interview on 08/29/23 at 1:28 PM, the Administrator further revealed that the medications should have been turned in by July 17, 2023, by the nursing staff, according to their policy. This would have stopped the opportunities from staff and prevention of diversion of narcotics. An interview on 08/29/23 at 1:11 PM with Licensed Practical Nurse (LPN)1 revealed she worked the weekend shift and Friday and Saturday she didn't notice any medication missing. On that Sunday morning, she and the night shift nurse were counting medications and realized they didn't put the cards back in the right way and that is what prompted her to check the medications with the other nurse. They were using the narcotic log to double check the medications and don't recall calling out Resident (R)1's name. She received a call from a nurse that said that R1's medications were missing, and she stated she knew for fact on Sunday it was there, but she does not remember for Friday or Saturday. LPN1 stated that basic protocol is to sign off with the oncoming nurse at the end of each shift. She included there wasn't a protocol that was used, they only used the cards that were in the box and used the sign-off sheets. LPN1 stated she worked the day shift on July 21-23, 2023. An interview on 08/29/23 at 2:02 PM with LPN2 revealed that she witnessed the medication in the card on Thursday, during her entire shift. She also counted off to the next shift nurse, but she doesn't remember who that nurse was. She was aware that R1 was not in the building and was at the hospital. She stated she assumed that when medication for a discharged resident is on their cart that it is given to the DON, but she works as needed and doesn't get many discharges. She also was included in in-services after the incident transpired. An interview on 08/29/23 at 2:15 PM with the Registered Nurse (RN)1 revealed if narcotics need to be discarded then the protocol is to wait until the DON is there and you provide them with the medication and sheets. On the weekends they leave the medication on the cart and continue to count as if the resident is still here. Each nurse counts the medication on the cart and doesn't leave the cart until the next nurse receives it. She included that she is aware that R1 was not there, but it was her understanding that he was returning. If nursing staff knows that a resident has been discharged , or no longer coming back then they would give the medication to the DON or the Administrator. An interview on 08/29/23 at 4:00 PM with LPN3 revealed that if there are medications for a discharged resident, she would leave them on the cart for the DON to dispose of them, being that she works night shift. She included that once she relieves another nurse, she is then responsible for everything that is on the cart. She was also aware the R1 was not currently in the facility. She explained that she is not familiar with discharges and during her shift, she counted what was on the cart and was not informed to remove any medications.

Based on observation, interview, and facility document and policy review, the facility failed to follow the planned menu and, specifically, failed to serve foods to residents in the amount indicated on the menu for 2 of 2 meals observed. Findings included: Review of a facility policy titled, Menus, with a revision date of 10/2017, revealed, Menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. The policy also indicated, 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences) and 8. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. Review of a facility policy titled, Kitchen Weights and Measures, with a revision date of 04/2007, revealed, Food Services staff will be trained in proper use of cooking and serving measurements to maintain portion control. The policy also indicated, 1. Cooks and Food Services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes, 3. Staff will be trained in size conversion of food cans to improve accurate measurements, 6. Staff will be trained in appropriate measurement and type of serving utensil to use for each food, and 7. The Food Service Supervisor will ensure cooks prepare the appropriate amount of food for the numbers of servings required. Review of a Cycle: [Facility Name] FW17-18 2nd Week - Day Number: 9 revealed menu items for breakfast, lunch, and dinner and various texture preparations, including regular, mechanical soft chopped meat, and mechanical soft ground meat. The menu indicated, for lunch, a diet of eight cut chicken, 1/2 cup of parsley buttered rice, 2 fluid ounces (oz.) of poultry gravy, 1/2 cup of seasoned green beans, one dinner roll, one (each) margarine, 1/2 cup of scalloped peaches, 8 oz. of milk, 8 oz. of beverage of choice, and one each of salt/pepper/sugar. The day number 9 menu indicated a puree diet of pureed chicken, 1/2 cup of mashed potatoes, 2 ounces (oz.) of poultry gravy, 1/2 cup of lima beans, 1/4 cup of dinner roll, one margarine, 1/2 cup of scalloped peaches, 8 oz. of milk, 8 fluid oz. of beverage of choice, and one (each) salt/pepper/sugar. Review of a Cycle: [Facility Name] FW17-18 2nd Week - Day Number: 10, revealed a regular lunch diet of 2 oz. of liver and onions, 1/2 cup of whipped potatoes, 1/2 cup of green peas, one (each) dinner roll, 1 (each) margarine, 1/2 cup of cherry gelatin parfait, 8 oz. choice of milk, 8 fluid oz. of beverage of choice, and one (each) salt and pepper. A review of a corresponding 2nd week cycle sheet revealed a mechanical soft chopped meat and mechanical soft ground meat diet of 2 oz. of liver and onions, 1/2 cup of whipped potatoes, 1/2 cup of green peas, one (each) dinner roll, one (each) margarine, 1/2 cup of cherry gelatin parfait, 8 fluid oz. of 2% milk, 8 fluid oz. of a beverage of choice, and one (each) salt/pepper/sugar. The sheet also revealed a puree diet called for 4 fluid oz. of pureed beef liver, 1/2 cup of whipped potatoes, 1/2 cup green peas, 1/4 cup pureed dinner roll, one (each) margarine, one ice cream, 8 fluid oz. of 2% milk, 8 fluid oz. of a beverage of choice, and one (each) salt/pepper/sugar. During a concurrent observation and interview on 05/08/2023 from 12:10 PM to 12:51 PM, Dietary Cook (DC) #5 was observed plating lunch menu items for the resident lunch meal trays from a steam table. DC5 was observed plating regular diets of chicken, parsley rice using a #8 scoop (4 oz.), gravy using a 2 oz. ladle, green beans using a 3 oz. ladle, and a dinner roll. DC5 was observed plating mechanical soft chopped meat diets of chicken using a 3 oz. ladle, parsley rice using a #8 scoop (4 oz.), gravy using a 2 oz. ladle, green beans using a 3 oz. ladle, and a dinner roll. DC5 was observed plating pureed diets of pureed chicken using a 3 oz. ladle, mashed potatoes using a #8 scoop (4 oz.), gravy using a 2 oz. ladle, lima beans using a 3 oz. ladle, and no pureed dinner roll. DC5, while standing on the serving line plating the resident trays, stated the above serving sizes were used for the lunch meal service and that no pureed bread was made. During a concurrent observation and interview on 05/09/2023 from 12:25 PM to 12:53 PM, DC6 was observed plating regular lunch menu items of 2 oz. of liver and onions, whipped potatoes using a #8 scoop, green beans using a 4 oz. ladle, and one dinner roll. DC6 was observed plating mechanical soft chopped meat and mechanical soft ground meat diets of 2 oz. of liver and onions, 1/2 cup of whipped potatoes, green peas using a 3 oz. ladle, and one dinner roll. DC6 was observed plating pureed diets of 2 oz. of liver and onions, 1/2 cup of whipped potatoes, green peas using a 3 oz. ladle, and dinner roll using 2 oz. ladle. DC6 identified the serving sizes listed during the plating of the trays. During an interview on 05/10/2023 at 8:35 AM, DC6 stated she was not aware regular meal trays were served green beans on 05/08/2023 and 05/09/2023. She stated she thought she used the correct portion size for the vegetable but after checking the menu, she realized she used a 3 oz. ladle instead of a 4 oz. ladle. She stated she had been trained to look at the menu and serving sizes indicated on the menu. She stated she expected the menu and serving sizes to be followed. During an interview on 05/10/2023 at 8:43 AM, DC5 stated the facility only had the smaller serving utensils so that was what she used. DC5 acknowledged certain residents did not get the correct portion of pureed chicken, chopped chicken, regular green beans, and pureed lima beans. She indicated puree diets received no pureed bread. She acknowledged puree diets did not get bread on Monday because it was not made. She stated she had been trained to look at menu and serving sizes. She stated she was expected to follow the menu and serving sizes. During an interview on 05/10/2023 at 8:56 AM, the Certified Dietary Manager (CDM) stated that, for the lunch meal on Monday, DC5 did not make any pureed bread. He indicated the regular diets during the lunch meal on Tuesday were supposed to get green peas, but they got green beans again by mistake. He stated he was not aware the correct serving sizes were not used for the lunch meal on Monday and Tuesday because he was in and out of the kitchen. He stated he expected the menu and serving sizes to be followed to meet the nutritional adequacy of all residents. He noted he expected residents to be served all menu items indicated on the menu. He stated he expected the menu to be varied, and for residents to not receive the same food two days in a row. He indicated he performed spot checks on the serving line periodically but did not have those spot checks documented. During an interview on 05/10/2023 at 3:37 PM, the Director of Nursing (DON) revealed she was not responsible for the kitchen or what was served. She indicated the Registered Dietician (RD) visited and audited the menu. She stated that residents on puree diets should be served the same or comparable items according to the planned menu. She stated she expected the menu and serving sizes to be followed, and residents should be provided with a variety of different meats, fruits, and vegetables in accordance with the menu. During an interview on 05/10/2023 at 4:32 PM, the Administrator stated menus should be followed, including serving/portion sizes. She stated the potential negative outcomes of residents not receiving what was indicated on the menu were weight loss and skin breakdown. She stated the RD visited weekly and monitored the line monthly. She stated the same menu items should not be served two days in a row. She stated she expected residents on a puree diet to receive the same or comparable food items as other diets as indicated on the menu. During an interview on 05/11/2023 at 8:04 AM, the Registered Dietician stated he visited the facility weekly and monitored dietary staff on the serving line. He stated he expected the menus, including serving sizes, to be followed. He noted he expected residents on puree diets to be served the same or comparable items and should be served a variety of food items and not the same menu items back-to-back.

Based on observations, interviews, facility document review, and facility policy review, the facility failed to repair peeling paint and an unattached vanity sink or clean substances from doors and door frames for 3 (Rooms 405, 704 and 718) of 23 rooms on 2 of 7 halls reviewed for the physical environment. The facility also failed to repair a couch containing a hole and missing fabric in 1 (700 Hall) of 1 halls containing a common area with common furniture. Findings included: Review of a facility policy titled, Quality of Life - Homelike Environment, revised 05/2017, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible and 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. 1. An observation on 05/08/2023 at 9:51 AM revealed the wall on the left side of room [ROOM NUMBER] had peeling paint, stained brown and tan streaks, and tan and brown dried substances. The entry door frame to room [ROOM NUMBER] had peeling paint and brown and black dried sticky substances. Approximately three feet from the bottom of room [ROOM NUMBER]'s entry door frame were thick layers of peeling paint and sharp and protruding pieces of paint sticking out of the frame. There were brown and tan sticky and dried substances around the doorknob extending to approximately one foot above the doorknob. An observation on 05/08/2023 at 10:33 AM revealed the day room located on the 700 Hall contained a green couch with peeling and missing fabric on the right arm and left arms. The green couch contained a hole in the front of the left arm about two inches long. An observation on 05/10/2023 at 10:07 AM revealed the environmental concerns found in room [ROOM NUMBER] remained. An observation on 05/10/2023 at 10:17 AM revealed the entry door to room [ROOM NUMBER] had brown and tan stains and dried substances. The doorframe, approximately 3.5 feet in length from the bottom half of the door frame, had peeling paint that was jagged and protruding. During an interview on 05/10/2023 at 10:54 AM, Housekeeping Employee (HK)10 stated the resident rooms on the 700 Hall were cleaned at least one time a day, with some rooms requiring two cleanings a day. She stated her job responsibilities included wiping the bed, dresser, mirror, window, blinds, and pictures in a room, as well as sweeping and mopping the floors. She stated she did not normally wipe down the resident entry doors daily. She stated she did not notice the dirty doors or dirty door frames in room [ROOM NUMBER]. HK #10 stated she expected the building to be clean. She said wiping dirty substances that were removable with a cloth should be done daily but she acknowledged they were not done for either room [ROOM NUMBER] or room [ROOM NUMBER]. She stated she was not required to document the rooms she cleaned daily. During an interview on 05/10/2023 at 11:07 AM, HK10 stated she simply did not notice the dirty doors, dirty door frames, dirt above the doorknob, or dirt on the wall by the bed in room [ROOM NUMBER]. She acknowledged the door, door frames, and walls were dirty and needed cleaning. During a concurrent observation and interview on 05/10/2023 at 12:32 PM, the Environmental Services Director (ESD) stated he did not have cleaning logs for the rooms on the 700 Hall to show where cleaning was completed except for the current week's rooms. He acknowledged nothing was documented on a Quality Housekeeping Inspection sheet except the date and room number. He stated he once kept a daily cleaning log but had stopped because he had been pulled to correct issues in the laundry. He stated he was responsible for completing the housekeeping inspection forms but that was not being done for the last couple of months until 05/10/2023. He stated he expected the housekeepers to check each room daily and clean the bed, bed boards, mattresses, dressers, pictures, walls, doors, doorknobs, items in the room, and door frames daily. He indicated he made rounds on the 700 Hall about three times a day and checked the rooms again before the housekeepers left for the day to identify cleaning concerns. The ESD then went to room [ROOM NUMBER] and room [ROOM NUMBER] and acknowledged the rooms needed cleaning and repair. The ESD stated he only noticed the dirty doors and door frames when HK #10 mentioned it today. He indicated his focus had been on the laundry facilities for the prior two months. He indicated he was aware the green couch was peeling and had holes, noting the Administrator told him she was going to replace it with another couch. He stated he expected a safe, clean, and sanitary environment. During an interview on 05/10/2023 at 1:13 PM, the Director of Maintenance (DMT) stated he had been employed by the facility for four months. He indicated the door frames to room [ROOM NUMBER] and room [ROOM NUMBER] needed to be sanded down and repainted. He stated there were layers of unsightly paint on the door frames, and the surface of the door frames for room [ROOM NUMBER] and room [ROOM NUMBER] were rough. He indicated he had not noticed the doorframes being rough because he had been so busy with other tasks and did not normally look that low on the door frames. He indicated and acknowledged that room [ROOM NUMBER] had paint that was peeling by the bed and had wipeable substances that needed to be cleaned. He acknowledged the doors and door frames for room [ROOM NUMBER] and room [ROOM NUMBER] were dirty. He stated he expected the facility to be maintained in a safe, sanitary, and orderly manner, but it was not. During an interview on 05/10/2023 at 3:46 PM, the Director of Nursing (DON) indicated that when something was not working or was in disrepair, staff were required to write the concern in the maintenance log, and the DMT was required to check the log daily and fix the concern, or make plans to fix the issue. She indicated the DMT was responsible for maintaining the building and had been employed by the facility for a couple of months. She stated the housekeeping staff were responsible for cleaning resident rooms daily. She stated certain rooms were scheduled to be deep cleaned daily as well. She indicated she made only clinical rounds daily, and the ESD was responsible for the cleanliness of the facility. She stated she believed the couch with peeling fabric and a hole was not homelike and was aware of the couch's condition. She stated the doorframes should be smooth, with no peeling or dirty substances. She stated she expected the environment to be clean, safe, and homelike. During an interview on 05/10/2023 at 4:40 PM, the Administrator stated she made daily walking rounds. She indicated the DMT was responsible for maintaining the building, and the ESD was responsible for the environment. She stated the ESD had been in the laundry area more as of late to fix issues. She stated the facility had maintenance logbooks at each nurses' station, and they were checked daily by the DMT. She noted she expected the DMT to check daily the maintenance logbooks and devise a plan to fix documented issues. She indicated she got rid of one couch on the 700 Hall and wanted to purchase another one, but the facility had no funds for that. She stated she expected the building to be safe, clean, and homelike. 31565 2. On 05/08/2023 at 2:15 PM, an observation of room [ROOM NUMBER] revealed the sink vanity was pulled away from the wall approximately one inch. The sink top was not secured to the vanity. During an interview on 05/10/2023 at 11:08 AM, Certified Nursing Assistant (CNA)1 said she was aware on 05/08/2023 that the vanity was pulled away from the wall in room [ROOM NUMBER]. She said she took the Director of Maintenance (DMT) to the room to show him the issue. During an interview on 05/10/2023 at 11:15 AM, the DMT said there were no pending work orders for the vanity. The DMT noted the work order book prior to 04/29/2023 could not be located. During a follow-up interview on 05/10/2023 at 11:24 AM, the DMT said he was told about the vanity and stated, I looked at it this past week and it was secure. I must have gone to the wrong room. The DMT said he remembered seeing a work order to repair the vanity. During an observation of the vanity, the DMT acknowledged the sink top was not secured to the vanity, or the wall and the vanity base would normally be secured to the wall with brackets, but it was not. During an interview on 05/10/2023 at 11:31 AM, CNA2 said she became aware the vanity in room [ROOM NUMBER] was not attached to the wall two to three weeks ago. She said she told the DMT, took him to the room to show him, and put a work order in the work order book. CNA #2 said the last time she was in room [ROOM NUMBER] was on 05/08/2023, and the vanity was still pulled away from the wall. During an interview on 05/10/2023 at 3:45 PM, the DON stated if any staff noticed anything in disrepair, they completed a work order that was located at each nurse's station. The DON stated, Maintenance checks the work order book daily. He evaluates it [and] makes a plan to fix it. The DON said she expected staff to complete the written work order for anything that needed repair and would expect the maintenance staff to complete the repairs. During an interview on 05/10/2023 at 4:49 PM, the Administrator said if staff saw any items in disrepair, it would be reported to the DMT. Per the Administrator, this report could be verbal or written in a work order book. The Administrator said she would expect that reported issues would be fixed. The Administrator also said the DMT was responsible for inspecting three resident rooms per week for any repair needs but had been busy dealing with other maintenance repairs and may not be getting that done. The Administrator stated there was no specific policy regarding maintenance repairs.

Based on interviews, facility policy review, and facility document review,the facility failed to document and ensure corrective action related to grievances was communicated to the Resident Council. This had the potential to affect all residents. Findings include: A review of the facility's policy titled, Grievances/Complaints, Recording and Investigating, with a revised date of April 2017, indicated that All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The policy further indicated that The Grievance Officer will record and maintain all grievances and complaints on the [Resident Grievance Complaint Log]. Furthermore, the policy indicated that information entered on the Resident Grievance Complaint Log included, The date the resident, or interested party, was informed of the findings; and the disposition of the grievance. A review of Resident Council Minutes from 12/07/2022 through 05/23/2023 indicated on 01/04/2023 and 02/01/2023, under the heading of old business, that CNA's still not introducing selves at beginning of shift. On 05/03/2023, new business included clothing getting mixed up in other people's closets and staff not introducing themselves at the beginning of shifts. There was no indication in the minutes of how or when grievances were resolved. A review of the Grievance/Complaint Log from 10/06/2022 through 02/13/2023 indicated two events related to personal possessions, dated 10/06/2022 and 01/29/2023. An interview was held with Resident (R)12 on 05/08/2023 at 1:27 PM, and the resident reported clothing, including pants and shirts, had been lost. The resident stated the lost clothing was reported at the Resident Council meeting. An interview was held with Certified Nursing Assistant (CNA)9 on 05/10/2023 at 10:56 AM. The CNA stated there was a huge problem with clothes coming back from the laundry and being placed in the wrong closet. She stated she had gone to look for a resident's clothing and would be unable to find clothing in the residents' closets. The CNA stated when a resident reported lost clothing, she reported it to the nurse and then would go to the laundry and look for the clothing. During a group meeting on 05/10/2023 at 2:00 PM, attending residents included Resident #40, who was the Resident Council president, and Residents #153, #47, #24, and #154. During the meeting, Resident #47 and Resident #153 stated if a grievance was not resolved, they were not told by the facility why the grievance was not resolved. Resident #40 stated staff still would not introduce themselves but added they gave their names after they were asked. Resident #40 stated the resident had vision problems and introductions were important. Resident #40 stated staff continued to wait for residents to ask their names, and Resident #154 stated they read the staff name from the name tag. During the meeting, Resident #24 and Resident #40 stated new clothes were always getting lost. Resident #24 stated the last time they remembered reporting lost clothing was four to five months ago, and nothing more had had been heard about the lost clothing. The residents agreed no one from administration had been back to the Resident Council meeting to inform the group of a plan to decrease missing clothing or plans to resolve the issue of staff not introducing themselves. Resident #40 stated that new issues would be discussed almost monthly, but there were no resolutions to the issues. Resident #24 added the Activity Director (AD) would invite the Administrator to the meeting, and the Administrator would talk about what was going to happen, but it seemed the Administrator could not get the rest of the staff to do what was needed to resolve the issues. The Activity Director (AD) was interviewed on 05/10/2023 at 2:56 PM and stated whether the grievance was a personal grievance or a group grievance, a form was completed and given to the Director of Nursing (DON) or the department that was responsible for the resident's complaint. The AD stated there should be an entry in the grievance log for everything the Resident Council had concerns with. The AD stated that once she gave the grievances to the DON or the related department manager, she received nothing back to present to the group. The AD stated some department managers spoke to the residents during the meeting, and some did not. The AD stated staff not introducing themselves had come up as an issue more than once, and she had not received any plan or resolution from the DON. She acknowledged missing clothing was an issue, but she had not received a plan or resolution for that, either. During an interview on 05/10/2023 at 4:13 PM, the Environmental Services Director (ESD) stated he received concerns about missing clothing from individual residents and from the Resident Council. The last concern he had received regarding lost clothing was two days ago, from Resident #40. The ESD stated staff searched for the missing clothing, and the clothing was found and placed in the resident's closet. The ESD stated a grievance form was filled out by whoever received the concern, and then the grievance form was sent to him. The ESD stated he hung the grievance form in the laundry, so all laundry staff knew what clothing was missing and looked for the clothing. The ESD stated once the clothing was found, he threw the grievance away. He stated he had received a grievance from the Resident Council about missing clothing and clothing in other people's closets. He stated he did go back to the Resident Council and spoke as a group about his plans to prevent the clothing from being placed in another closet or lost. The ESD stated he had not kept a copy of the plan presented to the Resident Council members, but the plan was to make sure residents' names were on the clothing and to hold on to the clothing until the owner was found. The ESD stated he had in-serviced laundry staff on missing/misplaced clothing since receiving the grievance from the Resident Council and presented a sign-in sheet, dated 03/15/2023. The ESD stated the in-service focused on sanitation of hands, infection control, and missing clothing/wrong spot for clothing. The ESD stated he had not given any written resolution to the residents or the Resident Council members for the missing and/or misplaced clothing. An interview was held with the DON on 05/11/2023 at 9:23 AM. The DON stated when concerns were received from the Resident Council, the concerns were communicated to the specific department. The DON stated the concerns were usually communicated verbally. The DON stated if the grievance involved a specific resident, the concern was addressed individually but was not placed on a grievance form. The DON added the plan to fix the problem was also communicated verbally. She stated there were not normally too many Resident Council complaints and added if there were a group complaint, the issue was fixed and that was it. The DON stated she was aware the Resident Council had an issue about staff not introducing themselves and the Resident Council wanting introductions. She stated she had not gone back to the Resident Council to explain the plan to fix the issue. The DON reviewed the regulation about how to handle grievances, which included written decisions about the plan to correct the grievance and stated she had not given the Resident Council a written conclusion or plan of correction. She stated she was unaware grievances had a specific way they had to be resolved. The DON stated she included the need of introducing self in the monthly in-services held and had observed shift change and then would ask alert and oriented residents if staff introduced themselves. She stated some residents would say yes, the staff had introduced themselves. The Administrator was interviewed on 05/11/2023 at 9:52 AM. The Administrator stated she kept the grievance book and followed up to make sure grievances were resolved. She said she was responsible for mailing the decision to the family and/or resident. The Administrator said the AD wrote up the concerns from the Resident Council on a grievance form and gave those grievances to the appropriate department manager. The Administrator said if a grievance occurred three times in six months, as the staff introduction had been, then that grievance needed to be addressed. The Administrator stated she expected the grievance process to be the same for the Resident Council as it was for individuals, which including a written decision.

Based on observations, interviews, and facility document and policy review, the facility failed to ensure privacy curtains were sufficient in length to provide visual privacy in 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 23 sampled rooms. Findings include: Facility policy titled, Resident Rights, with a revised date of February 2021, indicated, 1. Federal and State laws guarantee certain basic rights to all residents of the facility. The policy also indicated the rights included, t. privacy and confidentiality. During an observation on 05/08/2023 at 10:23 AM, the curtain in room [ROOM NUMBER] that separated the A bed from the B bed was observed to be approximately 18 inches too short to reach from the wall to the curtain that went across the foot of both beds. This made it impossible to provide visual privacy between the A and B beds. Residents were observed in both beds. During an observation on 05/08/2023 at 11:06 AM, the curtain in room [ROOM NUMBER] that separated the A bed from the B bed was observed to be approximately 18 inches too short to reach from the wall to the curtain that went across the foot of both beds. This made it impossible to provide visual privacy between the A and B beds. Residents were currently assigned to both beds. On 05/09/2023 at 12:12 PM, an interview was completed with Certified Nursing Assistant (CNA) #1. CNA #1 said curtains were pulled to completely enclose residents to provide privacy when care was being provided. If the curtain did not reach far enough to provide privacy, she would report it to the Environmental Services Director (ESD) or the Director of Maintenance (DMT). CNA #1 acknowledged the gap in the curtains in room [ROOM NUMBER] and room [ROOM NUMBER]. She said she noticed the gap in room [ROOM NUMBER] just today and that she had not had a chance to report it yet. CNA #1 said she was not aware of the gap in the curtain of room [ROOM NUMBER] prior to surveyor notification. An interview was completed with the Environmental Services Director (ESD) on 05/09/2023 at 12:28 PM, the ESD said he took privacy curtains down when they needed cleaned or were in disrepair and then hung cleaned or new privacy curtains. The ESD acknowledged the privacy curtains in room [ROOM NUMBER] and room [ROOM NUMBER] were not long enough to provide visual privacy. The ESD noted there were not enough hooks in the curtain tracks for every grommet in the curtains, so he folded the curtain so two grommets were on one hook. This caused an overall shortening of the curtain. ESD said he had reported the need for more curtain hooks to the DMT verbally, and there was a work order book where maintenance issues were relayed to maintenance staff and it may have been written there within the last month. The curtain in room [ROOM NUMBER] was noted to have four hooks with double curtain grommets attached. On 05/09/2023 at 12:43 PM, an interview was completed with the DMT. The DMT said staff wrote maintenance requests in a work order book. He reviewed the work order book each morning and prioritized any needed repairs. The DMT said there were no pending work orders related to privacy curtains. He acknowledged the privacy curtains in room [ROOM NUMBER] and room [ROOM NUMBER] were not long enough to ensure visual privacy. The DMT said he was not aware of any issues with the curtains in room [ROOM NUMBER] and room [ROOM NUMBER] prior to surveyor notification. The DMT did acknowledge the doubling of grommets on existing hooks and said he had extra hooks to install to allow the curtains to be spread out. The DMT said he performed a routine inspection of three resident rooms per week, looking for items that needed repair. He would fill out a checklist, noting any issues found. He said curtains were looked at, but he did not extend them to see if they provided privacy. An interview was completed with the Administrator (ADM) on 05/09/2023 at 12:52 PM. The ADM said privacy curtains had been replaced in a portion of the building, and curtains for the rooms on the 400 Hall were going to be ordered soon. The ADM said she was not aware that the curtains in room [ROOM NUMBER] and room [ROOM NUMBER] were not long enough to provide visual privacy. A follow-up interview was completed with the DMT on 05/10/2023 at 8:46 AM. The DMT had been requested to provide room inspection documentation for March 2023 through May 2023. The DMT provided the Maintenance Inspection Checklist Resident Rooms for March and April 2023. The forms contained a section titled Cubicle Curtains and had a single line drawn through it. Three rooms were identified as being inspected for those two months. There was no form provided for May 2023. The DMT acknowledged the rooms documented on the forms were the only rooms that had been inspected in March and April 2023. An interview was completed with the Director of Nurses (DON) on 05/10/2023 at 3:45 PM. The DON stated if any staff noticed anything in disrepair, they completed a work order that was located at each nurses' station. The DON stated, Maintenance checks the work order book daily. He evaluates it [and] makes a plan to fix it. The DON said she expected staff to complete the written work order, and issues with privacy curtains would be included in the things that would get recorded on a work order. A follow-up interview was completed with the ADM on 05/10/2023 at 4:49 PM. The ADM said if staff saw any items in disrepair, it should be reported to the DMT. This report could be verbal or written in a work order book. The ADM said she would expect reported issues would be fixed. The ADM said the DMT was responsible for inspecting three resident rooms per week for any repair needs but had been busy dealing with other maintenance repairs and may not be getting that done.

Based on observations, interviews, record review, and facility policy review, the facility failed to identify a mattress bolster as a physical restraint for 1 (Resident (R)52) of 2 residents reviewed. Findings included: The facility policy titled, Use of Restraints, with a revision date of April 2017, noted, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. A Face Sheet dated 05/10/23 indicated the facility admitted R52 on 06/14/2017 with diagnoses including cerebral infarction (stroke), gastrostomy tube, and schizophrenia. Review of R52's Comprehensive Care Plan(s) dated 09/17/2020 revealed a care plan goal indicating Will minimize the risk of fall related injury. The comprehensive care plan was updated on 06/19/2022 to add Bolsters [a long, narrow, tubular pillow] to bed to aid in maintaining boundaries. Review of a Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/03/2023, indicated R52 had no restraints in use. Per the MDS, R52 required extensive assistance of one person for bed mobility and extensive assistance of two staff for transferring. Review of a Physical Therapy Discharge Summary, dated 06/05/2019, noted R52 met the goal of reposition self in bed with stand-by assistance. During an observation on 05/08/2023 at 9:44 AM, R52 had bolsters down each side of the bed. The bolsters were approximately 12 inches wide and 30 inches long each. There was approximately 20 inches of space between the bolsters for R52. During an interview on 05/10/2023 at 10:29 AM, Certified Nursing Assistant (CNA)1 stated she was familiar with R52. CNA #1 stated, [R52] can stand and pivot. We have the pads [bolsters] on the bed because sometimes [R52] is being aggressive and trying to get out of bed. CNA #1 said R52 could throw their legs off the side of the bed and slide off onto the floor. She said R52 could use the side rail to turn. CNA #1 said the head of the resident's bed was kept elevated, which made it easier for R52 to sit up and get their legs off the side of the bed. CNA #1 said when the bolsters were not in place, she saw R52 sit up on the side of the bed and put their feet on the floor. CNA #1 said that had not happened since the bolsters were put in place. During an interview on 05/10/2023 at 3:05 PM, CNA #7 said she was familiar with R52. She stated R52 could get their leg off the side of the bed and bolsters were in place because R52 tries to get out of bed. CNA #7 stated, If the bolster isn't there, [R52] could sit up and hang [their] leg off the bed. CNA #7 said the bolsters kept R52's hips from coming out of the bed. During an interview on 05/10/2023 at 10:49 AM, Licensed Practical Nurse (LPN)3 said she was familiar with R52. She reported R52 could move around in the bed by holding the siderail. She said R52 could throw their legs off the side of the bed, but the bolsters prevented that from happening. She said if the bolsters were not on the bed keeping R52 centered, R52 could scoot to the side of the bed and fall off the bed. LPN3 said she was not aware of any restraints in the facility. LPN3 said she received training related to restraints, but restraints were not used because it inhibits the resident from trying to do things. LPN3 could not recall a definition of a restraint but said the floor nurses would not determine device use or restraints. She said that would be done in the morning management meeting. During an interview on 05/10/2023 at 11:53 AM, Unit Manager (UM)4 said the facility did not have any restraints. She said wedges were used to help position a resident and keep them on their side. UM4 said, We haven't had any training on restraints. We don't use them. She defined a restraint as anything that would confine them [the resident] physically or chemically to one space. UM4 said she was not aware of a facility process to evaluate devices to determine if they were restraints. UM4 said she was familiar with R52, but she was not sure why the bolsters were on the bed and was not aware that R52 would put their legs off the side of the bed. UM4 said R52 did not turn without help or using the siderails and could not sit up on the side of the bed. During an interview on 05/10/2023 at 12:39 PM, the Director of Nurses (DON) stated if residents continuously try to get out of bed with the bed low and locked and the mat on the floor, we would use a bolster. It will show them [the resident] the boundary. They [residents can still get over them. She said a device added to the bed for residents at risk for falls was a nursing judgement. The DON noted nurses could add them, and if it were an intervention after a fall, it would be discussed by the management team in the morning meeting. The DON stated We do restraint training during competencies. I do it or the risk manager does it. We don't have any restraints in the building. A restraint is something that intentionally restricts access or something specific occurring. The DON said R52 had bolsters because there was a history of falls where R52 used the siderails to pull up and sit on the side of the bed then fell to the floor. The DON said R52 could still sit on the side of the bed, but it would be on top of the bolsters. During an observation on 05/10/2023 at 2:40 PM, R52 was lying in bed between bolsters. The upper quarter rails were raised, and the head of the bed was elevated approximately 35 degrees. There was a bolster on each side of the bed that extended past the bottom of the side rails, leaving no gap. The area between the bolsters was approximately 24 inches. During an interview on 05/10/2023 at 2:54 PM, the MDS assessment nurse said if a resident had a restraint, she would verify there was a consent form signed, but she was not responsible for assessing devices to determine if they were a restraint. She said she was familiar with R52, and R52 could move independently around in bed. During an interview on 05/10/2023 at 5:01 PM, the Administrator said the use of mattresses, bolsters, and wedges would be a nursing judgement. The Administrator said there were currently no restraints in use at the facility, and a restraint would be something that impedes them [residents] from getting up or moving. The Administrator also said the facility did not have a process to evaluate devices to determine if they were restraints.

Based on observations, interviews, record review, and facility policy review, the facility failed to shave and keep fingernails trimmed and clean for 1 (Resident (R)45) of 4 residents reviewed for activities of daily living. Findings included: A review of a facility policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. A review of a Face Sheet for R45, dated 05/10/2023, revealed the facility readmitted the resident on 10/28/2022 with diagnoses that included quadriplegia (incomplete or complete paralysis affecting all or part of the trunk, legs, and pelvic organs). A review of a Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2023, indicated R45 had a score of 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had no cognitive deficits. The MDS also revealed R45 required extensive or total assistance with all ADLs, including personal hygiene. Per the MDS, R45's vision was revealed to be highly impaired, which indicated that object identification was in question, but the resident's eyes appeared to follow objects. The assessment indicated R45 had no behaviors or rejection of care. A review of an ADL Care Plan for R45, with a start date of 05/12/2022, indicated R45 was totally dependent on staff for ADL tasks, including personal hygiene, and would have all needs met by staff. After interviews were completed on 05/10/2023 about the resident's lack of shaving and nail care, an additional focus was added to the Care Plan, dated 05/10/2023, that indicated R45 would not have an increase in behaviors and would understand the importance of ADL care. On 05/08/2023 at 9:34 AM, R45 was observed with fingernails extending beyond the tip of the finger and a black substance underneath the nails. R45 stated staff had not offered to clean or trim the nails. When asked if the fingernails needed to be trimmed, R45 replied, Look at them. Facial hair was also present, and R45 stated the staff would not allow independent shaving. On 05/09/2023 at 1:45 PM, R45 was observed in bed being fed by staff. The resident remained with facial hair, and the resident's nails remained long, with a black substance underneath the nails. During an interview on 05/09/2023 at 3:22 PM, Certified Nursing Assistant (CNA)8 stated he worked both day and evening shifts and added that R45 was unable to do much independent care. He stated the resident ate finger foods, but was unable to use utensils. On 05/10/2023 at 10:13 AM, R45 was observed unshaven, and the resident's nails extended at least 1/4 inch beyond the tip of the finger, with a black substance underneath the nails. During an interview on 05/10/2023 at 10:48 AM, CNA9 stated the CNAs were responsible for shaving residents and cleaning and trimming nails. The CNA stated her assigned residents that day included R45 and added no residents had refused shaving or nail care thus far that day. CNA9 stated she had not provided care for R45 for the day. An observation was made of R45 with CNA9 on 05/10/2023 at 11:04 AM. CNA9 stated R45's facial hair looked fine to her, and she added she had seen the resident's facial hair looking worse. CNA9 stated R45 had been shaven one day last week when the resident received a shower. CNA9 observed the resident's fingers and stated R45's nails needed to be cut and the black matter under the nails needed to be removed. Aside from not providing care that day, on 05/10/2023, the CNA had no reason nail care and shaving had not been provided to R45. An observation was made of R45 with Licensed Practical Nurse (LPN)3 on 05/10/2023 at 11:08 AM. LPN3 asked R45 if the resident thought a shave was needed, and the resident replied, I want a shave. LPN3 observed R45's fingernails and stated the resident's fingernails needed to be trimmed and cleaned. LPN3 stated she was unsure how often residents were expected to receive a shave, adding Maybe a couple of times a week. LPN3 stated the CNAs were responsible for nail care, noting nail care should be provided on an individual basis. The LPN stated the expectation was for the nurse on the hall to make observations of the residents related to personal hygiene and then direct the CNAs regarding what was needed. The nurse stated this was her first time on the hall that week. The Director of Nursing (DON) was interviewed on 05/10/2023 at 1:17 PM. The DON stated the CNAs were responsible for keeping the residents clean shaven and for providing nail care. The DON stated on days the residents were given a shower, the shower team was responsible for shaving residents and cleaning nails. The DON stated she expected the residents to be clean, neat, and well groomed. During an interview on 05/11/2023 at 9:50 AM, the Administrator stated the expectation was for all residents to receive shaving, nail care, bathing, and oral care.

Based on record review, interview, and review of the facility's Abuse Policy, the facility failed to ensure policies and procedures prevented abuse of residents for 1 out of 15 residents reviewed for abuse (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An 04/05/19 Facility incident report for Resident #24 was reviewed on 09/17/19 at 10:03 AM. The incident report stated Certified Nursing Assistant (CNA) #4 punched Resident #24 in the face. The incident was witnessed by CNA orientee #1 and reported to the Facility Administrator and Director of Nursing (DON) immediately following the incident. The incident was initially reported to the State Agency on 04/05/19 at 5:01 PM and the follow up report was submitted on 04/09/19, within the 5 day timeframe. Review of Resident #24's medical record on 09/17/19 at 10:15 AM revealed no cognitive score had been completed due to Resident #24's inability to complete the questions related to Dementia. Review of the facility investigation of the incident revealed on 04/05/19 at 3:05 PM, CNA #4 and CNA orientee #1 were in Resident #24's room providing care. Resident #24 became combative and hit CNA #4 in the face. CNA #4 then punched Resident #24 twice in the face, causing a bloody nose and mouth. CNA #4 initially called CNA #5 to the room and stated Resident #24 hit his head on the bed, but then admitted to hitting Resident #24. CNA orientee #1 left the room and went to alert the nurse to Resident #24's injury and CNA #4 clocked out and left the facility. CNA orientee #1 went to the Facility Administrator and DON to inform them of the incident. Statements were taken from CNA orientee #1 and CNA #5 regarding the incident, with both statements indicating CNA #4 hit Resident #24 in the face. The facility contacted local law enforcement at 3:44 PM, reported the incident, and sent Resident #24 to the hospital for evaluation. CNA #4 was asked to return to the building to be questioned related to the incident. CNA #4 appeared to be under the influence of some substance, and a urine test was administered, but the urine specimen provided did not have a high enough temperature to be utilized. The local police initially declined to take the case, stating CNA #4 acted in self-defense. The Facility Administrator contacted the local Sheriff on 04/05/19 and further explained the situation. The Sheriff was informed that all staff, including CNAs, were trained to walk away and not retaliate when residents become combative. The sheriff stated the situation had been handled incorrectly by the police and a warrant should have been obtained for the CNA's arrest. The Assistant Chief of Police then called the facility and confirmed a warrant would be requested for CNA #4's arrest, but it would likely be Monday as it was the weekend. At 8:00 PM on 04/05/19, the Facility Administrator was informed that CNA #4 had been hospitalized after a car wreck in which CNA #4 was driving and tested positive for alcohol and an unknown substance. CNA #4 was contact via telephone on 04/08/19 at 10:30 AM and was terminated from employment. CNA orientee #1's statement confirmed CNA #4 had hit Resident #24. CNA #5's statement confirmed CNA #4 stated s/he had hit Resident #24 in the face. CNA #4 did not return a call to discuss the incident. CNA orientee #1 left employment with the facility and did not respond to attempted phone calls. The Facility Administrator was interviewed on 09/18/19 at approximately 3:45 PM and confirmed CNA #4 had been reported for hitting Resident #24 in the face. The FA confirmed police were called and after an initial refusal to pursue legal action against CNA #4, the police did become involved and charges were sought against CNA #4 for striking Resident #24. Review of the facility's Abuse Policy revealed, Residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property.

Based on record review and interview, the facility failed to ensure residents were free from abuse for 1 out of 15 residents reviewed for abuse (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An 04/05/19 Facility incident report for Resident #24 was reviewed on 09/17/19 at 10:03 AM. The incident report stated Certified Nursing Assistant (CNA) #4 punched Resident #24 in the face. The incident was witnessed by CNA orientee #1 and reported to the Facility Administrator and Director of Nursing (DON) immediately following the incident. The incident was initially reported to the State Agency on 04/05/19 at 5:01 PM and the follow up report was submitted on 04/09/19, within the 5 day timeframe. Review of Resident #24's medical record on 09/17/19 at 10:15 AM revealed no cognitive score had been completed due to Resident #24's inability to complete the questions related to Dementia. Review of the facility investigation of the incident revealed on 04/05/19 at 3:05 PM, CNA #4 and CNA orientee #1 were in Resident #24's room providing care. Resident #24 became combative and hit CNA #4 in the face. CNA #4 then punched Resident #24 twice in the face, causing a bloody nose and mouth. CNA #4 initially called CNA #5 to the room and stated Resident #24 hit his head on the bed, but then admitted to hitting Resident #24. CNA orientee #1 left the room and went to alert the nurse to Resident #24's injury and CNA #4 clocked out and left the facility. CNA orientee #1 went to the Facility Administrator and DON to inform them of the incident. Statements were taken from CNA orientee #1 and CNA #5 regarding the incident, with both statements indicating CNA #4 hit Resident #24 in the face. The facility contacted local law enforcement at 3:44 PM, reported the incident, and sent Resident #24 to the hospital for evaluation. CNA #4 was asked to return to the building to be questioned related to the incident. CNA #4 appeared to be under the influence of some substance, and a urine test was administered, but the urine specimen provided did not have a high enough temperature to be utilized. The local police initially declined to take the case, stating CNA #4 acted in self-defense. The Facility Administrator contacted the local Sheriff on 04/05/19 and further explained the situation. The Sheriff was informed that all staff, including CNAs, were trained to walk away and not retaliate when residents become combative. The sheriff stated the situation had been handled incorrectly by the police and a warrant should have been obtained for the CNA's arrest. The Assistant Chief of Police then called the facility and confirmed a warrant would be requested for CNA #4's arrest, but it would likely be Monday as it was the weekend. At 8:00 PM on 04/05/19, the Facility Administrator was informed that CNA #4 had been hospitalized after a car wreck in which CNA #4 was driving and tested positive for alcohol and an unknown substance. CNA #4 was contact via telephone on 04/08/19 at 10:30 AM and was terminated from employment. CNA orientee #1's statement confirmed CNA #4 had hit Resident #24. CNA #5's statement confirmed CNA #4 stated s/he had hit Resident #24 in the face. CNA #4 did not return a call to discuss the incident. CNA orientee #1 left employment with the facility and did not respond to attempted phone calls. The Facility Administrator was interviewed on 09/18/19 at approximately 3:45 PM and confirmed CNA #4 had been reported for hitting Resident #24 in the face. The FA confirmed police were called and after an initial refusal to pursue legal action against CNA #4, the police did become involved and charges were sought against CNA #4 for striking Resident #24.

Based on review of facility files and interview, the facility failed to develop and implement written policies and procedures that prohibit abuse, neglect, misappropriation of resident property or exploitation or establish policies and procedures to investigate any such allegations. Resident #1 was noted with an injury of unknown origin. The resident was found to have dislocated shoulder. Investigation into the incident revealed several staff members admitted to transferring the resident as a two person assist, while the resident required a mechanical lift. LPN (Licensed Practical Nurse) #1 was noted to walk around with a walker mocking Resident #2. The incident was recorded by CNA (Certified Nursing Aide) #5 and the video was uploaded to a social media website. Resident #3 was noted to have an allegation of physical abuse by a CNA. The facility did not obtain statements from other staff who were on duty on the unit at the time of the alleged incident. Three of three residents reviewed for abuse/neglect. The findings included: Resident #1 was noted with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Notes revealed a Weekly Nursing Summary dated 9/10/17 that indicated the resident transferred by 1-2 assist. The Nursing Note on 11/3/17 at 5:51 PM indicated a bruise was noted to the resident's left eye brow, the 1st shift CNA stated it was there at the start of his/her shift, the nurse looked at the left padded side rail and had to re-adjust the padding because the rail was exposed. MD (Medical Doctor) and responsible party were contacted. The Nursing Note dated 11/3/17 at 9:56 PM indicated a purple colored bruise was noted to the left side of the resident's eyebrow, area measures 2.5 cm x 3.2 cm. The Nursing Note dated 11/11/17 at 7:11 PM indicated Resident #1 had been up in the geri chair during the shift. When putting the resident to bed they noted bruising to the resident's left upper arm. Bruising was blue and approximately 8 x 4. Padding was in place to side rails. Responsible party was notified. Resident was non-verbal, showed no signs/symptoms of pain. On 11/12/17 at 3:50 AM the note indicated bruising was noted to the left upper arm and left side of forearm, small amount of bruising was noted to the right upper arm. On 11/13/17 at 1:59 PM the Nursing Note indicated bruising noted to the left upper arm and elbow area was purple in color, no signs/symptoms discomfort. On 11/15/17 at 6:53 PM the note indicated purple bruising was noted from left upper arm to left AC 19 cm x 17 cm and purple bruising was noted on the right arm near elbow 5.5 cm x 3 cm. The Nursing Note on 11/17/17 at 1:22 AM indicated bruises to left arm were getting less noticeable but the upper left arm was [MEDICAL CONDITION] and when you touched that area the resident grimaced. The arm also seemed a little warm to the touch. The Nursing Note on 11/17/17 at 2:33 PM indicated bruising still noted to left arm/elbow area with [MEDICAL CONDITION] noted as well, MD notified and x-ray was ordered. Responsible party attempted, no answer and message left. The Nursing Note on 11/17/17 at 9:33 PM indicated the mobile x-ray company came and took the ordered x-ray of the left shoulder and elbow. Received the fax that stated anterior dislocation left humeral head of uncertain age. Copy faxed to MD. Sent resident to ER via rescue squad. Responsible party was notified. The Nursing Note dated 11/18/17 at 2:27 AM indicated the resident returned to the floor, drowsy from medication given in the ER. Shoulder immobilizer and sling in place. Review of the Radiology Report dated 11/17/17 revealed the resident had an anterior dislocation of left humeral head of uncertain age. The report noted possible anterior subluxation of the radial head. Review of Resident #1's medical record revealed the Annual Minimum (MDS) data set [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making Review of the facility Incident Log revealed Resident #1 was listed as having an incident of bruising noted on 11/3/17. The Incident Log was noted to be for incidents occurring 11/1/17 - 11/30/17. The resident had no additional entries noted on the log. Review of the Incident Report for Resident #1 dated 11/3/17 revealed the resident was noted with bruising to the eyebrow. Review of Resident #1's care plan revealed resident is a fall risk, non-ambulatory was identified as a problem area. Interventions and approaches were listed on the care plan and included mechanical lift and 2 person assist with transfers. The care plan date was noted as 10/11/17. CNA #1's facility-obtained statement dated 11/21/17 indicated on 1st shift the CNA reported to the nurse about bruises on arm and also swelling of left arm. There was no indication of the date the incident was noted and reported. RN (Registered Nurse) #1's facility-obtained statement dated 11/18/17 indicated s/he was working 11 PM-7 AM. The CNA was giving Resident #1 a bath and called the nurse to look at the resident's arm. RN #1 checked the resident and his/her upper arm was bruised and the back of the arm also. RN #1 informed the oncoming nurse and asked if the nurse would call the doctor and responsible party. There was no indication of the date this happened. The first Progress Note related to bruising on the resident's arm by RN #1 was 11/16/17 at 3:15 AM. The note indicated bruise to left side of face and left upper arm improving. No swelling or skin tear noted. CNA #2's facility-obtained statement dated 11/20/17 indicated s/he asked CNA #3 to help him/her put Resident #1 to bed because the resident is a two person assist. While they were changing Resident #1's clothes to put on his/her night clothes they noticed a bruise on his/her upper left arm. They reported it to the nurse. There was no indication of the date this happened. CNA #3's facility-obtained statement dated 11/17/17 indicated on 11/11/17 when s/he came to work a CNA asked him/her to help with a resident. As they were getting the resident dressed, they noticed that his/her arm was bruised and they called the nurse to come in and look at the resident's arm. RN #2's facility-obtained statement indicated on 11/13/17 s/he returned to work and Resident #1 was on alert charting. The resident's left arm was bruised around the elbow area. On 11/16/17 s/he noticed that the arm still had some bruising but also the entire upper arm around the elbow and above was swollen. RN #2 noted this on night shift, so s/he gave report to the oncoming nurse so s/he could call the doctor and get an order. RN #4's facility-obtained statement dated 11/20/17 indicated s/he checked the schedule book for what charting needed to be done on 11/13/17. Resident #1 was on alert charting for bruising to the left upper arm/elbow area. Upon assessment of the area it showed bruising to the left upper arm near the elbow that covered the entire back of the arm with the front of the arm free from bruising. Resident #1 did not show any signs/symptoms of discomfort when RN #4 touched the resident's arm. Bruises were purple in color. The next day RN #4 worked on the unit was 11/17/17. When s/he assessed the bruises they had begun to turn yellow in color and [MEDICAL CONDITION] was noted to the entire arm from the upper arm to right above the wrist area. The physician was notified and an x-ray was ordered. Resident #1 did grimace on that day when the arm was touched/moved. RN #4 indicated s/he was not aware the DON (Director of Nursing) did not know about the bruising to the resident's arm as it was already on alert charting 2 days prior to his/her 1st assessment of it. There was no statement from the nurse, RN #3, who first noted the bruise to the resident's arm in the Nursing Notes on 11/11/17. In an interview with the surveyor on 12/12/17 at approximately 1:25 PM, the DON stated the bruising was reported to him/her on 11/17/17. The nurse reported to the DON that they were getting an x-ray of Resident #1's arm and shoulder area because of the bruising. The DON asked the nurse about the bruising, and the nurse stated that it was bruising that extended all the way up under the resident's arm and almost down to his/her elbow. It concerned them because it looked like it was swelling. The DON did not know Resident #1 had bruising prior to that time. The DON was still at the facility when the x-ray came back that it was a dislocation. When the DON left, the resident was still in the ER. Resident #1 required a total mechanical lift. The DON found that several CNAs stated they would get another person to help them if the lift was in use at the time. They would do a 2 person transfer rather than wait on the lift. She found 2 CNAs that stated they had transferred the resident without a lift a few times. The DON talked with the CNAs who normally work that unit and the nurses that work that unit. The bruising was initially found on 11/11/17 on the left upper arm and elbow area per the nursing notes. The nurse should complete an incident report if they find bruising, whether they know how it happened or not. If it is an injury of unknown origin, then they investigate to see if they know how it happened. The surveyor asked the DON about the CNAs transferring the resident without a lift and where that information was documented. The DON stated they asked the CNAs to address how they transferred the resident on their statements. The surveyor asked the DON if they review staff statements, the DON stated s/he and the ADON (Assistant) review staff statements. The DON stated none of the other residents on the same group require a total lift. The DON stated that if s/he had been notified when the bruising was first noted on 11/11/17 s/he would have started investigating at the time it was noted. The DON stated s/he goes online and reports incidents to licensure. The DON stated that is the only place s/he knows to report to. S/he has been the DON at the facility since 2014. With abuse, s/he reports to the ombudsman, the law as needed and to certification. The DON stated s/he faxes the abuse allegations and then completes the online form (licensure) for injuries of unknown origin. The DON stated s/he did not report the allegations of abuse for Resident #2 and Resident #3 to certification, only to licensing. In an interview with the surveyor on 12/13/17 at approximately 11:30 AM, the DON stated nursing did not complete an Incident Report for the bruising on the Resident #1's arm at all. There should have been an Incident Report completed when it was noted on 11/11/17. The bruising on the resident's arm and dislocated shoulder was not noted on the facility's Incident Log. In an interview with the surveyor on 12/13/17 at approximately 12:15 PM, CNA #2 stated she has been at the facility over a year. The CNA stated they have an ADL book at the nurses' station and an apple above the resident's head that indicates the residents' transfer status. CNA #2 stated Resident #1 transfers with a mechanical lift. CNA #2 stated s/he asked CNA #3 to help change the resident's gown. The resident use to be a 2 person assist. CNA #2 did not remember if they updated the resident's apple. CNA #2 stated they transferred the resident 2 person assist the day from his/her statement. CNA #2 stated s/he told the nurse about the bruising the day s/he saw it. The bruising was on Resident #1's arm and back. CNA #2 worked 7 AM - 7PM that day and saw the bruising around 5:30-6:30 PM that night. In an interview with the surveyor on 12/13/17 at approximately 12:30 PM, CNA #1 stated s/he had been at the facility for [AGE] years. The CNA stated there is an apple in the resident's room to let you know how to transfer the resident. CNA #1 stated they use a Marissa lift (total) for Resident #1. S/he transferred the resident one time without a lift, the resident's CNA asked for help. They transferred the resident from the bed to the geri chair. That was sometime last month. They were on each side of the resident and lifted Resident #1 under his/her arms. CNA #1 helped CNA #2, s/he did not pay attention to the apple. S/he did not look because CNA #2 said the resident was a 2 person assist. The transfer was before they found the bruising on the resident. In an interview with the surveyor on 12/13/17 at approximately 1:45 PM, CNA #4 stated she works with Resident #1. Resident #1 requires a mechanical lift with transfers. The resident use to be a 2 person assist, probably changed in the last 6 months. They have an ADL book that lets them know about the resident and how to care for them. There are also apples over the bed that indicate transfer status. Resident #1's apple says M2 which means mechanical with 2 or you can do a 2 person assist. M stands for mechanical lift. If they have 2 people then they don't have to have the lift, even with an M. Review of the facility's 5 day report to the Bureau of Health Facilities Licensing revealed on 11/17/17, around 4 PM, it was reported that Resident #1 had a bruise with some swelling to the left upper arm. It was also reported that this bruising was old in nature. The staff nurse called and received an order for [REDACTED]. The resident was sent to the emergency room . Investigation was started and revealed bruising was first noted on 11/11/17. Upon talking with staff and getting statements, it was concluded that the resident is a mechanical lift. Staff had not been lifting/transferring him/her appropriately. Staff had been lifting the resident by two person assist. The facility made a 24 hour report of neglect or exploitation, suspected or confirmed abuse to licensing on 11/13/17 for Resident #2. The email confirmation was on 11/13/17 at 5:09 PM. The email confirmed submission of the report to the Bureau of Health Facilities Licensing. Review of the 24 hour report to the Bureau of Health Facilities Licensing revealed LPN #1 was walking with a walker mocking a Resident #2 as s/he was walking. LPN #1 stated s/he was just playing around with the resident. While this was occurring, CNA #5 videoed the incident and the incident was uploaded to a social media website. The resident's face was not in the video, but family was somehow made aware of the video and were able to identify that the person in the video was indeed their parent. The incident occurred on 11/11/17, but management was not made aware until late evening on 11/12/17. Review of the 5 day report to the Bureau of Health Facilities Licensing revealed the investigation found that by definition of mental abuse, which includes the taking and posting of photographs or recordings, the incident was substantiated. The ADON's facility-obtained statement indicated s/he watched the video posted to a social media website. The video was posted to the social media website by CNA #5. CNA #5's facility-obtained statement dated 11/14/17 indicated s/he did not know his/her phone was recording. LPN #1 was saying to Resident #2 one minute you like me and the next minute you don't but at the same time LPN #1 and Resident #2 were laughing about it. CNA #5's statement indicated that by his/her phone moving in his/her pocket it posted the video. A note by QA nurse at the bottom of the statement indicated during interview the staff member admitted that s/he knew the phone was on and recording and s/he took the video. LPN #1's facility-obtained statement dated 11/15/17 indicated s/he was in the building walking around with another resident's walker which is something they do at times just being playful with the residents. LPN #1 and Resident #2 began exchanging words in a friendly manner. The resident said you pick on me and LPN #2 said no you pick on me and LPN #1 said you are mean to me at times. All of this was in a playful manner. Only playing around with the residents. LPN #2 then walked off with the walker down the hall. LPN #1 did not know that the whole instance was being recorded on video. CNA #6's facility-obtained statement dated 11/15/17 indicated everybody was around the front entrance. S/he saw LPN #1 sitting and s/he sat down beside him/her. Everyone was laughing but s/he didn't know what was going on. The were several staff members around. CNA #6 eventually saw the video later the next day. What s/he saw on it was LPN #1 playing with another walker passing Resident #2. S/he heard Resident #2 talking junk like s/he always does. S/he really didn't think anything of it. It was a stupid mistake. LPN #2's facility-obtained statement dated 11/15/17 indicated s/he saw LPN #1 walking with a rolling walker. S/he and several other residents and staff laughed at the fact s/he was playing with the walker. Review of the Disciplinary Warning Record for LPN #1 and CNA #5 indicated they participated in behavior that brought mental anguish to a resident at the time. A police Incident Report was completed on 11/15/17. The dispatch time was 1035 on 11/15/17 and arrived at 1100. The incident date was noted as 11/11/17 at 1430. In an interview with the surveyor on 12/12/17 at approximately 2:30 PM, the DON stated s/he got a phone call 11/12/17 from the ADON, who was on call. The ADON said that one of the nurses at the facility called him/her because Resident #2's family was at the facility and had a complaint. The complaint was that they saw a video posted to a social media website and they knew it was their parent, even though it didn't have their face in it. The family wanted to talk to administration now. The resident's son said the nurse was mocking his parent in the video. The administrator and ADON came to the facility and talked with the son. It was on Sunday 11/12/17 around 5:00 PM when s/he got the phone call about the incident. The DON saw the video and stated it was hard to understand what was being said. S/he saw Resident #2 standing with his/her walker and LPN #1 was walking with a walker in a fast paced mode, LPN #1 was saying something. The DON could not understand what LPN #1 was saying. LPN #1 said s/he was trying to get the resident's to laugh, not to make fun of Resident #2. The family took it as mocking Resident #2. CNA #5 admitted to taking the video but said s/he didn't upload it to a social media website. Later the day of the incident, other staff watched the video on CNA #5's phone. The resident's son said another family member saw the video on a social media website and that is how he found out. Review of the Reporting Form for Bureau of Health Facilities Licensing revealed a 5 day report for an allegation of abuse for Resident #3. The report indicated the incident occurred on 10/8/17. The description indicated Resident #4 was in bed in his/her room. CNA #7 brought roommate, Resident #3, in the room and put him/her in bed. Resident #4 stated that the CNA hit the roommate. After completing investigation, Resident #4 actually did not see the CNA hit Resident #3. Resident #4 stated s/he heard what sounded like a hit and when s/he lifted up from the bed, s/he saw Resident #3 hitting the CNA. Resident #3 was interviewed and s/he nodded, in the negative, that CNA #7 did not hit him/her. A witness statement was taken from the CNA and the two residents. There is also a statement from an employee to which Resident #4 first reported the incident to. The DON provided the surveyor with an email confirmation that the incident for Resident #3 was reported to Health Licensing. The email was dated 10/9/17 at 5:17 PM. The DON stated that the email was sent immediately after the report was sent to Health Licensing. Resident #3 was noted with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] indicated the resident had a Brief Interview for Mental Status score of 3. Review of the Daily Schedule for Sunday 10/8/17 revealed there was one nurse and seven CNAs on the schedule for Building 2 between 2nd and 3rd shift, which is where Resident #3 resided. The surveyor asked for a copy of the facility's complete investigation into the allegation. The facility provided a copy and the surveyor reviewed the information. There was a facility-obtained statement dated 10/13/17 from LPN #3 that indicated when taking the complaint from Resident #4 on 10/9/17, Resident #4 stated s/he heard two pops like someone was being hit. S/he raised up in bed to see on the other side of the cubicle to see what was going on. Resident #4 stated at this time Resident #3 was mad because CNA #7 hit him/her and s/he started fighting with the CNA. Resident #4 stated s/he heard CNA hitting Resident #3, but did not see it. There was a facility-obtained statement dated 10/12/17 from CNA #8 that indicated Resident #4 asked him/her who was the staff who came in after him/her for the 7PM-7AM shift and what was his/her name and s/he said CNA #7's name. There was a facility-obtained statement for CNA #7 dated 10/9/17. There was a witness statement completed by the DON for Resident #4. There were no additional statements from staff on the unit. In an interview with the surveyor on 12/12/17 at approximately 2:10 PM, the DON stated that s/he reported the allegation to licensure, not certification. She reported the allegation to licensing on 10/9/17 at 5:17 PM. The confirmation comes back from licensing immediately. The resident's roommate reported to the MDS nurse (LPN #3) that s/he thought Resident #3 had been hit by CNA #7. It was early one morning when the MDS nurse first got to the facility when Resident #4 reported the incident to him/her. When the DON arrived at the facility that morning, the MDS nurse (LPN #3) came and told him/her about it. LPN #3 had filled out a grievance and gave it to the DON when s/he got to work. The DON went and talked to Resident #4 to find out what happened. Resident #4 told the DON the same thing, but when they tried to get details they found the curtain was pulled and the resident couldn't see anything. Resident #4 said s/he heard a hit. They called the CNA and let him/her know s/he could not come to work that night but that s/he needed to come in to talk about the incident. The CNA said s/he didn't hit the resident, but that Resident #3 had gotten aggressive with him/her. CNA #7 was in the process of putting Resident #3 to bed. It was around 10:30 PM, so s/he just waited to let the next shift put him/her to bed. S/he left the resident, went out the room and told the nurse. The DON talked to Resident #3 and s/he wouldn't say anything, then the administrator talked to him/her and s/he said no, the CNA did not hit him/her. The DON stated that s/he thought s/he got some statements from other staff working on the unit that night. Reviewed investigative file and confirmed there are no statements or documentation of interviews of other staff on duty at the time of the incident. Review of the facility's Abuse Prohibition/Investigation Policy revealed the facility will prohibit abuse and neglect. The facility defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes the taking and posting of photographs or recordings in any manner that would demean or humiliate a resident. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Abuse Prohibition/Investigation Policy indicated training will be provided to all employees about how staff should report their knowledge related to allegations, what constitutes abuse and neglect, interacting with residents to maintain and enhance self esteem/self worth, and inappropriate use of electronic devices such as phones, photos or recordings of residents that are used to demean or humiliate. The Abuse Prohibition/Investigation Policy indicated staff will be responsible for identifying and reporting occurrences that may constitute events of abuse and neglect. Some examples may include suspicious bruising and any injury of unknown origin. Anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and to report it to the nursing supervisor immediately. All reports of suspected abuse must be reported to the Administrator immediately. The family is to be notified of the facts surrounding the allegations. The state/federal reporting requirements for alleged incidents must be followed. The administrator will report findings of all completed investigations per state requirements.

Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Resident #1 was noted with bruising to his/her arm on 11/11/17. The physician was notified on 11/17/17 and an x-ray was obtained which showed a displaced shoulder. The resident was sent out to the emergency room . There facility's investigation revealed that several staff were not following the resident's plan of care. One of three resident's reviewed for care plans. The findings included: Resident #1 was noted with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Notes revealed a Weekly Nursing Summary dated 9/10/17 that indicated the resident transferred by 1-2 assist. The Nursing Note on 11/3/17 at 5:51 PM indicated a bruise was noted to the resident's left eye brow, the 1st shift CNA (Certified Nursing Aide) stated it was there at the start of his/her shift, the nurse looked at the left padded side rail and had to re-adjust the padding because the rail was exposed. MD (Medical Doctor) and responsible party were contacted. The Nursing Note dated 11/3/17 at 9:56 PM indicated a purple colored bruise was noted to the left side of the resident's eyebrow, area measures 2.5 cm x 3.2 cm. The Nursing Note dated 11/11/17 at 7:11 PM indicated Resident #1 had been up in the geri chair during the shift. When putting the resident to bed they noted bruising to the resident's left upper arm. Bruising was blue and approximately 8 x 4. Padding was in place to side rails. Responsible party was notified. Resident was non-verbal, showed no signs/symptoms of pain. On 11/12/17 at 3:50 AM the note indicated bruising was noted to the left upper arm and left side of forearm, small amount of bruising was noted to the right upper arm. On 11/13/17 at 1:59 PM the Nursing Note indicated bruising noted to the left upper arm and elbow area was purple in color, no signs/symptoms discomfort. On 11/15/17 at 6:53 PM the note indicated purple bruising was noted from left upper arm to left AC 19 cm x 17 cm and purple bruising was noted on the right arm near elbow 5.5 cm x 3 cm. The Nursing Note on 11/17/17 at 1:22 AM indicated bruises to left arm were getting less noticeable but the upper left arm was [MEDICAL CONDITION] and when you touched that area the resident grimaced. The arm also seemed a little warm to the touch. The Nursing Note on 11/17/17 at 2:33 PM indicated bruising still noted to left arm/elbow area with [MEDICAL CONDITION] noted as well, MD notified and x-ray was ordered. Responsible party attempted, no answer and message left. The Nursing Note on 11/17/17 at 9:33 PM indicated Mobilex came and took the ordered x-ray of the left shoulder and elbow. Received the fax that stated anterior dislocation left humeral head of uncertain age. Copy faxed to MD. Sent resident to ER via rescue squad. Responsible party was notified. The Nursing Note dated 11/18/17 at 2:27 AM indicated the resident returned to the floor, drowsy from medication given in the ER. Shoulder immobilizer and sling in place. Review of the Radiology Report dated 11/17/17 revealed the resident had an anterior dislocation of left humeral head of uncertain age. The report noted possible anterior subluxation of the radial head. Review of Resident #1's medical record revealed the Annual Minimum (MDS) data set [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making Review of the facility Incident Log revealed Resident #1 was listed as having an incident of bruising noted on 11/3/17. The Incident Log was noted to be for incidents occurring 11/1/17 - 11/30/17. The resident had no additional entries noted on the log. Review of the Incident Report for Resident #1 dated 11/3/17 revealed the resident was noted with bruising to the eyebrow. Review of Resident #1's care plan revealed resident is a fall risk, non-ambulatory was identified as a problem area. Interventions and approaches were listed on the care plan and included mechanical lift and 2 person assist with transfers. The care plan date was noted as 10/11/17. CNA #1's facility-obtained statement dated 11/21/17 indicated on 1st shift the CNA reported to the nurse about bruises on arm and also swelling of left arm. There was no indication of the date the incident was noted and reported. RN (Registered Nurse) #1's facility-obtained statement dated 11/18/17 indicated s/he was working 11 PM-7 AM. The CNA was giving Resident #1 a bath and called the nurse to look at the resident's arm. RN #1 checked the resident and his/her upper arm was bruised and the back of the arm also. RN #1 informed the oncoming nurse and asked if the nurse would call the doctor and responsible party. There was no indication of the date this happened. The first Progress Note related to bruising on the resident's arm by RN #1 was 11/16/17 at 3:15 AM. The note indicated bruise to left side of face and left upper arm improving. No swelling or skin tear noted. CNA #2's facility-obtained statement dated 11/20/17 indicated s/he asked CNA #3 to help him/her put Resident #1 to bed because the resident is a two person assist. While they were changing Resident #1's clothes to put on his/her night clothes they noticed a bruise on his/her upper left arm. They reported it to the nurse. There was no indication of the date this happened. CNA #3's facility-obtained statement dated 11/17/17 indicated on 11/11/17 when s/he came to work a CNA asked him/her to help with a resident. As they were getting the resident dressed, they noticed that his/her arm was bruised and they called the nurse to come in and look at the resident's arm. RN #2's facility-obtained statement indicated on 11/13/17 s/he returned to work and Resident #1 was on alert charting. The resident's left arm was bruised around the elbow area. On 11/16/17 s/he noticed that the arm still had some bruising but also the entire upper arm around the elbow and above was swollen. RN #2 noted this on night shift, so s/he gave report to the oncoming nurse so s/he could call the doctor and get an order. RN #4's facility-obtained statement dated 11/20/17 indicated s/he checked the schedule book for what charting needed to be done on 11/13/17. Resident #1 was on alert charting for bruising to the left upper arm/elbow area. Upon assessment of the area it showed bruising to the left upper arm near the elbow that covered the entire back of the arm with the front of the arm free from bruising. Resident #1 did not show any signs/symptoms of discomfort when RN #4 touched the resident's arm. Bruises were purple in color. The next day RN #4 worked on the unit was 11/17/17. When s/he assessed the bruises they had begun to turn yellow in color and [MEDICAL CONDITION] was noted to the entire arm from the upper arm to right above the wrist area. The physician was notified and an x-ray was ordered. Resident #1 did grimace on that day when the arm was touched/moved. RN #4 indicated s/he was not aware the DON (Director of Nursing) did not know about the bruising to the resident's arm as it was already on alert charting 2 days prior to his/her 1st assessment of it. There was no statement from the nurse, RN #3, who first noted the bruise to the resident's arm in the Nursing Notes on 11/11/17. In an interview with the surveyor on 12/12/17 at approximately 1:25 PM, the DON stated the bruising was reported to him/her on 11/17/17. The nurse reported to the DON that they were getting an x-ray of Resident #1's arm and shoulder area because of the bruising. The DON asked the nurse about the bruising, and the nurse stated that it was bruising that extended all the way up under the resident's arm and almost down to his/her elbow. It concerned them because it looked like it was swelling. The DON did not know Resident #1 had bruising prior to that time. The DON was still at the facility when the x-ray came back that it was a dislocation. When the DON left, the resident was still in the ER. Resident #1 required a total mechanical lift. The DON found that several CNAs stated they would get another person to help them if the lift was in use at the time. They would do a 2 person transfer rather than wait on the lift. She found 2 CNAs that stated they had transferred the resident without a lift a few times. The DON talked with the CNAs who normally work that unit and the nurses that work that unit. The bruising was initially found on 11/11/17 on the left upper arm and elbow area per the nursing notes. The nurse should complete an incident report if they find bruising, whether they know how it happened or not. If it is an injury of unknown origin, then they investigate to see if they know how it happened. The surveyor asked the DON about the CNAs transferring the resident without a lift and where that information was documented. The DON stated they asked the CNAs to address how they transferred the resident on their statements. The surveyor asked the DON if they review staff statements, the DON stated s/he and the ADON (Assistant) review staff statements. The DON stated none of the other residents on the same group require a total lift. The DON stated that if s/he had been notified when the bruising was first noted on 11/11/17 s/he would have started investigating at the time it was noted. The DON stated s/he goes online and reports incidents to licensure. The DON stated that is the only place s/he knows to report to. S/he has been the DON at the facility since 2014. With abuse, s/he reports to the ombudsman, the law as needed and to certification. The DON stated s/he faxes the abuse allegations and then completes the online form (licensure) for injuries of unknown origin. In an interview with the surveyor on 12/13/17 at approximately 11:30 AM, the DON stated nursing did not complete an Incident Report for the bruising on the Resident #1's arm at all. There should have been an Incident Report completed when it was noted on 11/11/17. The bruising on the resident's arm and dislocated shoulder was not noted on the facility's Incident Log. In an interview with the surveyor on 12/13/17 at approximately 12:15 PM, CNA #2 stated she has been at the facility over a year. The CNA stated they have an ADL book at the nurses' station and an apple above the resident's head that indicates the residents' transfer status. CNA #2 stated Resident #1 transfers with a mechanical lift. CNA #2 stated s/he asked CNA #3 to help change the resident's gown. The resident use to be a 2 person assist. CNA #2 did not remember if they updated the resident's apple. CNA #2 stated they transferred the resident 2 person assist the day from his/her statement. CNA #2 stated s/he told the nurse about the bruising the day s/he saw it. The bruising was on Resident #1's arm and back. CNA #2 worked 7 AM - 7 PM that day and saw the bruising around 5:30-6:30 PM that night. In an interview with the surveyor on 12/13/17 at approximately 12:30 PM, CNA #1 stated s/he had been at the facility for [AGE] years. The CNA stated there is an apple in the resident's room to let you know how to transfer the resident. CNA #1 stated they use a Marissa lift (total) for Resident #1. S/he transferred the resident one time without a lift, the resident's CNA asked for help. They transferred the resident from the bed to the geri chair. That was sometime last month. They were on each side of the resident and lifted Resident #1 under his/her arms. CNA #1 helped CNA #2, s/he did not pay attention to the apple. S/he did not look because CNA #2 said the resident was a 2 person assist. The transfer was before they found the bruising on the resident. In an interview with the surveyor on 12/13/17 at approximately 1:45 PM, CNA #4 stated she works with Resident #1. Resident #1 requires a mechanical lift with transfers. The resident use to be a 2 person assist, probably changed in the last 6 months. They have an ADL book that lets them know about the resident and how to care for them. There are also apples over the bed that indicate transfer status. Resident #1's apple says M2 which means mechanical with 2 or you can do a 2 person assist. M stands for mechanical lift. If they have 2 people then they don't have to have the lift, even with an M. Review of the facility's 5 day report to the Bureau of Health Facilities Licensing revealed on 11/17/17, around 4 PM, it was reported that Resident #1 had a bruise with some swelling to the left upper arm. It was also reported that this bruising was old in nature. The staff nurse called and received an order for [REDACTED]. The resident was sent to the emergency room . Investigation was started and revealed bruising was first noted on 11/11/17. Upon talking with staff and getting statements, it was concluded that the resident is a mechanical lift. Staff had not been lifting/transferring him/her appropriately. Staff had been lifting the resident by two person assist.

Based on review of facility files and interview, the facility failed to ensure services provided or arranged by the facility meet professional standards of quality. Resident #1 was noted with bruising to his/her arm on 11/11/17. The physician was not notified and there was no Incident Report completed when the bruising was initially found. The physician was notified on 11/17/17 and an x-ray was obtained which showed a displaced shoulder. The resident was sent out to the emergency room . There was no Incident Report when the resident was found to have a displaced shoulder on 11/17/17. One of three resident's reviewed for professional standards. The findings included: Resident #1 was noted with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Notes revealed a Weekly Nursing Summary dated 9/10/17 that indicated the resident transferred by 1-2 assist. The Nursing Note on 11/3/17 at 5:51 PM indicated a bruise was noted to the resident's left eye brow, the 1st shift CNA (Certified Nursing Aide) stated it was there at the start of his/her shift, the nurse looked at the left padded side rail and had to re-adjust the padding because the rail was exposed. MD (Medical Doctor) and responsible party were contacted. The Nursing Note dated 11/3/17 at 9:56 PM indicated a purple colored bruise was noted to the left side of the resident's eyebrow, area measures 2.5 cm x 3.2 cm. The Nursing Note dated 11/11/17 at 7:11 PM indicated Resident #1 had been up in the geri chair during the shift. When putting the resident to bed they noted bruising to the resident's left upper arm. Bruising was blue and approximately 8 x 4. Padding was in place to side rails. Responsible party was notified. Resident was non-verbal, showed no signs/symptoms of pain. On 11/12/17 at 3:50 AM the note indicated bruising was noted to the left upper arm and left side of forearm, small amount of bruising was noted to the right upper arm. On 11/13/17 at 1:59 PM the Nursing Note indicated bruising noted to the left upper arm and elbow area was purple in color, no signs/symptoms discomfort. On 11/15/17 at 6:53 PM the note indicated purple bruising was noted from left upper arm to left AC 19 cm x 17 cm and purple bruising was noted on the right arm near elbow 5.5 cm x 3 cm. The Nursing Note on 11/17/17 at 1:22 AM indicated bruises to left arm were getting less noticeable but the upper left arm was [MEDICAL CONDITION] and when you touched that area the resident grimaced. The arm also seemed a little warm to the touch. The Nursing Note on 11/17/17 at 2:33 PM indicated bruising still noted to left arm/elbow area with [MEDICAL CONDITION] noted as well, MD notified and x-ray was ordered. Responsible party attempted, no answer and message left. The Nursing Note on 11/17/17 at 9:33 PM indicated the mobile x-ray company came and took the ordered x-ray of the left shoulder and elbow. Received the fax that stated anterior dislocation left humeral head of uncertain age. Copy faxed to MD. Sent resident to ER via rescue squad. Responsible party was notified. The Nursing Note dated 11/18/17 at 2:27 AM indicated the resident returned to the floor, drowsy from medication given in the ER. Shoulder immobilizer and sling in place. Review of the Radiology Report dated 11/17/17 revealed the resident had an anterior dislocation of left humeral head of uncertain age. The report noted possible anterior subluxation of the radial head. Review of Resident #1's medical record revealed the Annual Minimum (MDS) data set [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making Review of the facility Incident Log revealed Resident #1 was listed as having an incident of bruising noted on 11/3/17. The Incident Log was noted to be for incidents occurring 11/1/17 - 11/30/17. The resident had no additional entries noted on the log. Review of the Incident Report for Resident #1 dated 11/3/17 revealed the resident was noted with bruising to the eyebrow. Review of Resident #1's care plan revealed resident is a fall risk, non-ambulatory was identified as a problem area. Interventions and approaches were listed on the care plan and included mechanical lift and 2 person assist with transfers. The care plan date was noted as 10/11/17. CNA #1's facility-obtained statement dated 11/21/17 indicated on 1st shift the CNA reported to the nurse about bruises on arm and also swelling of left arm. There was no indication of the date the incident was noted and reported. RN (Registered Nurse) #1's facility-obtained statement dated 11/18/17 indicated s/he was working 11 PM-7 AM. The CNA was giving Resident #1 a bath and called the nurse to look at the resident's arm. RN #1 checked the resident and his/her upper arm was bruised and the back of the arm also. RN #1 informed the oncoming nurse and asked if the nurse would call the doctor and responsible party. There was no indication of the date this happened. The first Progress Note related to bruising on the resident's arm by RN #1 was 11/16/17 at 3:15 AM. The note indicated bruise to left side of face and left upper arm improving. No swelling or skin tear noted. CNA #2's facility-obtained statement dated 11/20/17 indicated s/he asked CNA #3 to help him/her put Resident #1 to bed because the resident is a two person assist. While they were changing Resident #1's clothes to put on his/her night clothes they noticed a bruise on his/her upper left arm. They reported it to the nurse. There was no indication of the date this happened. CNA #3's facility-obtained statement dated 11/17/17 indicated on 11/11/17 when s/he came to work a CNA asked him/her to help with a resident. As they were getting the resident dressed, they noticed that his/her arm was bruised and they called the nurse to come in and look at the resident's arm. RN #2's facility-obtained statement indicated on 11/13/17 s/he returned to work and Resident #1 was on alert charting. The resident's left arm was bruised around the elbow area. On 11/16/17 s/he noticed that the arm still had some bruising but also the entire upper arm around the elbow and above was swollen. RN #2 noted this on night shift, so s/he gave report to the oncoming nurse so s/he could call the doctor and get an order. RN #4's facility-obtained statement dated 11/20/17 indicated s/he checked the schedule book for what charting needed to be done on 11/13/17. Resident #1 was on alert charting for bruising to the left upper arm/elbow area. Upon assessment of the area it showed bruising to the left upper arm near the elbow that covered the entire back of the arm with the front of the arm free from bruising. Resident #1 did not show any signs/symptoms of discomfort when RN #4 touched the resident's arm. Bruises were purple in color. The next day RN #4 worked on the unit was 11/17/17. When s/he assessed the bruises they had begun to turn yellow in color and [MEDICAL CONDITION] was noted to the entire arm from the upper arm to right above the wrist area. The physician was notified and an x-ray was ordered. Resident #1 did grimace on that day when the arm was touched/moved. RN #4 indicated s/he was not aware the DON (Director of Nursing) did not know about the bruising to the resident's arm as it was already on alert charting 2 days prior to his/her 1st assessment of it. There was no statement from the nurse, RN #3, who first noted the bruise to the resident's arm in the Nursing Notes on 11/11/17. In an interview with the surveyor on 12/12/17 at approximately 1:25 PM, the DON stated the bruising was reported to him/her on 11/17/17. The nurse reported to the DON that they were getting an x-ray of Resident #1's arm and shoulder area because of the bruising. The DON asked the nurse about the bruising, and the nurse stated that it was bruising that extended all the way up under the resident's arm and almost down to his/her elbow. It concerned them because it looked like it was swelling. The DON did not know Resident #1 had bruising prior to that time. The DON was still at the facility when the x-ray came back that it was a dislocation. When the DON left, the resident was still in the ER. Resident #1 required a total mechanical lift. The DON found that several CNAs stated they would get another person to help them if the lift was in use at the time. They would do a 2 person transfer rather than wait on the lift. She found 2 CNAs that stated they had transferred the resident without a lift a few times. The DON talked with the CNAs who normally work that unit and the nurses that work that unit. The bruising was initially found on 11/11/17 on the left upper arm and elbow area per the nursing notes. The nurse should complete an incident report if they find bruising, whether they know how it happened or not. If it is an injury of unknown origin, then they investigate to see if they know how it happened. The surveyor asked the DON about the CNAs transferring the resident without a lift and where that information was documented. The DON stated they asked the CNAs to address how they transferred the resident on their statements. The surveyor asked the DON if they review staff statements, the DON stated s/he and the ADON (Assistant) review staff statements. The DON stated none of the other residents on the same group require a total lift. The DON stated that if s/he had been notified when the bruising was first noted on 11/11/17 s/he would have started investigating at the time it was noted. The DON stated s/he goes online and reports incidents to licensure. The DON stated that is the only place s/he knows to report to. S/he has been the DON at the facility since 2014. With abuse, s/he reports to the ombudsman, the law as needed and to certification. The DON stated s/he faxes the abuse allegations and then completes the online form (licensure) for injuries of unknown origin. In an interview with the surveyor on 12/13/17 at approximately 11:30 AM, the DON stated nursing did not complete an Incident Report for the bruising on the Resident #1's arm at all. There should have been an Incident Report completed when it was noted on 11/11/17. The bruising on the resident's arm and dislocated shoulder was not noted on the facility's Incident Log. In an interview with the surveyor on 12/13/17 at approximately 12:15 PM, CNA #2 stated she has been at the facility over a year. The CNA stated they have an ADL book at the nurses' station and an apple above the resident's head that indicates the residents' transfer status. CNA #2 stated Resident #1 transfers with a mechanical lift. CNA #2 stated s/he asked CNA #3 to help change the resident's gown. The resident use to be a 2 person assist. CNA #2 did not remember if they updated the resident's apple. CNA #2 stated they transferred the resident 2 person assist the day from his/her statement. CNA #2 stated s/he told the nurse about the bruising the day s/he saw it. The bruising was on Resident #1's arm and back. CNA #2 worked 7 AM - 7 PM that day and saw the bruising around 5:30-6:30 PM that night. In an interview with the surveyor on 12/13/17 at approximately 12:30 PM, CNA #1 stated s/he had been at the facility for [AGE] years. The CNA stated there is an apple in the resident's room to let you know how to transfer the resident. CNA #1 stated they use a Marissa lift (total) for Resident #1. S/he transferred the resident one time without a lift, the resident's CNA asked for help. They transferred the resident from the bed to the geri chair. That was sometime last month. They were on each side of the resident and lifted Resident #1 under his/her arms. CNA #1 helped CNA #2, s/he did not pay attention to the apple. S/he did not look because CNA #2 said the resident was a 2 person assist. The transfer was before they found the bruising on the resident. In an interview with the surveyor on 12/13/17 at approximately 1:45 PM, CNA #4 stated she works with Resident #1. Resident #1 requires a mechanical lift with transfers. The resident use to be a 2 person assist, probably changed in the last 6 months. They have an ADL book that lets them know about the resident and how to care for them. There are also apples over the bed that indicate transfer status. Resident #1's apple says M2 which means mechanical with 2 or you can do a 2 person assist. M stands for mechanical lift. If they have 2 people then they don't have to have the lift, even with an M. Review of the facility's 5 day report to the Bureau of Health Facilities Licensing revealed on 11/17/17, around 4 PM, it was reported that Resident #1 had a bruise with some swelling to the left upper arm. It was also reported that this bruising was old in nature. The staff nurse called and received an order for [REDACTED]. The resident was sent to the emergency room . Investigation was started and revealed bruising was first noted on 11/11/17. Upon talking with staff and getting statements, it was concluded that the resident is a mechanical lift. Staff had not been lifting/transferring him/her appropriately. Staff had been lifting the resident by two person assist.

Based on review of facility files and interview, the facility failed to ensure the resident remained free from abuse, neglect, misappropriation of resident property or exploitation. Resident #1 was noted with an injury of unknown origin. The resident was found to have a dislocated shoulder. Investigation into the incident revealed several staff members admitted to transferring the resident as a two person assist, while the resident required a mechanical lift. LPN (Licensed Practical Nurse) #1 was noted to walk around with a walker mocking Resident #2. The incident was recorded by CNA (Certified Nursing Aide) #5 and the video was uploaded to a social media website. Two of three residents reviewed for abuse/neglect. The findings included: Resident #1 was noted with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Notes revealed a Weekly Nursing Summary dated 9/10/17 that indicated the resident transferred by 1-2 assist. The Nursing Note on 11/3/17 at 5:51 PM indicated a bruise was noted to the resident's left eye brow, the 1st shift CNA stated it was there at the start of his/her shift, the nurse looked at the left padded side rail and had to re-adjust the padding because the rail was exposed. MD (Medical Doctor) and responsible party were contacted. The Nursing Note dated 11/3/17 at 9:56 PM indicated a purple colored bruise was noted to the left side of the resident's eyebrow, area measures 2.5 cm x 3.2 cm. The Nursing Note dated 11/11/17 at 7:11 PM indicated Resident #1 had been up in the geri chair during the shift. When putting the resident to bed they noted bruising to the resident's left upper arm. Bruising was blue and approximately 8 x 4. Padding was in place to side rails. Responsible party was notified. Resident was non-verbal, showed no signs/symptoms of pain. On 11/12/17 at 3:50 AM the note indicated bruising was noted to the left upper arm and left side of forearm, small amount of bruising was noted to the right upper arm. On 11/13/17 at 1:59 PM the Nursing Note indicated bruising noted to the left upper arm and elbow area was purple in color, no signs/symptoms discomfort. On 11/15/17 at 6:53 PM the note indicated purple bruising was noted from left upper arm to left AC 19 cm x 17 cm and purple bruising was noted on the right arm near elbow 5.5 cm x 3 cm. The Nursing Note on 11/17/17 at 1:22 AM indicated bruises to left arm were getting less noticeable but the upper left arm was [MEDICAL CONDITION] and when you touched that area the resident grimaced. The arm also seemed a little warm to the touch. The Nursing Note on 11/17/17 at 2:33 PM indicated bruising still noted to left arm/elbow area with [MEDICAL CONDITION] noted as well, MD notified and x-ray was ordered. Responsible party attempted, no answer and message left. The Nursing Note on 11/17/17 at 9:33 PM indicated Mobilex came and took the ordered x-ray of the left shoulder and elbow. Received the fax that stated anterior dislocation left humeral head of uncertain age. Copy faxed to MD. Sent resident to ER via rescue squad. Responsible party was notified. The Nursing Note dated 11/18/17 at 2:27 AM indicated the resident returned to the floor, drowsy from medication given in the ER. Shoulder immobilizer and sling in place. Review of the Radiology Report dated 11/17/17 revealed the resident had an anterior dislocation of left humeral head of uncertain age. The report noted possible anterior subluxation of the radial head. Review of Resident #1's medical record revealed the Annual Minimum (MDS) data set [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making Review of the facility Incident Log revealed Resident #1 was listed as having an incident of bruising noted on 11/3/17. The Incident Log was noted to be for incidents occurring 11/1/17 - 11/30/17. The resident had no additional entries noted on the log. Review of the Incident Report for Resident #1 dated 11/3/17 revealed the resident was noted with bruising to the eyebrow. Review of Resident #1's care plan revealed resident is a fall risk, non-ambulatory was identified as a problem area. Interventions and approaches were listed on the care plan and included mechanical lift and 2 person assist with transfers. The care plan date was noted as 10/11/17. CNA #1's facility-obtained statement dated 11/21/17 indicated on 1st shift the CNA reported to the nurse about bruises on arm and also swelling of left arm. There was no indication of the date the incident was noted and reported. RN (Registered Nurse) #1's facility-obtained statement dated 11/18/17 indicated s/he was working 11 PM-7 AM. The CNA was giving Resident #1 a bath and called the nurse to look at the resident's arm. RN #1 checked the resident and his/her upper arm was bruised and the back of the arm also. RN #1 informed the oncoming nurse and asked if the nurse would call the doctor and responsible party. There was no indication of the date this happened. The first Progress Note related to bruising on the resident's arm by RN #1 was 11/16/17 at 3:15 AM. The note indicated bruise to left side of face and left upper arm improving. No swelling or skin tear noted. CNA #2's facility-obtained statement dated 11/20/17 indicated s/he asked CNA #3 to help him/her put Resident #1 to bed because the resident is a two person assist. While they were changing Resident #1's clothes to put on his/her night clothes they noticed a bruise on his/her upper left arm. They reported it to the nurse. There was no indication of the date this happened. CNA #3's facility-obtained statement dated 11/17/17 indicated on 11/11/17 when s/he came to work a CNA asked him/her to help with a resident. As they were getting the resident dressed, they noticed that his/her arm was bruised and they called the nurse to come in and look at the resident's arm. RN #2's facility-obtained statement indicated on 11/13/17 s/he returned to work and Resident #1 was on alert charting. The resident's left arm was bruised around the elbow area. On 11/16/17 s/he noticed that the arm still had some bruising but also the entire upper arm around the elbow and above was swollen. RN #2 noted this on night shift, so s/he gave report to the oncoming nurse so s/he could call the doctor and get an order. RN #4's facility-obtained statement dated 11/20/17 indicated s/he checked the schedule book for what charting needed to be done on 11/13/17. Resident #1 was on alert charting for bruising to the left upper arm/elbow area. Upon assessment of the area it showed bruising to the left upper arm near the elbow that covered the entire back of the arm with the front of the arm free from bruising. Resident #1 did not show any signs/symptoms of discomfort when RN #4 touched the resident's arm. Bruises were purple in color. The next day RN #4 worked on the unit was 11/17/17. When s/he assessed the bruises they had begun to turn yellow in color and [MEDICAL CONDITION] was noted to the entire arm from the upper arm to right above the wrist area. The physician was notified and an x-ray was ordered. Resident #1 did grimace on that day when the arm was touched/moved. RN #4 indicated s/he was not aware the DON (Director of Nursing) did not know about the bruising to the resident's arm as it was already on alert charting 2 days prior to his/her 1st assessment of it. There was no statement from the nurse, RN #3, who first noted the bruise to the resident's arm in the Nursing Notes on 11/11/17. In an interview with the surveyor on 12/12/17 at approximately 1:25 PM, the DON stated the bruising was reported to him/her on 11/17/17. The nurse reported to the DON that they were getting an x-ray of Resident #1's arm and shoulder area because of the bruising. The DON asked the nurse about the bruising, and the nurse stated that it was bruising that extended all the way up under the resident's arm and almost down to his/her elbow. It concerned them because it looked like it was swelling. The DON did not know Resident #1 had bruising prior to that time. The DON was still at the facility when the x-ray came back that it was a dislocation. When the DON left, the resident was still in the ER. Resident #1 required a total mechanical lift. The DON found that several CNAs stated they would get another person to help them if the lift was in use at the time. They would do a 2 person transfer rather than wait on the lift. She found 2 CNAs that stated they had transferred the resident without a lift a few times. The DON talked with the CNAs who normally work that unit and the nurses that work that unit. The bruising was initially found on 11/11/17 on the left upper arm and elbow area per the nursing notes. The nurse should complete an incident report if they find bruising, whether they know how it happened or not. If it is an injury of unknown origin, then they investigate to see if they know how it happened. The surveyor asked the DON about the CNAs transferring the resident without a lift and where that information was documented. The DON stated they asked the CNAs to address how they transferred the resident on their statements. The surveyor asked the DON if they review staff statements, the DON stated s/he and the ADON (Assistant) review staff statements. The DON stated none of the other residents on the same group require a total lift. The DON stated that if s/he had been notified when the bruising was first noted on 11/11/17 s/he would have started investigating at the time it was noted. The DON stated s/he goes online and reports incidents to licensure. The DON stated that is the only place s/he knows to report to. S/he has been the DON at the facility since 2014. With abuse, s/he reports to the ombudsman, the law as needed and to certification. The DON stated s/he faxes the abuse allegations and then completes the online form (licensure) for injuries of unknown origin. The DON stated s/he did not report the allegations of abuse for Resident #2 to certification, only to licensing. In an interview with the surveyor on 12/13/17 at approximately 11:30 AM, the DON stated nursing did not complete an Incident Report for the bruising on the Resident #1's arm at all. There should have been an Incident Report completed when it was noted on 11/11/17. The bruising on the resident's arm and dislocated shoulder was not noted on the facility's Incident Log. In an interview with the surveyor on 12/13/17 at approximately 12:15 PM, CNA #2 stated she has been at the facility over a year. The CNA stated they have an ADL book at the nurses' station and an apple above the resident's head that indicates the residents' transfer status. CNA #2 stated Resident #1 transfers with a mechanical lift. CNA #2 stated s/he asked CNA #3 to help change the resident's gown. The resident use to be a 2 person assist. CNA #2 did not remember if they updated the resident's apple. CNA #2 stated they transferred the resident 2 person assist the day from his/her statement. CNA #2 stated s/he told the nurse about the bruising the day s/he saw it. The bruising was on Resident #1's arm and back. CNA #2 worked 7 AM - 7 PM that day and saw the bruising around 5:30-6:30 PM that night. In an interview with the surveyor on 12/13/17 at approximately 12:30 PM, CNA #1 stated s/he had been at the facility for [AGE] years. The CNA stated there is an apple in the resident's room to let you know how to transfer the resident. CNA #1 stated they use a Marissa lift (total) for Resident #1. S/he transferred the resident one time without a lift, the resident's CNA asked for help. They transferred the resident from the bed to the geri chair. That was sometime last month. They were on each side of the resident and lifted Resident #1 under his/her arms. CNA #1 helped CNA #2, s/he did not pay attention to the apple. S/he did not look because CNA #2 said the resident was a 2 person assist. The transfer was before they found the bruising on the resident. In an interview with the surveyor on 12/13/17 at approximately 1:45 PM, CNA #4 stated she works with Resident #1. Resident #1 requires a mechanical lift with transfers. The resident use to be a 2 person assist, probably changed in the last 6 months. They have an ADL book that lets them know about the resident and how to care for them. There are also apples over the bed that indicate transfer status. Resident #1's apple says M2 which means mechanical with 2 or you can do a 2 person assist. M stands for mechanical lift. If they have 2 people then they don't have to have the lift, even with an M. Review of the facility's 5 day report to the Bureau of Health Facilities Licensing revealed on 11/17/17, around 4 PM, it was reported that Resident #1 had a bruise with some swelling to the left upper arm. It was also reported that this bruising was old in nature. The staff nurse called and received an order for [REDACTED]. The resident was sent to the emergency room . Investigation was started and revealed bruising was first noted on 11/11/17. Upon talking with staff and getting statements, it was concluded that the resident is a mechanical lift. Staff had not been lifting/transferring him/her appropriately. Staff had been lifting the resident by two person assist. The facility made a 24 hour report of neglect or exploitation, suspected or confirmed abuse to licensing on 11/13/17 for Resident #2. The email confirmation was on 11/13/17 at 5:09 PM. The email confirmed submission of the report to the Bureau of Health Facilities Licensing. Review of the 24 hour report to the Bureau of Health Facilities Licensing revealed LPN #1 was walking with a walker mocking a Resident #2 as s/he was walking. LPN #1 stated s/he was just playing around with the resident. While this was occurring, CNA #5 videoed the incident and the incident was uploaded to a social media website. The resident's face was not in the video, but family was somehow made aware of the video and were able to identify that the person in the video was indeed their parent. The incident occurred on 11/11/17, but management was not made aware until late evening on 11/12/17. Review of the 5 day report to the Bureau of Health Facilities Licensing revealed the investigation found that by definition of mental abuse, which includes the taking and posting of photographs or recordings, the incident was substantiated. The ADON's facility-obtained statement indicated s/he watched the video posted to a social media website. The video was posted to the social media website by CNA #5. CNA #5's facility-obtained statement dated 11/14/17 indicated s/he did not know his/her phone was recording. LPN #1 was saying to Resident #2 one minute you like me and the next minute you don't but at the same time LPN #1 and Resident #2 were laughing about it. CNA #5's statement indicated that by his/her phone moving in his/her pocket it posted the video. A note by QA nurse at the bottom of the statement indicated during interview the staff member admitted that s/he knew the phone was on and recording and s/he took the video. LPN #1's facility-obtained statement dated 11/15/17 indicated s/he was in the building walking around with another resident's walker which is something they do at times just being playful with the residents. LPN #1 and Resident #2 began exchanging words in a friendly manner. The resident said you pick on me and LPN #2 said no you pick on me and LPN #1 said you are mean to me at times. All of this was in a playful manner. Only playing around with the residents. LPN #2 then walked off with the walker down the hall. LPN #1 did not know that the whole instance was being recorded on video. CNA #6's facility-obtained statement dated 11/15/17 indicated everybody was around the front entrance. S/he saw LPN #1 sitting and s/he sat down beside him/her. Everyone was laughing but s/he didn't know what was going on. There were several staff members around. CNA #6 eventually saw the video later the next day. What s/he saw on it was LPN #1 playing with another walker passing Resident #2. S/he heard Resident #2 talking junk like s/he always does. S/he really didn't think anything of it. It was a stupid mistake. LPN #2's facility-obtained statement dated 11/15/17 indicated s/he saw LPN #1 walking with a rolling walker. S/he and several other residents and staff laughed at the fact s/he was playing with the walker. Review of the Disciplinary Warning Record for LPN #1 and CNA #5 indicated they participated in behavior that brought mental anguish to a resident at the time. A police Incident Report was completed on 11/15/17. The dispatch time was 1035 on 11/15/17 and arrived at 1100. The incident date was noted as 11/11/17 at 1430. In an interview with the surveyor on 12/12/17 at approximately 2:30 PM, the DON stated s/he got a phone call 11/12/17 from the ADON, who was on call. The ADON said that one of the nurses at the facility called him/her because Resident #2's family was at the facility and had a complaint. The complaint was that they saw a video posted to a social media website and they knew it was their parent, even though it didn't have their face in it. The family wanted to talk to administration now. The resident's son said the nurse was mocking his parent in the video. The administrator and ADON came to the facility and talked with the son. It was on Sunday 11/12/17 around 5:00 PM when s/he got the phone call about the incident. The DON saw the video and stated it was hard to understand what was being said. S/he saw Resident #2 standing with his/her walker and LPN #1 was walking with a walker in a fast paced mode, LPN #1 was saying something. The DON could not understand what LPN #1 was saying. LPN #1 said s/he was trying to get the resident's to laugh, not to make fun of Resident #2. The family took it as mocking Resident #2. CNA #5 admitted to taking the video but said s/he didn't upload it to a social media website. Later the day of the incident, other staff watched the video on CNA #5's phone. The resident's son said another family member saw the video on the social media website and that is how he found out. Review of the facility's Abuse Prohibition/Investigation Policy revealed the facility will prohibit abuse and neglect. The facility defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes the taking and posting of photographs or recordings in any manner that would demean or humiliate a resident. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Abuse Prohibition/Investigation Policy indicated training will be provided to all employees about how staff should report their knowledge related to allegations, what constitutes abuse and neglect, interacting with residents to maintain and enhance self esteem/self worth, and inappropriate use of electronic devices such as phones, photos or recordings of residents that are used to demean or humiliate. The Abuse Prohibition/Investigation Policy indicated staff will be responsible for identifying and reporting occurrences that may constitute events of abuse and neglect. Some examples may include suspicious bruising and any injury of unknown origin. Anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and to report it to the nursing supervisor immediately. All reports of suspected abuse must be reported to the Administrator immediately. The family is to be notified of the facts surrounding the allegations. The state/federal reporting requirements for alleged incidents must be followed. The administrator will report findings of all completed investigations per state requirements.

Based on review of facility files and interview, the facility failed to immediately inform the resident's physician when there was an incident involving the resident which resulted in injury and had the potential for requiring physician intervention. Resident #1 was noted with bruising to his/her arm on 11/11/17. The physician was not notified and there was no Incident Report completed when the bruising was initially found. The physician was notified on 11/17/17 and an x-ray was obtained which showed a displaced shoulder. The resident was sent out to the emergency room . One of three resident's reviewed for notification. The findings included: Resident #1 was noted with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Notes revealed a Weekly Nursing Summary dated 9/10/17 that indicated the resident transferred by 1-2 assist. The Nursing Note on 11/3/17 at 5:51 PM indicated a bruise was noted to the resident's left eye brow, the 1st shift CNA (Certified Nursing Aide) stated it was there at the start of his/her shift, the nurse looked at the left padded side rail and had to re-adjust the padding because the rail was exposed. MD (Medical Doctor) and responsible party were contacted. The Nursing Note dated 11/3/17 at 9:56 PM indicated a purple colored bruise was noted to the left side of the resident's eyebrow, area measures 2.5 cm x 3.2 cm. The Nursing Note dated 11/11/17 at 7:11 PM indicated Resident #1 had been up in the geri chair during the shift. When putting the resident to bed they noted bruising to the resident's left upper arm. Bruising was blue and approximately 8 x 4. Padding was in place to side rails. Responsible party was notified. Resident was non-verbal, showed no signs/symptoms of pain. On 11/12/17 at 3:50 AM the note indicated bruising was noted to the left upper arm and left side of forearm, small amount of bruising was noted to the right upper arm. On 11/13/17 at 1:59 PM the Nursing Note indicated bruising noted to the left upper arm and elbow area was purple in color, no signs/symptoms discomfort. On 11/15/17 at 6:53 PM the note indicated purple bruising was noted from left upper arm to left AC 19 cm x 17 cm and purple bruising was noted on the right arm near elbow 5.5 cm x 3 cm. The Nursing Note on 11/17/17 at 1:22 AM indicated bruises to left arm were getting less noticeable but the upper left arm was [MEDICAL CONDITION] and when you touched that area the resident grimaced. The arm also seemed a little warm to the touch. The Nursing Note on 11/17/17 at 2:33 PM indicated bruising still noted to left arm/elbow area with [MEDICAL CONDITION] noted as well, MD notified and x-ray was ordered. Responsible party attempted, no answer and message left. The Nursing Note on 11/17/17 at 9:33 PM indicated Mobilex came and took the ordered x-ray of the left shoulder and elbow. Received the fax that stated anterior dislocation left humeral head of uncertain age. Copy faxed to MD. Sent resident to ER via rescue squad. Responsible party was notified. The Nursing Note dated 11/18/17 at 2:27 AM indicated the resident returned to the floor, drowsy from medication given in the ER. Shoulder immobilizer and sling in place. Review of the Radiology Report dated 11/17/17 revealed the resident had an anterior dislocation of left humeral head of uncertain age. The report noted possible anterior subluxation of the radial head. Review of Resident #1's medical record revealed the Annual Minimum (MDS) data set [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making Review of the facility Incident Log revealed Resident #1 was listed as having an incident of bruising noted on 11/3/17. The Incident Log was noted to be for incidents occurring 11/1/17 - 11/30/17. The resident had no additional entries noted on the log. Review of the Incident Report for Resident #1 dated 11/3/17 revealed the resident was noted with bruising to the eyebrow. Review of Resident #1's care plan revealed resident is a fall risk, non-ambulatory was identified as a problem area. Interventions and approaches were listed on the care plan and included mechanical lift and 2 person assist with transfers. The care plan date was noted as 10/11/17. CNA #1's facility-obtained statement dated 11/21/17 indicated on 1st shift the CNA reported to the nurse about bruises on arm and also swelling of left arm. There was no indication of the date the incident was noted and reported. RN (Registered Nurse) #1's facility-obtained statement dated 11/18/17 indicated s/he was working 11 PM-7 AM. The CNA was giving Resident #1 a bath and called the nurse to look at the resident's arm. RN #1 checked the resident and his/her upper arm was bruised and the back of the arm also. RN #1 informed the oncoming nurse and asked if the nurse would call the doctor and responsible party. There was no indication of the date this happened. The first Progress Note related to bruising on the resident's arm by RN #1 was 11/16/17 at 3:15 AM. The note indicated bruise to left side of face and left upper arm improving. No swelling or skin tear noted. CNA #2's facility-obtained statement dated 11/20/17 indicated s/he asked CNA #3 to help him/her put Resident #1 to bed because the resident is a two person assist. While they were changing Resident #1's clothes to put on his/her night clothes they noticed a bruise on his/her upper left arm. They reported it to the nurse. There was no indication of the date this happened. CNA #3's facility-obtained statement dated 11/17/17 indicated on 11/11/17 when s/he came to work a CNA asked him/her to help with a resident. As they were getting the resident dressed, they noticed that his/her arm was bruised and they called the nurse to come in and look at the resident's arm. RN #2's facility-obtained statement indicated on 11/13/17 s/he returned to work and Resident #1 was on alert charting. The resident's left arm was bruised around the elbow area. On 11/16/17 s/he noticed that the arm still had some bruising but also the entire upper arm around the elbow and above was swollen. RN #2 noted this on night shift, so s/he gave report to the oncoming nurse so s/he could call the doctor and get an order. RN #4's facility-obtained statement dated 11/20/17 indicated s/he checked the schedule book for what charting needed to be done on 11/13/17. Resident #1 was on alert charting for bruising to the left upper arm/elbow area. Upon assessment of the area it showed bruising to the left upper arm near the elbow that covered the entire back of the arm with the front of the arm free from bruising. Resident #1 did not show any signs/symptoms of discomfort when RN #4 touched the resident's arm. Bruises were purple in color. The next day RN #4 worked on the unit was 11/17/17. When s/he assessed the bruises they had begun to turn yellow in color and [MEDICAL CONDITION] was noted to the entire arm from the upper arm to right above the wrist area. The physician was notified and an x-ray was ordered. Resident #1 did grimace on that day when the arm was touched/moved. RN #4 indicated s/he was not aware the DON (Director of Nursing) did not know about the bruising to the resident's arm as it was already on alert charting 2 days prior to his/her 1st assessment of it. There was no statement from the nurse, RN #3, who first noted the bruise to the resident's arm in the Nursing Notes on 11/11/17. In an interview with the surveyor on 12/12/17 at approximately 1:25 PM, the DON stated the bruising was reported to him/her on 11/17/17. The nurse reported to the DON that they were getting an x-ray of Resident #1's arm and shoulder area because of the bruising. The DON asked the nurse about the bruising, and the nurse stated that it was bruising that extended all the way up under the resident's arm and almost down to his/her elbow. It concerned them because it looked like it was swelling. The DON did not know Resident #1 had bruising prior to that time. The DON was still at the facility when the x-ray came back that it was a dislocation. When the DON left, the resident was still in the ER. Resident #1 required a total mechanical lift. The DON found that several CNAs stated they would get another person to help them if the lift was in use at the time. They would do a 2 person transfer rather than wait on the lift. She found 2 CNAs that stated they had transferred the resident without a lift a few times. The DON talked with the CNAs who normally work that unit and the nurses that work that unit. The bruising was initially found on 11/11/17 on the left upper arm and elbow area per the nursing notes. The nurse should complete an incident report if they find bruising, whether they know how it happened or not. If it is an injury of unknown origin, then they investigate to see if they know how it happened. The surveyor asked the DON about the CNAs transferring the resident without a lift and where that information was documented. The DON stated they asked the CNAs to address how they transferred the resident on their statements. The surveyor asked the DON if they review staff statements, the DON stated s/he and the ADON (Assistant) review staff statements. The DON stated none of the other residents on the same group require a total lift. The DON stated that if s/he had been notified when the bruising was first noted on 11/11/17 s/he would have started investigating at the time it was noted. The DON stated s/he goes online and reports incidents to licensure. The DON stated that is the only place s/he knows to report to. S/he has been the DON at the facility since 2014. With abuse, s/he reports to the ombudsman, the law as needed and to certification. The DON stated s/he faxes the abuse allegations and then completes the online form (licensure) for injuries of unknown origin. In an interview with the surveyor on 12/13/17 at approximately 11:30 AM, the DON stated nursing did not complete an Incident Report for the bruising on the Resident #1's arm at all. There should have been an Incident Report completed when it was noted on 11/11/17. The bruising on the resident's arm and dislocated shoulder was not noted on the facility's Incident Log. In an interview with the surveyor on 12/13/17 at approximately 12:15 PM, CNA #2 stated she has been at the facility over a year. The CNA stated they have an ADL book at the nurses' station and an apple above the resident's head that indicates the residents' transfer status. CNA #2 stated Resident #1 transfers with a mechanical lift. CNA #2 stated s/he asked CNA #3 to help change the resident's gown. The resident use to be a 2 person assist. CNA #2 did not remember if they updated the resident's apple. CNA #2 stated they transferred the resident 2 person assist the day from his/her statement. CNA #2 stated s/he told the nurse about the bruising the day s/he saw it. The bruising was on Resident #1's arm and back. CNA #2 worked 7 AM - 7 PM that day and saw the bruising around 5:30-6:30 PM that night. In an interview with the surveyor on 12/13/17 at approximately 12:30 PM, CNA #1 stated s/he had been at the facility for [AGE] years. The CNA stated there is an apple in the resident's room to let you know how to transfer the resident. CNA #1 stated they use a Marissa lift (total) for Resident #1. S/he transferred the resident one time without a lift, the resident's CNA asked for help. They transferred the resident from the bed to the geri chair. That was sometime last month. They were on each side of the resident and lifted Resident #1 under his/her arms. CNA #1 helped CNA #2, s/he did not pay attention to the apple. S/he did not look because CNA #2 said the resident was a 2 person assist. The transfer was before they found the bruising on the resident. In an interview with the surveyor on 12/13/17 at approximately 1:45 PM, CNA #4 stated she works with Resident #1. Resident #1 requires a mechanical lift with transfers. The resident use to be a 2 person assist, probably changed in the last 6 months. They have an ADL book that lets them know about the resident and how to care for them. There are also apples over the bed that indicate transfer status. Resident #1's apple says M2 which means mechanical with 2 or you can do a 2 person assist. M stands for mechanical lift. If they have 2 people then they don't have to have the lift, even with an M. Review of the facility's 5 day report to the Bureau of Health Facilities Licensing revealed on 11/17/17, around 4 PM, it was reported that Resident #1 had a bruise with some swelling to the left upper arm. It was also reported that this bruising was old in nature. The staff nurse called and received an order for [REDACTED]. The resident was sent to the emergency room . Investigation was started and revealed bruising was first noted on 11/11/17. Upon talking with staff and getting statements, it was concluded that the resident is a mechanical lift. Staff had not been lifting/transferring him/her appropriately. Staff had been lifting the resident by two person assist.

Based on review of facility files and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted with bruising to his/her arm on 11/11/17. The physician was notified on 11/17/17 and an x-ray was obtained which showed a displaced shoulder. The resident was sent out to the emergency room . There facility investigation revealed several staff were transferring Resident #1 with 2 person assist, not using the total lift that the resident required. Interview with staff revealed they did not know how to appropriately transfer the resident at the time of the complaint investigation. One of three resident's reviewed for accidents. The findings included: Resident #1 was noted with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Notes revealed a Weekly Nursing Summary dated 9/10/17 that indicated the resident transferred by 1-2 assist. The Nursing Note on 11/3/17 at 5:51 PM indicated a bruise was noted to the resident's left eye brow, the 1st shift CNA (Certified Nursing Aide) stated it was there at the start of his/her shift, the nurse looked at the left padded side rail and had to re-adjust the padding because the rail was exposed. MD (Medical Doctor) and responsible party were contacted. The Nursing Note dated 11/3/17 at 9:56 PM indicated a purple colored bruise was noted to the left side of the resident's eyebrow, area measures 2.5 cm x 3.2 cm. The Nursing Note dated 11/11/17 at 7:11 PM indicated Resident #1 had been up in the geri chair during the shift. When putting the resident to bed they noted bruising to the resident's left upper arm. Bruising was blue and approximately 8 x 4. Padding was in place to side rails. Responsible party was notified. Resident was non-verbal, showed no signs/symptoms of pain. On 11/12/17 at 3:50 AM the note indicated bruising was noted to the left upper arm and left side of forearm, small amount of bruising was noted to the right upper arm. On 11/13/17 at 1:59 PM the Nursing Note indicated bruising noted to the left upper arm and elbow area was purple in color, no signs/symptoms discomfort. On 11/15/17 at 6:53 PM the note indicated purple bruising was noted from left upper arm to left AC 19 cm x 17 cm and purple bruising was noted on the right arm near elbow 5.5 cm x 3 cm. The Nursing Note on 11/17/17 at 1:22 AM indicated bruises to left arm were getting less noticeable but the upper left arm was [MEDICAL CONDITION] and when you touched that area the resident grimaced. The arm also seemed a little warm to the touch. The Nursing Note on 11/17/17 at 2:33 PM indicated bruising still noted to left arm/elbow area with [MEDICAL CONDITION] noted as well, MD notified and x-ray was ordered. Responsible party attempted, no answer and message left. The Nursing Note on 11/17/17 at 9:33 PM indicated Mobilex came and took the ordered x-ray of the left shoulder and elbow. Received the fax that stated anterior dislocation left humeral head of uncertain age. Copy faxed to MD. Sent resident to ER via rescue squad. Responsible party was notified. The Nursing Note dated 11/18/17 at 2:27 AM indicated the resident returned to the floor, drowsy from medication given in the ER. Shoulder immobilizer and sling in place. Review of the Radiology Report dated 11/17/17 revealed the resident had an anterior dislocation of left humeral head of uncertain age. The report noted possible anterior subluxation of the radial head. Review of Resident #1's medical record revealed the Annual Minimum (MDS) data set [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making Review of the facility Incident Log revealed Resident #1 was listed as having an incident of bruising noted on 11/3/17. The Incident Log was noted to be for incidents occurring 11/1/17 - 11/30/17. The resident had no additional entries noted on the log. Review of the Incident Report for Resident #1 dated 11/3/17 revealed the resident was noted with bruising to the eyebrow. Review of Resident #1's care plan revealed resident is a fall risk, non-ambulatory was identified as a problem area. Interventions and approaches were listed on the care plan and included mechanical lift and 2 person assist with transfers. The care plan date was noted as 10/11/17. CNA #1's facility-obtained statement dated 11/21/17 indicated on 1st shift the CNA reported to the nurse about bruises on arm and also swelling of left arm. There was no indication of the date the incident was noted and reported. RN (Registered Nurse) #1's facility-obtained statement dated 11/18/17 indicated s/he was working 11 PM-7 AM. The CNA was giving Resident #1 a bath and called the nurse to look at the resident's arm. RN #1 checked the resident and his/her upper arm was bruised and the back of the arm also. RN #1 informed the oncoming nurse and asked if the nurse would call the doctor and responsible party. There was no indication of the date this happened. The first Progress Note related to bruising on the resident's arm by RN #1 was 11/16/17 at 3:15 AM. The note indicated bruise to left side of face and left upper arm improving. No swelling or skin tear noted. CNA #2's facility-obtained statement dated 11/20/17 indicated s/he asked CNA #3 to help him/her put Resident #1 to bed because the resident is a two person assist. While they were changing Resident #1's clothes to put on his/her night clothes they noticed a bruise on his/her upper left arm. They reported it to the nurse. There was no indication of the date this happened. CNA #3's facility-obtained statement dated 11/17/17 indicated on 11/11/17 when s/he came to work a CNA asked him/her to help with a resident. As they were getting the resident dressed, they noticed that his/her arm was bruised and they called the nurse to come in and look at the resident's arm. RN #2's facility-obtained statement indicated on 11/13/17 s/he returned to work and Resident #1 was on alert charting. The resident's left arm was bruised around the elbow area. On 11/16/17 s/he noticed that the arm still had some bruising but also the entire upper arm around the elbow and above was swollen. RN #2 noted this on night shift, so s/he gave report to the oncoming nurse so s/he could call the doctor and get an order. RN #4's facility-obtained statement dated 11/20/17 indicated s/he checked the schedule book for what charting needed to be done on 11/13/17. Resident #1 was on alert charting for bruising to the left upper arm/elbow area. Upon assessment of the area it showed bruising to the left upper arm near the elbow that covered the entire back of the arm with the front of the arm free from bruising. Resident #1 did not show any signs/symptoms of discomfort when RN #4 touched the resident's arm. Bruises were purple in color. The next day RN #4 worked on the unit was 11/17/17. When s/he assessed the bruises they had begun to turn yellow in color and [MEDICAL CONDITION] was noted to the entire arm from the upper arm to right above the wrist area. The physician was notified and an x-ray was ordered. Resident #1 did grimace on that day when the arm was touched/moved. RN #4 indicated s/he was not aware the DON (Director of Nursing) did not know about the bruising to the resident's arm as it was already on alert charting 2 days prior to his/her 1st assessment of it. There was no statement from the nurse, RN #3, who first noted the bruise to the resident's arm in the Nursing Notes on 11/11/17. In an interview with the surveyor on 12/12/17 at approximately 1:25 PM, the DON stated the bruising was reported to him/her on 11/17/17. The nurse reported to the DON that they were getting an x-ray of Resident #1's arm and shoulder area because of the bruising. The DON asked the nurse about the bruising, and the nurse stated that it was bruising that extended all the way up under the resident's arm and almost down to his/her elbow. It concerned them because it looked like it was swelling. The DON did not know Resident #1 had bruising prior to that time. The DON was still at the facility when the x-ray came back that it was a dislocation. When the DON left, the resident was still in the ER. Resident #1 required a total mechanical lift. The DON found that several CNAs stated they would get another person to help them if the lift was in use at the time. They would do a 2 person transfer rather than wait on the lift. She found 2 CNAs that stated they had transferred the resident without a lift a few times. The DON talked with the CNAs who normally work that unit and the nurses that work that unit. The bruising was initially found on 11/11/17 on the left upper arm and elbow area per the nursing notes. The nurse should complete an incident report if they find bruising, whether they know how it happened or not. If it is an injury of unknown origin, then they investigate to see if they know how it happened. The surveyor asked the DON about the CNAs transferring the resident without a lift and where that information was documented. The DON stated they asked the CNAs to address how they transferred the resident on their statements. The surveyor asked the DON if they review staff statements, the DON stated s/he and the ADON (Assistant) review staff statements. The DON stated none of the other residents on the same group require a total lift. The DON stated that if s/he had been notified when the bruising was first noted on 11/11/17 s/he would have started investigating at the time it was noted. The DON stated s/he goes online and reports incidents to licensure. The DON stated that is the only place s/he knows to report to. S/he has been the DON at the facility since 2014. With abuse, s/he reports to the ombudsman, the law as needed and to certification. The DON stated s/he faxes the abuse allegations and then completes the online form (licensure) for injuries of unknown origin. In an interview with the surveyor on 12/13/17 at approximately 11:30 AM, the DON stated nursing did not complete an Incident Report for the bruising on the Resident #1's arm at all. There should have been an Incident Report completed when it was noted on 11/11/17. The bruising on the resident's arm and dislocated shoulder was not noted on the facility's Incident Log. In an interview with the surveyor on 12/13/17 at approximately 12:15 PM, CNA #2 stated she has been at the facility over a year. The CNA stated they have an ADL book at the nurses' station and an apple above the resident's head that indicates the residents' transfer status. CNA #2 stated Resident #1 transfers with a mechanical lift. CNA #2 stated s/he asked CNA #3 to help change the resident's gown. The resident use to be a 2 person assist. CNA #2 did not remember if they updated the resident's apple. CNA #2 stated they transferred the resident 2 person assist the day from his/her statement. CNA #2 stated s/he told the nurse about the bruising the day s/he saw it. The bruising was on Resident #1's arm and back. CNA #2 worked 7 AM - 7 PM that day and saw the bruising around 5:30-6:30 PM that night. In an interview with the surveyor on 12/13/17 at approximately 12:30 PM, CNA #1 stated s/he had been at the facility for [AGE] years. The CNA stated there is an apple in the resident's room to let you know how to transfer the resident. CNA #1 stated they use a Marissa lift (total) for Resident #1. S/he transferred the resident one time without a lift, the resident's CNA asked for help. They transferred the resident from the bed to the geri chair. That was sometime last month. They were on each side of the resident and lifted Resident #1 under his/her arms. CNA #1 helped CNA #2, s/he did not pay attention to the apple. S/he did not look because CNA #2 said the resident was a 2 person assist. The transfer was before they found the bruising on the resident. In an interview with the surveyor on 12/13/17 at approximately 1:45 PM, CNA #4 stated she works with Resident #1. Resident #1 requires a mechanical lift with transfers. The resident use to be a 2 person assist, probably changed in the last 6 months. They have an ADL book that lets them know about the resident and how to care for them. There are also apples over the bed that indicate transfer status. Resident #1's apple says M2 which means mechanical with 2 or you can do a 2 person assist. M stands for mechanical lift. If they have 2 people then they don't have to have the lift, even with an M. Review of the facility's 5 day report to the Bureau of Health Facilities Licensing revealed on 11/17/17, around 4 PM, it was reported that Resident #1 had a bruise with some swelling to the left upper arm. It was also reported that this bruising was old in nature. The staff nurse called and received an order for [REDACTED]. The resident was sent to the emergency room . Investigation was started and revealed bruising was first noted on 11/11/17. Upon talking with staff and getting statements, it was concluded that the resident is a mechanical lift. Staff had not been lifting/transferring him/her appropriately. Staff had been lifting the resident by two person assist.

Based on record review and interview it was determined the facility failed to follow care plan interventions for 1 resident. Resident #135 was identified with a fall history and sustained a fall with significant injuries on 5/2/15. The facility developed interventions to place the resident at the nurses' station for closer supervision when agitated. On 5/28/15 the resident was placed in the nurses' station while agitated and was left unsupervised. The resident sustained [REDACTED].-legs and Geri-sleeves as care planned for Resident #72. The findings include: Closed record review revealed Resident #135 was admitted to facility 3/3/15 with [DIAGNOSES REDACTED]. Admission MDS 3/9/15 BIMS 12 with moderately impaired cognitions and no behaviors noted. Total dependent on staff for ADLs with one person assist. Incontinent of bowel and bladder no impairment of upper and lower extremities but has [DIAGNOSES REDACTED]. Care plan dated 3/3/15 with revision date 6/5/15 identified problem with ADL deficit requiring extensive to total staff assistance. Problem at risk for impaired skin integrity related to incontinence and vaginal drainage-perform weekly skin assessments; report any skin breakdown to MD/NP; incontinent care as needed (resident has problem with frequent episodes of diarrhea related to ATB therapy); turn and reposition frequently. Problem resident with significant fall history interventions include dysom cushion to chair; up in w/c at nurses station do not leave alone unless in high traffic areas. Floor mats to bedside; bolster cushion when in bed; pressure pad alarm when in bed. Nursing notes dated 5/28/15 5:30pm documents the resident fell out of the w/c resident was sitting at nurses ' station, nurse left bldg. And CNAs providing care to other residents, fell out of w/c on floor has laceration and skin tear to left knee. MD and resp. party notified. Sent to ER for evaluation and treatment. Interview on 6/9/16 at 3:30pm with the LPN #8 assigned to the resident on 5/28/15. The nurse stated the resident initially was in bed but was becoming agitated and trying to get out of bed. The staff decided to put the resident in wheelchair and position her at the nurses ' station for closer observation according to the care plan. The nurse states that she had to leave the nursing unit for few minutes but instructed the CNAs to monitor this resident at the nurses ' station. There were 3 CNAs assigned to the unit and the CNAs were providing care to the other residents and answering call lights leaving the resident unsupervised at the nurses ' station for a few minutes. The resident wiggles out of the wheelchair and fell to floor and chair alarm alerted the CNAs to the resident ' s fall. LPN #8 states the CNAs immediately informed her of the incident and the nurse returned to the unit; examined the resident who had sustained a laceration to the lip and skin tear to the knee. The nurse notified the MD and obtained orders to have her sent to the ER for evaluation and treatment. The responsible party was notified. The nurse stated she assumed the CNAs would follow her instructions to monitor the resident while she was gone. The facility failed to follow the care plan interventions to place the resident in a w/c at the nurses station and not leave alone unless in high traffic areas. (Cross reference to F323) Resident #72 admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] recorded the Brief Interview for Mental Status (BIMS) score of two (2): severe cognitive impairment. The MDS recorded the resident required total staff dependence for transfers, locomotion off the unit, personal hygiene and bathing, and required extensive staff assistance for bed mobility, locomotion in the corridor and dressing. The Pressure Ulcer Care Area Assessment (CAA) dated 12/6/15 included, Heels floated when in bed as (the resident) will allow. Wears geri legs at all times. The physician's orders [REDACTED]. The pressure ulcer care plan dated 5/30/16 directed staff to place a cushion in the seat of the wheelchair, float heels in bed as resident will allow, and Geri-legs and Geri-sleeves at all times except during Activities of Daily Living (ADL) care. The fall care plan and contractures care plan dated 5/30/16 directed staff to observe sitting position when in chair and assist with repositioning when noted sliding or leaning. Observation on 6/7/16 at 11:54 AM revealed the resident in the dining area, leaning to the left in the wheelchair with the resident's right arm up on the armrest that appeared almost at shoulder height. The wheelchair lacked a cushion. Staff failed to reposition the resident in the wheelchair. Observation on 6/8/16 at 9:36 AM, 12:07 PM, 12:49 PM, 1:00 PM, 1:11 PM and 2:39 PM revealed the resident in bed in short-sleeved pajamas and no Geri-sleeves. Interview on 6/8/16 at 2:41 PM with Direct Care (DC) staff #A who stated he/she turned and repositioned the resident with pillows in bed, but did not float the resident's heels on a pillow, and did not apply the Geri-legs and Geri-sleeves as directed. Observation and interview on 6/8/16 at 2:53 PM, LN #3 stated the resident should have had pillows under his/her lower legs to float the heels. Observation revealed the resident wore white cotton socks. No Geri-sleeves or Geri-legs observed. LN #3 stated, I try to do my best to monitor the devices and residents when I am out on the floor. Observation on 6/9/16 at 11:37 AM revealed the resident in the wheelchair leaning to the left. The wheelchair lacked a cushion. Staff failed to reposition the resident in the wheelchair. During interview on 6/9/16 at 11:56 AM, LN #6, Unit Manager, acknowledged Direct Care staff failed to implement the resident's care plan for wheelchair positioning, cushion use, floating the heels, application of Geri-sleeves and Geri-legs for the resident. LN #6 stated DC staff should have followed the Nurse Aide's Information Sheet in the ADL book, which directs, Float heels when in bed, and Geri-legs and Geri-sleeves at all times except during ADL care. LN #6 acknowledged the Licensed Nurse failed to monitor DC staff to provide the resident's care plan interventions. Interview and observation on 6/9/16 at 1:55 PM. Upon request, the Physical Therapist observed the resident in the wheelchair and stated, .It would also help to have a cushion in the chair because the cushion would change the dynamics of the positioning. During interview on 6/9/16 at 3:51 PM, the Director of Nursing (DON) acknowledged the lack of staff providing the care plan interventions: failing to provide the wheelchair cushion, failing to reposition the resident in the wheelchair, failing to float the heels, and failing to apply the resident ' s Geri-legs and Geri-sleeves. The DON was informed that even after staff was notified about these concerns on 6/8/16, staff failed to implement the interventions again on 6/9/16.

Based on record review, interview, and review of facility policy, it was determined the facility failed to provide adequate supervision for 1 resident identified with a history of falls. Resident #135 was identified at risk for falls and has sustained several falls prior to 5/28/15. On 5/28/15 the resident was placed in wheelchair at the nurses ' station for closer supervision. The resident was left unattended and sustained a fall with injuries requiring treatment at the emergency room . The findings include: Fall and Falls Risk Policy with revision date 12/2007 outlines the facility staff will identify interventions related to the resident ' s specific risk and causes to try to prevent the resident from falling and to try to minimize the complications from falling. Accident and Incident Investigation policy dated 6/2001 outlines the facility will investigate all incidents in a timely manner to promote the safety of the residents, visitors and employees. Closed record review revealed Resident #135 was admitted to facility 3/3/15 with [DIAGNOSES REDACTED]. Admission Minimum Data Set ((MDS) dated [DATE] documents the resident with a Brief Interview Mental Status (BIMS) score of 12 indicating the resident was moderately impaired cognitions and no behaviors noted. Total dependence on staff for ADLs with 1 person assist. Incontinent of bowel and bladder no impairment of upper and lower extremities but has [DIAGNOSES REDACTED]. Care Area Assessment Summary dated 3/9/15 shows triggers for ADL functions cognition, incontinence feeding dehydration, pressure ulcers and pain. The resident ' s care plan dated 3/3/15 with revision date 6/5/15 identified problem with ADL deficit requiring extensive to total staff assistance. Problem at risk for impaired skin integrity related to incontinence and vaginal drainage-perform weekly skin assessments; report any skin breakdown to MD/NP; incontinent care as needed (resident has problem with frequent episodes of diarrhea related to ATB therapy); turn and reposition frequently. Problem resident with significant fall history interventions include dysom cushion to chair; up in w/c at nurses station do not leave alone unless in high traffic areas. Floor mats to bedside; bolster cushion when in bed; pressure pad alarm when in bed. Nursing notes dated 5/28/15 65:30pm documents the resident fell out of the w/c resident was sitting at nurses ' station, nurse left bldg. And CNAs providing care to other residents, fell out of w/c on floor has laceration and skin teat to left knee. MD and resp. party notified. Sent to ER for evaluation and treatment. Interview on 6/9/16 at 3:30pm with the LPN #8 assigned to the resident on 5/28/15. The nurse stated the resident initially was in bed but was becoming agitated and trying to get out of bed. The staff decided to put the resident in wheelchair and position her at the nurses ' station for closer observation according to the care plan. The nurse states that she had to leave the nursing unit for few minutes but instructed the CNAs to monitor this resident at the nurses ' station. There were 3 CNAs assigned to the unit and the CNAs were providing care to the other residents and answering call lights leaving the resident unsupervised at the nurses ' station for a few minutes. The resident wiggles out of the wheelchair and fell to floor and chair alarm alerted the CNAs to the resident ' s fall. LPN#8 states the CNAs immediately informed her of the incident and the nurse returned to the unit; examined the resident who had sustained a laceration to the lip and skin tear to the knee. The nurse notified the MD and obtained orders to have her sent to the ER for evaluation and treatment. The responsible party was notified. The nurse stated she assumed the CNAs would follow her instructions to monitor the resident while she was gone. Interview with LN #6 on 6/9/16 at 2:30 pm revealed the resident did sustain the fall and was sent to the emergency room for evaluations and treatment for [REDACTED]. And the lack of supervision resulted in the resident falling from the wheelchair. LN #6 also acknowledged the facility failed to thoroughly investigate as to how the incident occurred according to the facility ' s Accident and Incident Investigation policy. As indicated Reviewed falls with RN supervisor and confirmed the failure to complete thorough investigation into the cause of each fall and staff failure to follow care plan intervention. LN #6 stated a ' teaching moment was provided for LPN #8 only; no training was provided for the CNAs involved. The facility failed to provide adequate supervision for Resident #135 in accordance with the resident ' s fall care plan interventions.